ORIGINAL ARTICLE

Is population flow an unintended consequence of alcohol management plans? Kim Usher, Cindy Woods, Paul Lynch, Shane Boris Pointing, Lea Budden, Ruth Barker, Jesani Catchpoole and Alan Clough

Aims and objectives. The aim of this study was to gauge whether, and to what extent, population flow occurred as a result of the implementation of alcohol management plans in Indigenous communities. Background. Alcohol management plans involving carriage limits and dry places were introduced into 15 Queensland Indigenous communities between 2002–2004. Controls on alcohol availability were further tightened between 2008–2010, seeing the closure of eight mainly remote community taverns/canteens. Design. A retrospective observational study was undertaken using data from the Queensland Injury Surveillance Unit. Methods. Population flow was measured by changing patterns of alcohol-related injuries in a mining region near dry Indigenous communities following the introduction of alcohol management plans and a control mining region distant from Indigenous communities with alcohol management plans. Data were analysed using descriptive and inferential statistics. Logistic regression was used for the comparison of the characteristics between the emergency department presentations. The rates of alcohol-related injury presentations per 1000/population were calculated and age-standardised to the Australian population. Results. Between the five-year periods 2003–2007 and 2008–2012, alcoholrelated injury presentations to the Mount Isa emergency department trebled from an age-adjusted average annual rate of 95/1000 in the region’s population to 271/1000 population. In the control region, alcohol-related emergency department injury presentations did not increase to the same degree with age-adjusted average annual rates of 142/1000 and 221/1000, respectively. Conclusions. The 10-year pattern of emergency department presentations for alcohol-related injuries increased significantly in the Mount Isa region compared

What does this paper contribute to the wider global clinical community?

• Rural and remote areas are asso-





ciated with more problematic drinking resulting in high numbers of alcohol-related injuries. Australian ED presentations for alcohol-related injuries are increasingly likely to be Indigenous women. Population movements are an unintended consequence of changed government policy; this should be considered before the implementation of similar policies in the future.

Authors: Kim Usher, BHSc, MNSt, PhD, Head, School of Health, University of New England, Armidale, NSW; Cindy Woods, PhD, BEd, Senior Research Fellow, School of Health, University of New England, Armidale, NSW; Paul Lynch, PhD, MBA, Early Career Development Fellow, College of Business, Law and Governance, James Cook University, Cairns, Qld; Shane Boris Pointing, BPsych, Senior Research Officer, The Cairns Institute, James Cook University, Cairns, Qld; Lea Budden, RN, DipAppSc, GradDipEd(Tert), BHlthSc, MNurs, PhD, Senior Lecturer, College of Healthcare Sciences, Centre for Nursing and Midwifery Research (CNMR), James Cook University, Townsville, Qld; Ruth Barker, MBBS,

FRACPaeds, MPH, Director, Queensland Injury Surveillance Unit, Mater Health Services, South Brisbane, Qld; Jesani Catchpoole, BHlthSc, PhD, Research Officer, Queensland Injury Surveillance Unit, Mater Health Services, South Brisbane, Qld; Alan Clough, PhD, MSc, BSc, Research Fellow, Australian Institute Of Tropical Health & Medicine (AITHM), James Cook University, Cairns, Qld, Australia Correspondence: Cindy Woods, Senior Research Fellow, School of Health, University of New England, Armidale, NSW 2351, Australia. Telephone: +61 (02) 6773 5762. E-mail: [email protected]

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© 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 26, 668–677, doi: 10.1111/jocn.13534

Original article

Population flow and alcohol management plans

with the control region. Further research should investigate the impacts of population flow related to Indigenous community alcohol management plans. Relevance to clinical practice. Although initiatives such as alcohol management plans have been implemented to reduce alcohol use and related consequences in Indigenous communities, there needs to be a greater consideration of the impact of these policies in nearby towns in the future.

