Promoting the musculoskeletal health of Indigenous Australians living in rural Communities Aboriginal health in Aboriginal hands Volume one Dein Vindigni, B.App.Sc. (Chiro.), B.A. (Soc. Sc.), Master Med. Sc. Submitted to the University of Newcastle For the degree of Doctor of Philosophy October 2004 Declaration I hereby certify that the work embodied in this thesis is the result of original research and has not been submitted for a higher degree to any other University or Institution. (Signed) ___________________________ Dein Vindigni University of Newcastle October 2004 ii Acknowledgments I would like to thank my supervisor, Dr Janice Perkins, for her guidance and support, particularly at the beginning of this PhD. Janice introduced me to the Indigenous Community with whom she had worked closely over many years. Her knowledge, insights and sensitivity to Indigenous cultural issues lay the foundations for working in this Community. I thank her for her belief in my abilities to undertake the PhD within the Discipline of Behavioural Health. I would also like to thank the other supervisors appointed to the project in the latter part of the study including Dr Lynne Parkinson, Dr Darren Rivett and Dr John Wiggers. Lynne assisted in the role of primary supervisor and gave the constructive feedback necessary to write the main body of the thesis. Her patience and persistence contributed greatly to completing the document. The input of Darren and John as senior research academics was also very helpful in giving the thesis the scientific rigour required in writing it. One of the challenges of conducting the study and reporting the results has been the distance. The regular trips from Melbourne (Victoria) to Newcastle and Kempsey (New South Wales) were rewarding but trying at times. Terese Alder from the Discipline of Behavioural Health assisted greatly in arranging regular telephone conferences and in providing the administrative support for conducting both the prevalence study and the training program for Aboriginal Health Workers (AHWs). Despite regular telephone communication, however, there is no substitute for face-to-face discussion. My colleagues in Melbourne were a constant source of support and encouragement. Associate Professor Cliff Da Costa provided statistical and, importantly, moral encouragement and support throughout the study. iii Mr Michael Dalton and Mrs Enriquetta Dalton spent countless hours developing the user-friendly database required to input the data from the Community, and with analysis of parts of the data. Dr Simon French assisted in locating references and conducting literature searches. Also Professor Rosalie Hudson for editorial assistance, Mr Ian Hoad for proofing the thesis and the support, encouragement and help of other colleagues and friends including, Dr Barbara Polus, Dr Bruce Walker, Dr John Duggan, Mrs Carole Duggan, Dr Paul Noone, Ms Kathleen Stacey, Dr Phillip Ebrall, Professor Andries Kleynhans, Mr Marcello D’Amico, Ms Robynne Smith, Ms Maree Keating, Dr Malcolm Powell, Dr Barrie Stokes, Mr Christophe Lecathelinais, Ms Josephine Gwynn, Ms Vesna Nedelkovski, Mrs Wendy Byrne and Mrs Michelle Walsh. Thanks also to Dr Max Walsh, Senior Lecturer from the School of Chiropractic, RMIT University, who also accompanied us to the Community and volunteered his time in conducting the demanding clinical assessment. He has since established an outreach program based, in part, on the work of the Kempsey Community. Kempsey-based massage therapist, Pamela McKirdy, and local chiropractor, Barbara McCormack, also volunteered their time in conducting assessments and providing management advice to Community members. They have an ongoing commitment to mentoring the graduates of the sports massage program through long-term training of AHWs and providing treatment for members of the Community. Also, Course Accreditation Consultant Amy Boleszny volunteered much of her time in working through the many bureaucratic hurdles required in the accreditation of the Community-based and owned Sports massage course that forms the basis of the intervention. I would like to extend thanks to Tuesday Browell and the Murray School of Health Education. Tuesday gave of her time to conduct the sports massage training course for Indigenous Health Workers and to see the first group of Aboriginal Health Workers through to graduation. Thanks also to Dr Felicity Redpath, who in many ways, was the inspiration for this program. Felicity spent 18 months in Manila, The Philippines, living among iv the people of the squatter areas, as well as treating them, to become an active part of their lives. People in these communities usually have large families to support, so if a parent becomes ill there is little recourse to health care. As most of the jobs require heavy, physical labour, the incidence of musculoskeletal injury and the resultant pain and impairment is extremely high. Felicity responded to these striking health needs by developing and then implementing a sustainable clinical massage therapy-training program (with certification) for the health workers in the poorest communities. More than 50 squatter area residents have since graduated as health workers from the six- week intensive training program which Felicity began over seven years ago. Felicity’s program inspired volunteers from Hands on Health Australia (HOHA), a voluntary health organisation, to seed the training program among Indigenous Australians described in this thesis. A special thanks also to Cultural Elders, Uncle Neville Buchanan and Uncle Paul Gordon, who not only introduced us to Indigenous approaches to managing pain and disability, but made all aware of the importance of ‘working together at the grass-roots to bring renewed hope and help to all people of Australia working with black and white with a common heart for people and the gift of creation’. The picture which appears at the beginning of the thesis was kindly painted by Rodney Augustine. Rodney is a descendant of the Nyul Nyul people, the traditional guardians of the northern Broome