The Pituri Learning Circle: central Australian Aboriginal women's knowledge and practices around the use of <I>Nicotiana</I> spp. as a chewing tobacco

INTRODUCTION

Tobacco smoking has a range of known and predictable adverse outcomes, and across the world sustained smoking reduction campaigns are targeted towards reducing individual and public risk and harm. Conversely, more than 87 million women, mostly in low- and middle-income countries, use smokeless tobacco, yet the research examining the effect of this form of tobacco exposure on women is remarkably scant. In central Australia, the chewing of wild <i>Nicotiana</i> spp., a tobacco plant, commonly known as <i>pituri</i> and <i>mingkulpa</i>, is practised by Aboriginal groups across a broad geographical area. Until recently, there had been no health research conducted on the effects of chewing <i>pituri.

METHODS

This article reports on one component of a multidimensional <i>pituri</i> research agenda. A narrative approach utilising the methodology of the Learning Circle was used to interview three key senior central Australian Aboriginal women representative of three large geographical language groupings. The participants were selected by a regional Aboriginal women's organisation. With the assistance of interpreters, a semistructured interview, and specific trigger resources, participants provided responses to enable an understanding of the women's ethnobotanical <i>pituri</i> knowledge and practices around the use of <i>pituri</i> within the context of Aboriginal women's lives. Data were transcribed, and by using a constant comparison analysis, emergent themes were categorised. The draft findings and manuscript were translated into the participants' language and validated by the participants.

RESULTS

Three themes around <i>pituri</i> emerged: (a) the plants, preparation and use; (b) individual health and wellbeing; and (c) family and community connectedness. The findings demonstrated similar participant ethnobotanical knowledge and practices across the geographical area. The participants clearly articulated the ethnopharmacological knowledge associated with mixing <i>pituri</i> with wood ash to facilitate the extraction of nicotine from <i>Nicotiana </i>spp., the results of which were biochemically verified. The participants catalogued the pleasurable and desired effects obtained from <i>pituri</i> use, the miscellaneous uses of <i>pituri</i>, as well as the adverse effects of <i>pituri</i> overdose and toxicity, the catalogue of which matched those of nicotine. The participants' overarching <i>pituri</i> theme was related to the inherent role <i>pituri</i> has in the connectiveness of people to family, friends and community.

CONCLUSIONS

Central Australian Aboriginal women have a firmly established knowledge and understanding of the pharmacological principles related to the content of <i>Nicotiana</i> spp. and the extraction of nicotine from the plant. Widespread use of <i>Nicotiana</i> spp. as a chewing tobacco by Aboriginal populations in the southern, central and western desert regions of Australia is attested to by participants who assert that <i>everyone uses it</i>, with girls in these remote areas commencing use between 5 and 7 years of age. Central Australian Aboriginal people who chew <i>Nicotiana</i> spp. do not consider it to be a tobacco plant, and will strongly refute that they are tobacco users. Central Australian Aboriginal people do not consider that the Western health information regarding tobacco (as a smoked product) is applicable or aligned to their use of <i>pituri</i>. <i>Nicotiana</i> spp. users will deny tobacco use at health assessment. There is a requirement to develop and provide health information on a broader range of tobacco and nicotine products in ways that are considered credible by the Aboriginal population. Health messages around <i>pituri</i> use need to account for the dominant role that <i>pituri</i> occupies in the context of central Australian Aboriginal women's lives.<br /> Information for readers: A consultative organisation of Aboriginal women has as a strategic intent and operational agenda the improvement of Aboriginal women's and children's health across the research region. The group seeks opportunities to enhance their knowledge based on legitimate collaborative research; accordingly, they sought to participate in a range of research activities regarding the use of <i>pituri</i> and women's health outcomes. Of particular note, the group's participants chose to be identified by name in the publication of this research activity. In this article, the term 'Aboriginal' has been chosen by the central Australian women to refer to both themselves and the Aboriginal people in their communities; 'Indigenous' has been chosen to refer to the wider Australian Aboriginal and Torres Strait Islander people. The term <i>Nicotiana</i> spp. is used when referring to the plants from a Western perspective; <i>pituri</i> is used when referring to the plants, the tobacco quid, and the practice of chewing from a general Aboriginal perspective; and <i>mingkulpa</i> is used when the participants are voicing their specific knowledge and practices.

Prescription opioid prescribing, use/misuse, harms and treatment among Aboriginal people in Canada: a narrative review of available data and indicators

INTRODUCTION

Prescription opioid (PO) misuse and related harms are high in Canada, and a major public health challenge. In Canada, 1.4 million individuals (4.3% of the total population) self-identify as Aboriginal, among whom substance use and related harms are elevated. While there are reports of PO use and associated problems among Aboriginal groups, no comprehensive data review currently exists.