Key words: alcohol-related injury, emergency department, indigenous, injuries Accepted for publication: 12 August 2016

Introduction The relationship between alcohol consumption and risk of injury is well documented (World Health Organization [WHO] 2007), and alcohol-related harms include road transport injuries, falls, fires, injuries resulting from domestic violence, assault, drowning and self-harm (WHO 2000, Catalano et al. 2001, Williams et al. 2011). In Australia, alcohol consumption accounts for 33% of the total burden of disease and injury (National Health and Medical Research Council 2014). Where alcohol is a factor, injured patients presenting to hospital emergency departments (EDs) tend to be predominantly male (M:F, 24:1), young, and are regular heavy drinkers (Cherpitel et al. 2003, Cherpitel 2007, WHO 2007, Cherpitel & Ye 2008, Williams et al. 2011).

Background In Queensland, Australia, alcohol contributed to at least 3% of all ED injury presentations (>12 years of age) as measured across 31 hospitals between January 1999–June 2010 (Barker et al. 2011). Between 2007–2010, Queensland saw the highest rate of increase in ED presentations for alcohol-related injuries of any Australian state or territory (68% per year) (Australian Institute of Health and Welfare (AIHW) 2011). Queensland is a particularly diverse, decentralised state in the Commonwealth, and the contributions the different Queensland regions make to these overall patterns and trends have not been examined. Regional differences in the proportion of ED presentations for alcohol-related injury are likely to reflect differences in patterns of consumption due to demographics, social and cultural variations, socio-economic status and educational attainment, and variable impacts of local alcohol policies (WHO 2007). Indigenous Australians experience health and social problems resulting from alcohol use at a rate disproportionate © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 26, 668–677

to non-Indigenous Australians (AIHW 2008). The burden of disease associated with alcohol use by Indigenous Australians is almost double that of the non-Indigenous population (Vos et al. 2007) and the prevalence of harmful alcohol use in the Indigenous population is about twice as great as that in the non-Indigenous population (Wilson et al. 2010). The higher rates of alcohol consumption by Indigenous Australians are reflected in higher rates of alcohol-related hospital admissions among this population (Wilson et al. 2010). The introduction of alcohol management plans (AMPs) in Indigenous communities has the potential to bring about important changes to the lives of people living in these communities. However, unintended consequences may result from such interventions. Alcohol management plans in Queensland were introduced under new Queensland government policy in response to the Cape York Justice Study, which found that alcohol abuse and violence were becoming normalised in Cape York Indigenous communities (Fitzgerald & Queensland Department of the Premier and Cabinet 2001, Queensland Government 2002). An AMP is an agreement across the community to tackle the harm caused by alcohol abuse. AMPs include provisions that ban or restrict the supply, possession and/or consumption of alcohol in Indigenous communities. AMPs involving carriage limits and dry places were initially introduced into 15 Indigenous communities in northern Queensland from 2002 onwards, limiting the amount of alcohol a person can carry within a restricted area. Some communities introduced a zero carriage limit, while others introduced a restricted carriage limit. Controls on alcohol availability were further tightened between 2008–2010, seeing the closure of eight mainly remote community taverns/canteens. A limited number of evaluations of the impact of Queensland Indigenous community AMPs have been undertaken. Two studies have been conducted using Royal Flying Doctor Service (RFDS) trauma retrieval rates (Margolis et al. 2008, 2011). The studies found a decline in trauma