territory in Western Australia. The painting tells of the endless possibilities when black and white people meet on common ground united by common good. I am also indebted to Julie Bateman and John Woulfe for their ongoing assistance with formatting and computer-related challenges. Julie, in particular, tackled the ongoing challenges of formatting and collating the thesis with tremendous patience, comprehensiveness and expertise. I would also like to thank the Board of Directors of HOHA which provided much v of the financial assistance to conduct the many field trips to the Community. In particular our Patron Dr Sam Ginsberg and Mrs Jenny Ginsberg for their leadership and wisdom in seeing this as an important step in a life-long commitment to building bridges of hope and trust between Indigenous and non- Indigenous people. Also Mrs Nancy Lowe and Bill Lowe, administrators for HOHA, for their administrative support in arranging the trips to the Community and preparing materials for the training of AHWs and the thesis. I extend my gratitude to the Board of Directors, Administrators and Health Workers at the Durri Aboriginal Corporation Medical Service and the Booroongen Djugun Aboriginal Health Workers College. Without their interest and willingness to collaborate, the study would not have been possible. A special thanks to the Elders of the Community and the many Indigenous people who participated in the study. Many expressed their belief in learning from each other and the practical value of a ‘hands on’ approach to understanding and addressing the needs of their Community. I would like to thank my wife, Catherine, and children, Daniel and Chiara, for their infinite patience, understanding and support throughout the many nights and weekends consumed by the thesis. In particular to my mentor and closest friend Catherine for sharing the desire to learn from the richness of Indigenous people and culture and to make a practical and positive contribution to the Communities that we have been privileged to meet. Finally, I would like to dedicate this thesis to my parents, Gino and Frances, my sister Connie and parents-in-law Beryl and Norman Hall. Despite their diverse Italian and Anglo-Celtic origins, they reflect a belief shared by many Indigenous and traditional communities that unity and diversity can co-exist and that, despite our differences, we are all part of each other and have a duty to respect and care for all of creation. vi Table of Contents Publications & Conferences .............................................................................1 Peer reviewed journals and publications............................................2 Non-peer reviewed publications ..........................................................4 Presentations at Conferences and Lectures ......................................5 Prologue .............................................................................................................7 Synopsis...........................................................................................................25 Chapter one An overview of the burden of illness imposed by musculoskeletal conditions.........................................................................................................32 1.1 Introduction .........................................................................................33 1.2 Definition of musculoskeletal conditions .........................................36 1.3 Implications of musculoskeletal morbidity.......................................39 1.4 Burden of illness associated with musculoskeletal conditions internationally......................................................................................40 1.5 The burden of illness imposed by musculoskeletal conditions in Australia...........................................................................................48 1.6 The burden of illness imposed by musculoskeletal conditions among Indigenous people internationally ........................................52 1.7 Musculoskeletal conditions among Indigenous Australians ..........56 1.8 The prevalence of musculoskeletal conditions among Indigenous Australians living in rural Communities: a review of the literature ....................................................................................62 1.9 Musculoskeletal conditions among Indigenous people living in urban and rural Communities ........................................................65 1.10 Discussion ...........................................................................................68 vii Chapter two A critical review of methodologies identifying musculoskeletal conditions among rural Indigenous Communities ......................................70 2.1 Preamble .............................................................................................71 2.2 Introduction ........................................................................................72 2.3 Development of minimum methodological criteria for musculoskeletal prevalence studies ................................................74 2.4 Review of the literature according to developed methodological criteria for prevalence studies...............................80 2.5 Discussion ..........................................................................................84 Chapter three A review of the literature for modifiable musculoskeletal risk factors, opportunities for managing these conditions and barriers to their management.....................................................................................................86 3.1 Preamble ..............................................................................................87 3.2 Introduction .........................................................................................88 3.2.1 Prevention ...............................................................................89 3.2.2 Classification of modifiable musculoskeletal risk factors .....................................................................................89 