Selecting Interventions for Food Security in Remote Indigenous Communities
Improving the food security of people living in remote Indigenous communities is an identified priority of Australian Governments. As Indigenous Australians suffer a disproportionate burden from diet-related diseases, improved food security will result in health gains. This chapter describes a practical approach to developing and selecting interventions to improve food security in remote Indigenous communities. Food security interventions aim to achieve a secure, sustainable and healthy food supply to remote Indigenous communities with increased purchase and consumption of a healthy diet by community members as the outcome. Therefore, the menu of interventions must address both supply and demand issues. Policy makers need to take three simple, yet difficult steps when choosing which interventions are suitable to improve public health. Firstly, define the problem; secondly, consider ‘what could or should be done?’; and thirdly, appraise a full range of intervention options to choose the most effective in the real world.
The types of public health interventions that could be selected to improve food security are numerous, from regulatory options, to mass media campaigns, to one-on-one health ‘education’ in a clinical setting. Sustained action across all sectors and governments are required to address the structural and systemic problems that have resulted in poor food security for many remote Indigenous communities.
This chapter focuses on the potential role of community stores in remote Indigenous communities to improve food and nutrition security and subsequent health outcomes and describes store-based government policy approaches to improving nutrition and health of Aboriginal people.
7.2 Remote Indigenous Australian Communities
Australia is a vast land with a low population density of 2.8 people per square kilometre (p/km2) which varies by geographical location (from <0.1 p/km2 in remote areas to >100 p/km2 in inner-city areas) (Australian Bureau of Statistics 2010a, b). Most Australians reside in major cities, with only 2.3% living in remote or very remote areas, yet population estimates of Indigenous Australians suggest that about 25% of Australian Indigenous people and 38% of Indigenous children live in remote areas (Australian Institute of Health and Welfare 2009; Australian Bureau of Statistics 2008). The Northern Territory and Western Australia, large proportions of the Indigenous population live in remote areas, 81 and 41% respectively.
Remoteness is measured by geographical location and access to goods, services and social interactions. There are over a thousand remote or very remote Indigenous communities in Australia, many with a population of less than a hundred people. About 175 community food stores provide the main source of food for many of these communities (House of Representatives and Aboriginal and Torres Strait Islander Affairs Committee 2009).
7.3 The Health Status of Indigenous Australians
Aboriginal and Torres Strait Islander people or Indigenous Australians, comprise approximately 2.5% of the overall Australian population, and is relatively young compared to the non-Indigenous population with 65% aged under 30 years of age, and almost half under 20 years. Indigenous children comprised 4.8% of the Australian child population in 2007, and although they represent a relatively small proportion of the Australian population, they represent 38% of the Indigenous population (Australian Institute of Health and Welfare 2009).
Indigenous Australians are the least healthy of all Australians. Significant gaps exist between the health status of Aboriginal and non-Aboriginal people and, for some health conditions, the gaps are widening (Kunitz 2000). Bailie and Wayte (2006) broadly described the health problems faced by people in remote communities using three interrelate categories: infectious diseases; problems resulting from social disruption and despair; and ‘lifestyle related’ disease (poor nutrition and lack of exercise and emotional stress) (Bailie and Wayte 2006). There is a significant disproportionate risk of lifestyle-related chronic diseases, low birth weight and poor dental health among Australian Indigenous people, that is, in part, preventable through diet. ‘Lifestyle related’ implies individual choice, but must include the significant environmental and supply side barriers that make it difficult to make lifestyle choices to reduce chronic disease risk in these communities.
Food has a direct influence on health and the prevention of non-communicable disease through improving nutrition (World Health Organization 2003). It has been estimated that poor diet contributes to approximately 19% of the Indigenous health gap overall (Vos et al. 2007a). Indigenous Australians have a lower life expectancy than their non-Indigenous counterparts, 12 years less for males and 10 years less for females in 2010 (Australian Institute of Health and Welfare 2011), although rates vary between jurisdictions and location including the extent of remoteness. Chronic disease including obesity, hypertension, cardiovascular disease, diabetes and renal failure accounts for about 80% of the mortality gap (Council of Australian Governments 2009). Australian infant mortality rates are very low overall, but Indigenous infant mortality rates, particularly those living in remote areas, are about three times higher. Indigenous mothers are twice as likely to have low birth weight infants, again, even more likely in very remote areas. Australian Indigenous children have almost twice the number of decayed, missing or filled teeth at 12 years.