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retrieval rates in the two years following the commencement of AMPs, and in the two years following the tightening of alcohol restrictions. However, media reports and anecdotal evidence indicate population flow from Indigenous communities with an AMP to communities without an AMP, which may have skewed the trauma retrieval results (Ironside 2009, Waters 2014). The Northern Territory National Emergency Response (NTER), also known as ‘the intervention’, was introduced in 2007 to address allegations of Indigenous child sexual abuse and family violence. One of the introduced measures was widespread alcohol restrictions within Northern Territory Aboriginal land, prohibiting the sale, consumption or purchase of alcohol. It is probable that in regional and remote populations, such significant social changes are reflected in altered numbers and types of injury presentations to the local EDs servicing these populations, as well as to EDs in surrounding areas. To begin to investigate the possible impacts of population flow in response to AMPs and the NTER in more detail, two Queensland regions were selected for this study, one in Mount Isa, north-west Queensland, and the other in the Bowen Basin region situated near the east coast of Queensland, as a control. In both regions, mining is the predominant industry. Mount Isa has a large Indigenous population (151% compared with 36% in Queensland and 25% in Australia) compared with the Indigenous population in the three selected townships in the Bowen Basin region (26%) (Australian Bureau of Statistics (ABS) 2015). Neither region has an AMP, but there are several regions with AMPs nearby to Mount Isa, in the Gulf of Carpentaria and in the Northern Territory. Apart from differences in Indigenous populations, the two regions have similar-sized populations, and proportion of visitors/non-residents, and the same major industry making Bowen Basin a reasonable match as a control community to compare changes in patterns of alcoholrelated injuries. Mount Isa is located 160 km from the Northern Territory border and 350 km south of the Gulf of Carpentaria. Traditionally, mining activity in the region has been predominately base metal mining, with employees domiciled in the major township of Mount Isa. However, over the last decade mining operations in this region continue to employ larger numbers of FIFO contractors. One hospital with an ED service is located in Mount Isa. In 2006, the population of Mount Isa was 19,663, and in 2011, it was 21,237 (ABS 2015). At the time of the 2011 census, 28% (n = 2896) of the Mount Isa population (aged ≥15 years) were employed in the metal ore mining industry – an increase of 35% from the 2006 census –

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and 3172 visitors were counted as non-residents of Mount Isa (ABS 2011). The Bowen Basin region is an elongated strip more than 600 km long running approximately parallel to the east coast lying 40–80 km away. The Bowen Basin contains roughly 50 coal mines. To meet the demand for coal, which dramatically accelerated from 2003 onwards, mining companies in this region built work camps for non-resident employees with single persons’ quarters and mess halls (Petkova-Timmer et al. 2009). Non-resident employees tend to use this subsidised accommodation rather than live in the local communities (Lockie et al. 2008, Petkova-Timmer et al. 2009). Three hospitals, with EDs, service this region, one in each of three small regional towns. The combined population of these towns in 2006 was 13,254 and 15,026 in 2011 (ABS 2015). In the Bowen Basin region, 25% (n = 393), 39% (n = 1947), and 48% (n = 773) of the selected three townships’ population (aged ≥15 years) were employed in the coal mining industry – an increase of 6%, a reduction of 3%, and an increase of 2%, respectively, from the 2006 census – and 4993 visitors were counted as non-residents of the Bowen Basin region (ABS 2011). It is unknown what proportion of visitors to these regions are tourists or fly-in-fly-out (FIFO) mining industry workers. Alcohol abuse and violence have long been an issue in Mount Isa. In the last three decades, at least three major initiatives have been undertaken in Mount Isa in regard to alcohol-related problems. In 2002, restrictions were imposed on alcohol sales in Mount Isa for a trial period. Although alcohol sales decreased in Mount Isa during the intervention, they increased in a nearby town indicating an increased demand from Mount Isa residents and a willingness to travel to a region without restrictions (d’Abbs et al. 2003). Reports indicate high levels of alcohol use throughout the Mount Isa community with 10% of the population reporting being heavy to very heavy drinkers (Healy et al. 1985, Northern Regional Health Authority 1991). Drinking has been described as a major social activity entrenched in the culture of the Mount Isa community (Healy et al. 1985, Northern Regional Health Authority 1991). These high levels of alcohol consumption have been partly attributed to high disposable income of males in Mount Isa (Northern Regional Health Authority 1991). Population flow is potentially an unintended consequence of AMPs, shifting alcohol abuse and violence from one location to another without alcohol restrictions (Memmott & Nash 2012). For decades, Indigenous people from communities in Queensland and the Northern Territory have visited Mount Isa for various reasons, to visit family, hospital appointments and to attend court, and for social reasons © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 26, 668–677

Original article

including heavy drinking (Dalley 2012, cited in Memmott & Nash 2012). It is likely that additional population flow as a consequence of AMPs will be evidenced in changing patterns of alcohol-related injury presentations pre- and postintervention. To date, there have been no published studies that have investigated the impact of changes in government alcohol supply restriction policies on patterns of ED presentations for alcohol-related injuries in neighbouring townships without an AMP. Evidence of population flow as a result of AMPs and the NTER is limited (Memmott & Nash 2012) and this issue requires further investigation. The aim of this study was to gauge whether, and to what extent, population flow occurred as a result of the implementation of AMPs in Indigenous communities, measured by an increase in alcohol-related harms in Mount Isa, as compared to the control region of Bowen Basin. Although the problem of alcohol abuse/misuse is complex and multifaceted, it is important to try to understand the underlying causes of changes in patterns of ED presentations for alcohol-related injuries so appropriate health promotion, education or preventive strategies can be developed.