3.3 Methods ...............................................................................................91 3.3.1 Search strategies and levels of evidence.............................91 3.3.2 Classification of modifiable musculoskeletal risk factors .....................................................................................92 3.4 Modifiable musculoskeletal risk factors ...........................................93 3.4.1 Modifiable risk factors for low back pain (LBP)...................93 3.4.2 Modifiable risk factors for neck pain ..................................109 3.4.3 Modifiable risk factors for upper extremity conditions (UEC)......................................................................................111 3.4.4 Modifiable risk factors for lower extremity conditions (LEC) including hip, knee, ankle and foot pain ..................113 3.5 Opportunities for managing musculoskeletal conditions .............116 3.5.1 LBP ........................................................................................116 3.5.2 Neck pain...............................................................................127 viii 3.5.3 Upper extremity conditions (UEC) ......................................128 3.5.4 Lower extremity conditions (LEC) ......................................128 3.6 Barriers to managing musculoskeletal conditions among Indigenous people living in rural Communities..............................131 3.6.1 Physical factors ....................................................................131 3.6.2 Economic factors .................................................................132 3.6.3 Cultural barriers....................................................................132 3.6.4 Personal factors ...................................................................133 3.6.5 Addressing the barriers to managing musculoskeletal conditions .............................................................................133 3.7 Conclusion.........................................................................................134 Chapter four Development of measures for assessing the prevalence of musculoskeletal conditions, associated risk factors and barriers to management among Indigenous people living in rural Australia..............135 4.1 Preamble ............................................................................................136 4.2 Introduction .......................................................................................137 4.3 Developing the Kempsey survey .....................................................139 4.3.1 Methods.................................................................................139 4.4 Developing the Clinical Assessment...............................................148 4.5 Piloting of the draft Kempsey Survey and Clinical Assessment ..152 4.5.1 Methods.................................................................................152 4.5.2 Results...................................................................................154 4.6 Conclusions.......................................................................................160 Chapter five The prevalence of musculoskeletal conditions, associated risk factors and barriers to managing these conditions among Indigenous peoples living in one of the largest rural Australian Communities ...........161 5.1 Preamble ............................................................................................162 5.2 Introduction .......................................................................................163 5.3 Methods .............................................................................................165 5.3.1 Design ...................................................................................165 ix 5.3.2 Setting ...................................................................................165 5.3.3 Sample...................................................................................175 5.3.4 Procedure..............................................................................178 5.3.4.1 Ethical considerations ........................................178 5.3.4.2 Training of research staff ...................................180 5.3.4.3 Recruitment..........................................................181 5.3.4.4 Logistics...............................................................183 5.3.5 Data handling........................................................................184 5.3.6 Measures ...............................................................................188 5.3.7 Agreement between the Kempsey survey and the clinical assessment..............................................................190 5.3.8 Analyses................................................................................191 5.4 Results ...............................................................................................193 5.4.1 Contact and consent rates...................................................193 5.4.2 Characteristics of the sample..............................................195 5.4.3 Report of musculoskeletal conditions................................203 5.4.4 Factors associated with report of musculoskeletal conditions .............................................................................208 5.4.5 Reported levels of Pain and Limitation...............................210 5.4.6 Factors associated with reported pain and limitation from musculoskeletal conditions........................................210 5.4.7 Reported causes of musculoskeletal conditions ..............210 5.4.8 Occupational and lifestyle risk factors ...............................215 5.4.9 Management and barriers to accessing management for musculoskeletal conditions...........................................217 5.4.10 Agreement between Kempsey survey and Clinical Assessment ..........................................................................220 5.5 Discussion .........................................................................................222 x