7.4 Food Security, Progress and Government
‘People hope to have a long life, free from pain, illness or disability. Good health for all brings social and economic benefits to individuals, their families and the wider community’ (Health: Key Points 2009). It has been asserted that ‘The ultimate aim… [of] …food security is to arrive at a healthy and well-nourished population that can take on, to the maximum of its capacities, the development of its own community, area or country’ (Roetter and Van Keulen 2008).
Government policy responses to food security focus on different issues at a global, national and household level. Global responses are generally about meeting the demand for food; ensuring primary food production and distribution networks meet the needs for the expanding world population by encouraging agricultural sustainability and international free trade (Hazell and Wood 2008). National policy responses usually also consider economic conditions, agro-ecological factors, wealth distribution and social justice issues (Ehrlich et al. 1993). At the household level, the local food supply and accessibility (ability to access food) which depends on financial and physical resources are the focus (Kamphuis et al. 2006).
Government agricultural agencies often lead and implement government policy responses to food insecurity, with health as minor or secondary consideration. Health agencies are becoming more involved in food security policy development. The World Health Organization Assembly resolution 56.23 in 2003, called for Member States to develop national food and agricultural policies consistent with the protection and promotion of public health, highlighting food safety and sustainable food security through promotion of food products consistent with a healthy diet, fiscal policies, food programmes and agricultural policies (World Health Organization 2003).
when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy lifestyle (Australian Government 2004).
The strategy recognises an available and reliable food supply at all times and asserts that at community level the security is simply a matter of access to food.
The Australian government’s domestic food security response occurs in the areas of health, agriculture and trade, if at all. Governments’ commitment to implement policies to improve food security is key to the success of the 1996 World Food Summit pledge to reduce respectively the proportion and number of people who suffer from hunger and malnutrition by half by the year 2015. However, there is little evidence of the likelihood of reaching this target. Government food security policy responses need to focus on increasing the supply of nutritious foods, the distribution of food and the causes of food insecurity to be effective.
Australians living in remote Indigenous communities are susceptible to food insecurity (Australian Institute of Health and Welfare 2008b). The increased susceptibility to food insecurity for Australians living in remote Indigenous communities coupled with significantly poorer health outcomes has lead the Council of Australian Governments (COAGs) to consider strategies to improve both the supply and demand for nutritious foods in remote Indigenous communities to address these health disparities (Council of Australian Governments 2009). Improving the supply (affordability, quality and availability) and consumption of nutritious foods in remote areas is one important strategy to improve the health of Indigenous people (Australian Institute of Health and Welfare 2008a).
Little is known about the food purchasing and dietary consumption patterns of people residing in very remote Indigenous communities in Australia. Community store turnover provides apparent consumption data and has been used to assess the impact of interventions intended to improve dietary change such as the food BasicCard, which aims to quarantine money for allowable purchases e.g. food, whilst banning tobacco, alcohol, pornography and gambling products purchases through licenced retailers (Brimblecombe et al. 2010). These stores often operate as relatively closed markets serving small populations of isolated Indigenous communities, often providing a not-for-profit community service (Altman et al. 2002). However, it should be noted that it is likely that the community store is not the only available food source in these remote areas where fishing and hunting in groups is part of the food culture (Altman 2007). Also, food sharing is a common practice among Indigenous Australians, so traditional food consumption information, based on the individual, may need to be interpreted with caution.
7.5 Food Supply in Remote Communities
The food supply in remote Indigenous communities is poor. Perishable food delivery is irregular, the variety of food available is limited and often of low quality, food prices are high and food storage and preparation facilities are inadequate (Council of Australian Governments 2009). Supply chain logistics, in part, determine food security. The integrity of the food supply chain and storage facilities determines the quality of food available for sale, particularly perishable foods. All food costs more in remote areas. Surveys consistently find that healthy food baskets cost about 20–43% more in remote areas than in major cities (Harrison et al. 2007; House of Representatives Standing Committee on Aboriginal and Torres Strait Islander Affairs 2009; Landrigan and Pollard 2011; Givoni and Palermo 2010; Commonwealth Government 2011). The increase in the cost of healthy food rises faster than the Consumer Price Index for Australia. Most of the increase is due to the increasing cost of foods in very remote areas rather than in the major cities (Queensland Government 2007; Harrison et al. 2007, 2010; Commonwealth Government 2011). The cost of a basic healthy food basket was 32.6% higher in stores that were more than 2,000 km from Brisbane in 2006 (Harrison et al. 2010).
7.5.1 Transport: More than Just Kilometres
Floods have forced a re-route of Kimberley supplies through two States and the Northern Territory in a return journey covering the same distance as New York to Shanghai.