Methods Data collection The National Injury Surveillance Unit has defined a set of data standards for public health injury surveillance (Australian Institute of Health and Welfare National Injury Surveillance Unit 1998). Level 1 standard is used for basic, routine public health surveillance. At this level, a narrative description of the injury event, four categorical injury items, based on International Classification of Disease (ICD), and 10 general items are recorded. Level 2 standard is used for hazard identification, target setting, and for monitoring unique or unusual injury events. At this level, the same data as for level 1 are collected except finer details of ICD classification are used, extended classifications for place and activity are used, and four additional injury items and three additional general items are recorded. The Queensland Injury Surveillance Unit (QISU) provides all-age, all-injury data on the occurrence, causes and type of injuries presenting to EDs in Queensland. The data are obtained from hospitals in three distinct areas of Queensland: urban, rural and remote, and represent approximately a quarter of the state. QISU collects level 2 National Data Standards for Injury Surveillance (NDS-IS) data at triage in participating EDs across Queensland using a standardised data collection tool. Additional data are available in the © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 26, 668–677

Population flow and alcohol management plans

form of triage free text that describes the patient’s reason for presentation. These data are not standardised, but frequently a rich source of additional injury information. The four hospitals in this study have collected injury surveillance data for the duration of the study period. Case ascertainment relates to the completeness and accuracy of data. The annual ascertainment rate is defined as the number of injury cases captured (regardless of data completeness) over the total number of injury cases (identified using injury ICD codes) per site. For sites using electronic information systems, injury data collection is triggered on entry of an ICD 10 code in the injury range. For sites using paper-based collection, data are recorded on standardised forms, which are then coded in accordance with the National Data Standard for Injury Surveillance (NDS-IS) and stored on the QISU database. Not all injury cases are captured, and reasons for missing data include the following: ‘did not wait’ or ‘left after treatment’ codes were used; generic codes were entered such as ‘back pain’; an injury occurred, but presentation is a result of a complicating issue such as infection; an incorrect diagnostic code may have been entered. Case ascertainment cannot be calculated for the sites that collected data using paper. For the period of this study, Mount Isa Hospital has used electronic methods to record ED data and case capture (ascertainment) has varied between 30–90% ascertainment annually. The three Bowen Basin hospitals were all using paper data collection until 2009 and ascertainment rates cannot be calculated for the period 2003–2009. After 2009, the three Bowen Basin hospitals began using electronic methods to record ED data and their annual ascertainment rate has been close to 100%. Therefore, changes in numbers of ED presentations for alcohol-related injuries in both areas should be interpreted with caution. Case ascertainment decreased in Mount Isa over the years studied, and therefore, the data presented for Mount Isa may under-represent the rise in alcohol-related injuries. However, alcohol-related injuries expressed as a proportion of all ED injury presentations is likely to be unaffected by variations in ascertainment. Using a combination of standardised coded and nonstandardised free-text data, QISU has established and published a robust methodology for attributing and validating the role of alcohol in an injury presentation (Barker et al. 2011). For the two regions, QISU has applied this methodology consistently for a 10-year period from 2003–2012. The data include standard data items: age, gender, date of ED presentation, location of injury (licensed venue, private dwelling, other public space or institution, street), body region injured, intent (unintentional injury/assault), triage

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category and admission status. Nonstandard data (triage free text) were used in combination with the items above to validate whether alcohol was a factor in the presentation and identify where possible incidents associated with police involvement or drug use (deliberate/drink spiking).

of differences in population age structure for comparisons of different time periods, different geographic areas, and Indigenous and non-Indigenous populations. Alpha

Is population flow an unintended consequence of alcohol management plans?

The aim of this study was to gauge whether, and to what extent, population flow occurred as a result of the implementation of alcohol management plans...
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