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Objectives: To analyse rates of avoidable mortality in Aboriginal and non-Aboriginal residents of the Northern Territory (NT) from 1985 to 2004, in order to assess the contribution of health care to life expectancy improvements. Methods: Australian Bureau of Statistics (ABS) death registration data for NT residents were used to identify 'avoidable' deaths, with further separation into three categories of conditions amenable to either medical care or health policy, and a category for ischaemic heart disease (IHD). A Poisson regression model was used to calculate the average annual change in avoidable mortality by sex and Aboriginality in the NT compared with Australia as a whole. Results: In the 20 years between 1985 and 2004, avoidable mortality rates fell 18.9% in NT Aboriginal people, 61.1% in NT non-Aboriginal people and 59.5% in Australians overall. NT Aboriginal people continued to experience higher avoidable mortality than other Australians and the disparity increased over time. Most of the decline in avoidable mortality for Aboriginal Territorians occurred for conditions amenable to medical care. Conclusion: Medical care has made a significant contribution to improvements in Aboriginal life expectancy in the NT, however, reductions in avoidable mortality from IHD and conditions amenable to health policy have been variable. Implications: The results highlight the need for ongoing investment in comprehensive programs incorporating appropriate health policy interventions and management of chronic diseases. Key words: avoidable mortality, Aboriginal health, Northern Territory, health care. Aust NZ J Public Health. 2009; 33:544-50 doi: 10.1111/j. 1753-6405.2009.00451.x

Objective: To assess trends in chronic disease mortality in the Aboriginal population of the Northern Territory (NT), using both underlying and multiple causes of death. Method: Death registration data from 1997 to 2004, were used for the analysis of deaths from five chronic diseases; ischaemic heart disease (IHD), diabetes, chronic obstructive pulmonary disease (COPD), renal failure and stroke. Negative binomial regression models were used to estimate the average annual change in mortality rates for each of the five diseases. Chi squared tests were conducted to determine associations between the five diseases. Results: The five chronic diseases contributed to 49.3% of all Aboriginal deaths in the NT. The mortality rate ratio of NT Aboriginal to all Australian death rates from each of the diseases ranged from 4.3 to 13.0, with the lowest rate ratio for stroke and highest for diabetes. There were significant statistical associations between IHD, diabetes, renal failure and stroke. The mortality rates for diabetes, COPD and stroke declined at estimated annual rates for NT Aboriginal males of 3.6%, 1.0% and 11.7% and for Aboriginal females by 3.5%, 6.1% and 7.1% respectively. There were increases in mortality rates for Aboriginal males and females for IHD and a mixed result for renal failure. Conclusion: NT Aboriginal people experience high chronic disease mortality, however, mortality rates appear to be declining for diabetes, COPD and stroke. The impact of chronic disease on mortality is greater than previously reported by using a single underlying cause of death. The results highlight the importance of integrated chronic disease interventions. Key words: chronic disease, mortality trend, Aboriginal health. Aust NZ J Public Health. 2009; 33:551-5 doi: 10.1111/j.1753-6405.2009.00452.x

Objective: To determine the prevalence rates of hypertension, diabetes, ischaemic heart disease (IHD), renal disease and chronic obstructive pulmonary disease (COPD), and their co-occurrence among the remote Aboriginal population of the Northern Territory (NT) in 2005. Methods: Information from a primary care chronic disease register (CDR) and hospital inpatient database were linked to a population list by using a unique patient identifier. A capture-recapture method (CRM) and multivariate log-linear models were then applied to analyse the multiple datasets to estimate the prevalence rates for the selected diseases and case ascertainment in each data source. Results: The NT remote Aboriginal communities had considerably higher prevalence rates across all five chronic diseases than national health survey figures. At ages 50 years and over, the prevalence rates for hypertension and renal disease were above 50%, diabetes 40%, COPD 30% and IHD above 20%. In terms of data completeness, CDR and hospital sources were both relatively incomplete, generally around 20-60%. The most common co-occurrences for the five chronic diseases were between hypertension, diabetes, IHD and renal disease. Conclusions and implications: The prevalence rates calculated using this method are comparable to estimates from rigorous small area studies, but are markedly higher than those from single clinical data sources. The results indicate that there is a considerable underdiagnosis of preventable chronic diseases in the Aboriginal communities. Keywords: Prevalence, data collection, epidemiology, chronic diseases, Indigenous health services doi: 10.1111/j.1753-6405.2008.00245.x