Transport logistics contend with extreme outside temperatures, long distance hauls, poor road conditions (and sometimes road closures due to flooding). Adequate refrigeration is needed so that perishable foods arrive in good condition—with regard to both quality and food safety. Some remote communities only have food delivered fortnightly or monthly. The 2008 Australian Parliamentary enquiry into food stores servicing remote Indigenous communities found that the food costs were high because of transport logistics required to deliver food to small communities in isolated geographical locations (House of Representatives and Aboriginal and Torres Strait Islander Affairs Committee 2009).
7.5.2 Food Business or Essential Service?
Market forces and business drivers dictate grocery store locations and food prices. Global grocery chains (e.g. Woolworths and Coles) service areas of high population density but most grocery stores in regional or remote areas are independently owned. A community food store has ‘one of the main purposes of the business as the provision of grocery items and drinks’ (Northern Territory National Emergency Response at 2007: An Act to respond to the Northern Territory’s National emergency, and for related purposes 2007). As the main, and sometimes the ‘only’, provider of food in many of these isolated areas, typically servicing communities of less than 150 people, the Indigenous community food store could be considered an ‘essential service’ rather than a viable business. Store governance, financial and retail management practices influence their ability to provide a consistent and affordable food supply to the community. Store ownership and management varies. Some communities own and run the store, others are subsidised by government, or managed by a management company, usually not-for-profit (in some cases establish by government) (House of Representatives and Aboriginal and Torres Strait Islander Affairs Committee 2009). Food businesses are required to meet regular regulatory requirements to enforce basic standards in food safety. Staff need to be adequately trained and standards maintained. There may be only limited training opportunities, if any, in remote communities. Building conditions are often poor and maintenance services are not readily available and/or very expensive.
7.5.3 Capacity to Access Food in Remote Indigenous Communities
Some stores offer a tab, credit or ‘Book-up’ for food when community members do not have enough money to purchase foods (Australian Securities and Investments Commission 2005). Money management issues are relatively common for people on very low incomes, particularly if people run up big debts and cannot pay them off. Book-up systems may assist in emergency food relief in some communities provided they are transparently operated with achievable repayments (Altman et al. 2002). Where this is not the case there have been issues regarding theft, fraud and disclosure of PIN numbers.
Food access in remote communities may be dependent on personal transport. Many people use the community food store as their main source of food because the nearest option is in the next town which, due to distance, requires travel by car. Ready access to motor vehicles is low for Indigenous households in remote areas, 52 compared to 90% of non-Indigenous households (Australian Health Ministers’ Advisory Council 2006).
Market Baskets Comparison per Fortnight for Perth (2010), Darwin (2008) and Brisbane (2006) Inflated with Consumer Price Index (CPI) Increases to September 2010 (Landrigan and Pollard 2011)
Increase from major cities to very remote
Employment rates and household income levels of families living in remote areas are lower since many families are dependent on welfare. Welfare recipients need to spend a significantly greater proportion of their disposable income on food to achieve a healthy diet than those on an average income; 36–50 compared to 15–20% (Kettings et al. 2009; Landrigan and Pollard 2011; Commonwealth Government 2011).
7.5.4 The Solution: Addressing the Demand Side as Well as the Supply
Improving the affordability, quality and availability of foods and beverages consistent with dietary recommendations is likely to increase their consumption, particularly perishable foods (fruit, vegetables and dairy foods). But, simply increasing supply and affordability of food does not mean community members will purchase and eat it. Strategies are required to increase the ‘demand’ for nutritious foods whilst reducing the purchase of foods and drinks high in sugar, fat and salt. Achieving both these steps would see a dietary pattern consistent with dietary guidelines and help to protect Indigenous people in remote Australia from diet-related chronic disease.
7.6 Background to Australian Government Food Security Policy
2001—Health Ministers approve the National Aboriginal and Torres Strait Island Nutrition Strategy and Action Plan, 2000–2010 (NATSINSAP)—priority action areas: food supply in remote communities; food security; environmental and household infrastructure; workforce; and monitoring systems. (Strategic International Nutrition Alliance 2001).
2002/2003—Northern Australian Health Ministers committee releases Food North: Food for Health in Northern Australia with options to improve food availability and affordability (Office of Aboriginal Health 2003).
2004—Food Security Strategy announces initiatives to enhance food security in the developing world (Australian Government 2004).
2005—Remote Indigenous Stores and Takeaways (RIST) develops a national approach to improving access to healthy foods. Indigenous Business Australia commits to improve community stores sustainability and Outback Stores is established to improve the supply, quality and range of nutritious food.