METHODS

A review of available data sources (ie journal publications, public reports and 'grey' literature) was conducted following principles of a scoping review. Information and data were identified, extracted, and organized into major indicator categories: PO prescribing/dispensing, use/abuse, morbidity/mortality harms and treatment, and narratively reported.

RESULTS

Data suggest that PO dispensing, use and misuse levels among Aboriginal populations are high and/or rising in select settings when compared to the general Canadian population. High levels of PO-related dependence and pregnancy harms exist (mainly in Northern Ontario); there is some indication of elevated opioid mortality among Aboriginals. Vast discrepancies in availability and access to interventions exist; some recent pilot studies suggest improved care.

CONCLUSIONS

Data regarding PO use and harms among Aboriginal people are limited, even though elevated problem levels are indicated; improved monitoring, and more effective yet culturally and contextually appropriate interventions for this acute problem are needed.

Developing and sustaining human resources in the health supply chain in Ethiopia: barriers and enablers

INTRODUCTION

The health supply chain is often the weakest link in achieving the health-related Millennium Development Goals and universal health coverage, requiring trained professionals who are often unavailable. In Ethiopia there have been recent developments in the area of health supply chain management. The aim of this study was to explore the current status of the development of human resources in health supply chain management in Ethiopia and to identify important factors affecting this development.

METHODS

A series of face-to-face interviews with key stakeholders was carried out in 2014. The interviews were conducted using a semi-structured interview guide. The interview guide comprised 51 questions. A qualitative analysis of transcripts was made.

RESULTS

A total of 25 interviews were conducted. Three themes were identified: General changes: recognition, commitment and resources, Education and training, and Barriers and enablers. Results confirm the development of human resources in health supply chain management in many areas. However, several problems were identified including lack of coordination, partly due to the large number of stakeholders; reported high staff mobility; and a lack of overall strategy regarding the job/career structures necessary for maintaining human resources. Rural areas have a particular set of problems, including in transportation of goods and personnel, attracting and keeping personnel, and in communication and access to information.

CONCLUSIONS

Ethiopia is on the way to developing a nationwide viable system for health supply chain management. However, there are still challenges. Short-term challenges include the importance of highlighting strategies and programs for human resources in health supply chain management. In the long term, commitments to financial support must be obtained. A strategy is needed for the further development and sustainability of human resources in the health supply chain in Ethiopia.

Exploration of Aboriginal and Torres Strait Islander perspectives of Home Medicines Review

INTRODUCTION

In Australia, Home Medicines Review (HMR) has been found to be an important tool to raise awareness of medication safety, reduce adverse events and improve medication adherence. Aboriginal and Torres Strait Islander people are 'underserviced' by the HMR program and are the most likely of all Australians to miss out on HMRs despite their high burden of chronic disease and high rates of hospitalisation due to medication misadventure. The goal of this study was to explore Aboriginal and Torres Strait Islander perspectives of the Home Medicines Review program and their suggestions for an 'improved' or more readily accessible model of service.

METHODS

Eighteen semi-structured focus groups were conducted with 102 Aboriginal and Torres Strait Islander patients at 11 Aboriginal Health Services (AHSs). Participants who were multiple medication users and understood English were recruited to the study by AHS staff. Seven focus groups were conducted for people who had already used the HMR program (User, n=23) and 11 focus groups were conducted for people who had not had an HMR (Non User, n=79). Focus groups were recorded, de-identified and transcribed. Transcripts were coded and analysed for themes. Focus groups continued and concepts were explored until no new findings were being generated and thus saturation of data occurred.

RESULTS

Focus group participants who had not had an HMR had little or no awareness of the HMR program. All the participants felt that lack of awareness and promotion of the HMR program were contributing factors to the low uptake of the HMR program by Aboriginal and Torres Strait Islander people. Most participants felt that an HMR would assist them to better understand their medicines, would empower them to seek information about medicines, would improve relationships with health professionals and would increase the likelihood of medication adherence. Most of the User participants reported that the HMR interview had been very useful for learning more about their medicines. However, many reported that they found the process confusing and confronting. The majority of participants felt HMRs for Aboriginal and Torres Strait Islander patients should be organised by AHS staff, with patients being offered a choice of location for the HMR interview. Participants identified that Aboriginal Health Workers should play a key role in communication, knowledge translation, referral and follow-up.

CONCLUSIONS

Current HMR rules impede rather than facilitate HMRs for Aboriginal and Torres Strait Islander people. Tailoring and remodelling of the HMR program is needed to increase the awareness, accessibility, acceptability and effectiveness of the HMR program for Aboriginal and Torres Strait Islander people.