Objective: To investigate markers of reproductive health in a remote Indigenous community in Northern Australia. Methods: A retrospective, cross-sectional analysis of case notes of 342 women between the ages of 20 and 45 years, living in one community in a remote region of the Northern Territory. Results: The total rate of current infertility in the community was 26.3%; 8.2% for primary infertility and 18.1% for secondary infertility. An additional 3.3% of women had resolved infertility. Only 43% of the women had sought medical help for the problem. A history of ectopic pregnancy was recorded in 2.6%, stillbirth in 1.8%, miscarriage in 14.3% and neonatal death in 12.3%. Depot steroidal contraception or tubal ligation were used by 50% of the women but 45.9% used no contraception. A history of pelvic inflammatory disease (PID), T. vaginalis N. gonorrhoeae, genital C. trachornatis infection, syphilis or bacterial vaginosis was noted in 32%, 46%, 27%, 30%, 41% and 9% respectively. Current alcohol consumption was reported in 23% and cigarette smoking in 76%. In multivariate analysis, infertility was strongly associated with PID (adjusted OR 8.5), alcohol consumption (AOR 3.1 ), T. vaginalis (AOR 2.5), N. g,norrhoeae (AOR 2.2) and bacterial vaginosis (AOR 2.9). Conclusion: Reproductive health is poor in this community of Indigenous women, with endemic levels of STDs, PID and tobacco consumption. The absence of barrier contraception (e.g. condoms, diaphragms) has implications for HIV and STD control. Clinical and public health interventions are urgently required but the implementation of these is hindered by a number of structural, social and economic barriers.

Surveys of Australian aborigines in the Northern Territory show unusually high rates of rheumatic fever and rheumatic heart disease. Many with this condition are in their most productive years and often die. Programs to treat these preventable diseases would lower the Aboriginal death rate, which is currently 4 times that in developing countries.