2006—Aboriginal and Torres Strait Islander Health Performance Framework reports improvements but emphasises addressing chronic disease determinants, particularly nutrition.
2007—Northern Territory National Emergency Response Act 2007 (NTER) responds to the Board of Inquiry into the Protection of Aboriginal Children from Sexual Abuse (Northern Territory Government 2007). A community stores licencing scheme improves supply and consumption of nutritious food using income management and employment reforms.
2008—House Standing Committee on Aboriginal and Torres Strait Islander Affairs, Everybody’s Business: Remote Aboriginal and Torres Strait Community Stores report outlines options for the role and management of community stores and strategies to improve nutrition, transport, food supply and affordability, regulation, policy and interventions (House of Representatives and Aboriginal and Torres Strait Islander Affairs Committee 2009).
2009—COAGs National Remote Indigenous Food Security Strategy (NRIFSS) announced to improve health through supply and demand side strategies to increase the consumption of healthy food (Council of Australian Governments 2009). NTRE evaluation reports that income management increased household expenditure on food and children, more young men shopping and reductions in drinking and gambling, and half parents said their children eat more, weigh more and were healthier (Australian Government 2010). Income management disadvantages: less discretionary cash, managed money restrictions, blanket coverage discriminatory. NATSINSAP review highlights poor nutrition and the need for ongoing specific actions and adequate resourcing for implementation.
2010—range, quality and affordability of nutritious food improved through income management and store licencing—income management extended to 66 community stores assisting 16,600 people. Strategies are needed to increase demand for and consumption of healthy food even with 83 stores licenced and reports of 71% of income management money allocated towards food (Australian Government 2009a, b). National Preventative Taskforce recommended subsidies for remote area transport of fresh foods (National Preventative Health Taskforce 2009).
Over the decade, in response to consultations, internal and external advocacy, and research providing evidence to inform actions, governments appear to be more willing to strategically address the problem through a comprehensive range of interventions, including ‘hard’ policy options such as regulation and fiscal measures.
7.7 Steps to Develop a Strategic Policy Approach to Improve Food Security
A system-wide approach is required when developing policies and interventions to reduce diet-related diseases (Hawkes 2007, 2008; Hawkes et al. 2006). Specific influences and points of leverage along the entire food supply chain can be used to modify the foods available for purchase and consumption as well as food choice (Hawkes 2008). A systematic approach consists of four main steps: firstly, define the public health problem and its key determinants; secondly, work out what can be done and what should be done; thirdly, assess and select appropriate actions; and fourthly monitor and evaluate intervention impacts to inform the policy cycle (National Public Health Partnership 2000b).
7.7.1 Step 1: Defining the Problem—Food Security and Its Determinants
How you define and measure a problem influences how you respond. This is particularly true for policy development. Achieving an agreed and specific definition of food security and its determinants is essential, as well as an understanding of the determinants. A clear definition provides the context for action and assists with identifying the desired outcomes. Farrell (2007) asserts that the Australian government’s definition of remote Indigenous communities as being in a very remote location with a population of more than 100 people and predominantly of Aboriginal or Torres Strait Islander origin’ would exclude 75% of the 1,187 discrete remote communities with populations of less than 50 (Farrell 2007).
Pinstrup-Andersen reminds us that ‘food security’ is a valuable concept if it is used with a clear understanding of what it means, its interactions and how it interacts with behaviour and non-food factors (Pinstrup-Andersen 2009).
‘the availability, cost, quality, variety and promotion of foods for local population groups that will meet nutritional requirements’ and food access refers to ‘the range of physical and financial resources, supports, and knowledge, skills and preferences that people have to access and consume nutritious food’ (Council of Australian Governments 2009, p 3).
Food security would be achieved through equitable access to a reliable supply of safe, nutritious, culturally appropriate and affordable food; social and economic status providing an adequate income, and food consumption consistent with dietary recommendations.
The COAGs NRIFSS aimed to deliver improved health outcomes by improving the supply and consumption of healthy food through a series of small, coordinated actions. Each state and territory has different local conditions and current activities e.g. the number and location of stores, store ownership, community readiness and existing interventions. The NRIFSS built on the NTER and aims to improve food security through a nationally coordinated approach to increase the supply of and demand for nutritious foods through community stores and for the partnerships to increase the capacity and infrastructure to sustain these changes. The systematic approach to identifying the problem, determinants and potential solutions engaged a number of sectors.