OBJECTIVE: To describe variation in all cause and selected cause-specific mortality rates across Australia. METHODS: Mortality and population data for 1997 were obtained from the Australian Bureau of Statistics. All cause and selected cause-specific mortality rates were calculated and directly standardised to the 1997 Australian population in 5-year age groups. Selected major causes of death included cancer, coronary artery disease, cerebrovascular disease, diabetes, accidents and suicide. Rates are reported by statistical division, and State and Territory. RESULTS: All cause age-standardised mortality was 6.98 per 1000 in 1997 and this varied 2-fold from a low in the statistical division of Pilbara, Western Australia (5.78, 95% confidence interval 5.06-6.56), to a high in Northern Territory-excluding Darwin (11.30, 10.67-11.98). Similar mortality variation (all p Page 234 Cost estimates for hospital inpatient care in Australia: evaluation of alternative sources OBJECTIVE: This paper presents a framework for evaluation of alternative sources of estimates of the costs of hospital inpatient care in Australia, It argues that the choice of costing methods depends on the decision-context and the sensitivity of the decision to estimation errors. METHOD: Five criteria are proposed for evaluation of sources of hospital cost data, with detailed consideration of the way estimates are derived in two computerised approaches which use accounting data. Three broad approaches to cost estimation are evaluated against these criteria. RESULTS: Choosing an estimation method entails an optimisation analysis for each decision context. 'Microcosting' techniques remains the most valid approach to cost estimation, but are costly and this may, in turn, limit the sample of patients or institutions. Protocol-based cost estimates vary widely in their validity, depending on source data, but there is little justification for continued use of crude per diem cost estimates in such protocols. When precision and resolution are important objectives, clinical costing approaches provide the most valid inpatient cost estimates at a reasonable data cost. When external validity is important, or where standardisation of hospital costs is desired, use of published national cost weights may be preferred. CONCLUSION: Both primary and secondary sources of cost data must withstand challenges to internal and external validity. The 'resolution' (or precision) of cost estimates and the relative costs of collection must also be considered. IMPLICATIONS: Studies using estimates of the costs of hospital care should defend the appropriateness of the costing approach and data source for the decision context. Page 242 A randomised trial of an intervention to develop health promoting schools in Australia: the south western Sydney study OBJECTIVE: This paper describes the evaluation of a health promoting schools intervention carried out in the south western region of Sydney, Australia. The evaluation sought to assess the project's impact on structures to support the health promoting school concept and changes in health-related policies and practices within 22 local schools. METHODS: A randomised controlled study was employed. Intervention schools were offered seminars and training in the health promoting schools concept, encouraged to use a resource kit to help them establish their school as health promoting and invited to participate in a support network. Pre- and post measures of awareness, school structures and policies and practices to support the development of a health promoting school were taken and intervention and control schools compared. RESULTS: There was an increased level of awareness of the health promoting school concept among intervention schools. However, there were no significant changes in health-related policies and practices at the school level, among both intervention and control schools. CONCLUSIONS: A longer time frame and more structured support are required to influence school structures to support the development of a health promoting school. IMPLICATIONS: To facilitate organisational change in schools, health promoting school interventions need to provide structured support for schools and recognise that change takes time. A committee to initiate action, a plan to guide work and school support are likely to facilitate the adoption of the health promoting schools approach. Further work to refine the measurement of school-based action and its outcome and the development of indicators for a health promoting school is needed. Page 247 Cost effectiveness analysis of school based mantoux screening for TB infection OBJECTIVE: To assess the cost-effectiveness of adding school based Mantoux screening programs to the New South Wales current TB prevention strategy. METHOD: A decision analysis model compared the costs and consequences of screening strategies against the current no-screen strategy, Costs associated with screening and with treating future cases of TB were considered. Consequences considered were deaths and adult cases of TB prevented. The study was based on data from prevalence surveys conducted in 1992 and 1994 in Central and South Western Sydney, New South Wales. Screening strategies considered were screening all or only overseas born (OSB) 6 year olds and all or only OSB 14 year olds in school settings. RESULTS: Screening 14 year olds prevented more deaths and adult cases of TB than screening 6 year olds for a similar cost. For both age groups targeted screening of OSB children was more cost-effective than screening all children. Targeted screening of 14 year olds - the most cost effective option - cost $17,956 (costs and benefits discounted at 5%) per adult case prevented, equivalent to approximately $130,000 per life year saved. The cost-effectiveness ratios decline substantially if lower discount rates and less conservative assumptions are applied. CONCLUSION: Targeted screening was more cost effective than screening all children, however, there are ethical implications of targeting a group based on their origin of birth. IMPLICATIONS: As prevention and control of TB continues to be a high priority for NSW, the implications of a school based screening program should be seriously considered. Page 254 'Sending the wrong signal': Analysis of print media reportage of the ACT heroin prescription trial proposal, August 1997 OBJECTIVE: To analyse and compare newspaper coverage about heroin during a period spanning two government policy decisions to approve, then prevent, a trial of heroin prescription to dependent users. METHOD: All articles published about heroin spanning the two policy decisions (1-19 August 1997) were collected from seven major Australian newspapers. Analyses included content and orientation analyses of all articles and discourse analysis of articles (excluding letters) containing value-laden statements about heroin prescription. Comparisons were made of content, orientation and subtextual themes employed by opponents and proponents of heroin prescription. RESULTS: 231 articles with references to heroin were identified from seven newspapers, 28% were published by The Daily Telegraph. This newspaper campaigned against the heroin prescription trial with 66% of news articles and 100% of opinion items negative in orientation, compared to averages of 11% and 16% of news and opinion articles published by comparison newspapers. Seven subtexts were identified in coverage opposing heroin prescription including 'surrender in the war on drugs', 'government as drug pedlar' and 'deserving/undeserving citizens'. Six subtexts supportive of heroin prescription were identified including 'failure of prohibition' and 'time for new approaches'. CONCLUSION: The mid-1997 policy reversal on heroin prescription was due, in part, to the higher activity of opponents following approval of the trial and because proponents did not reframe discourses used to denigrate the proposal. IMPLICATIONS: To be successful, advocates of new policy need to recognise and reframe negative discourses to create new dominant themes which address the concerns of the public.

Objective: The Strong Women Strong Babies Strong Culture Program had specific goals to increase infant birthweights by earlier attendance for antenatal care and improved maternal weight status. Starting in August 1993, Aboriginal women in three pilot communities worked with pregnant women in a program that emphasised both traditional practices and Western medicine. Method: Two sources of data were used to examine different aspects of program effects. Results: Data from the NT Midwives Collection shows that the mean birthweight of infants of Aboriginal women increased by 171 g between 1990/91 and 1994/95 in the pilot communities and by 92 g in the surrounding three rural regions. Data extracted from clinic records in the pilot communities found that changes in maternal weight were associated with change in birthweight over time. Conclusion: Changes in birthweight coincide with the commencement of the program and are larger than the secular trend in surrounding communities. Implications: Ongoing evaluation of the expanded program will help to determine the extent to which the change in birthweight can be attributed to the program and whether the effects can be replicated. (Aust N Z J Public Health 2001;25:34-40)

An Aboriginal environmental health worker program for 10 communities in the Northern Territory was found to be inadequate, according to a study that gathered information from 15 environmental health workers supporting the program. The respondents reported they lacked preparation and training, did not have a clear understanding of the program, and lacked confidence to provide support and education to those they were working with.