7.7.2 Step 2: What Could or Should Be Done?
Better health is the ultimate outcome, but many of the determinants of the problem lie outside health’s sphere of influence or are often the responsibility of other sectors, for example, agriculture, transport, education or trade. A comprehensive range of interventions need to be considered (National Public Health Partnership 2000a). Effective intervention development looks for opportunities for action at all levels and builds on what has gone before. Governments look to existing strategies, particularly those which have been well described and evaluated (often within the peer reviewed literature or through relevant consultation) to identify the critical factors for success. For example, two effective interventions to improve the food supply and increase the purchase of healthy foods in remote community stores were considered were regulatory interventions and creating demand through price elasticity.
Replication of this intervention was not realistic due to the cost of implementation (over $100 million over 4 years in the NT) and different regulatory environment in states not allowing for replication of the Emergency Response Intervention. However, given the effectiveness of the intervention, other ways to achieve the same end were sought, through the notion of a voluntary licencing scheme.
Price elasticity of demand options can influence food choice. A 10% reduction in the cost of vegetables could facilitate a 7% increase in purchase (Bond et al. 2010) and a 10% increase in soft drinks price would reduce consumption by 8–10% (Andreyeva et al. 2010). Food pricing surveys show opportunities to reduce the comparative cost of fruit, vegetables and dairy foods in remote stores (Landrigan and Pollard 2011; Queensland Government 2007).
Income management including the use of a food BasicsCard, quarantining a proportion of welfare payments for use at the store dis-allowing the purchase of alcohol, tobacco and pornography appears to have had a temporary effect on food purchasing (Brimblecombe et al. 2010). However, there are conflicting findings concerning longer term outcomes. Government reports show a range of benefits (Australian Government 2009a, b) whereas other authors suggest limited impact and question the value for those most at risk (Brimblecombe et al. 2010; Farrell 2011).
7.7.3 Step 3: Appraising Interventions to Decide Options
Improving the supply of healthy food in remote Indigenous community.
Increasing the consumption of healthy food in remote Indigenous community.
Improving the way sectors worked together.
The relative strengths and weaknesses of interventions are systematically assessed against criteria (National Public Health Partnership 2000a; Pollard et al. 2008). Discussing intervention assessments leads to a shared understanding of what is being proposed. Views on the potential effectiveness of interventions will vary based on and experience. Ample opportunity should be provided to share the reasoning behind each sector’s ranking to form an agreed understanding of the relative benefit, or not, of each intervention type (see Figure 7.4).
Relying on the available evidence, their knowledge and professional judgement, each decision-maker weights each intervention to select priorities for action. Seven intervention types across 12 priority areas are ranked against each criterion (effectiveness, sustainability, feasibility and political acceptability (National Public Health Partnership 2000a, b)) to assess their suitability. The grid is deceptive in its simplicity, but it is a broad-brush assessment that works best when well-informed decision makers are at the table and when evidence of effectiveness of interventions is available. As always, the devil is in the detail. Once interventions are assessed, difficult decisions relating to potential partners, funding and specific responsibilities need to be considered.
Ministers agreed on specific strategic actions that could be undertaken by the Commonwealth of Australia, QLD, WA, SA and the NT (Council of Australian Governments 2009). Strategic actions were to develop national community stores standards (e.g. retail and financial management, governance, infrastructure, nutrition promotion and food safety); a Quality Improvement Scheme; incorporate stores under the Corporations (Aboriginal and Torres Strait Islander) Act 2006 to ensure high standards of governance and accountability of stores; and a national healthy eating action and workforce plan.
7.7.4 Step 4: Continuous Improvement Cycle
Specific and measurable goals and targets help manage policy implementation, and require a prediction of the amount of change that would reasonably be expected in a given time (Nutbeam et al. 1993). Aboriginal and Torres Strait Islander Social Justice Commissioner and the Steering Committee for Indigenous Health Equality targets to close the Indigenous health gap include; that >90 per cent of indigenous families have access to a healthy food basket for a cost of less than 25 per cent of their available income (Aboriginal and Torres Strait Islander Social Justice Commissioner and the Steering Committee for Indigenous Health Equality 2008). This would require monitoring of food pricing, household income, expenditure and welfare payments. Targets measuring change in food security in remote Indigenous community are difficult due to the lack of monitoring and surveillance of the issues and reliance on proxy measures (Webb et al. 2006). Comprehensive monitoring and evaluation of the impact of food security interventions using indicators such as food chain management outcomes (quality, affordability, reliability), access (income, economy), supply, purchasing, consumption and nutrition is warranted with an emphasis on those most at risk—infants, children and the elderly.
Policy makers need to take four steps when choosing which interventions to improve food security. Define the problem, consider ‘what could or should be done?’, appraise the intervention options and then monitor the impacts to continue the improvements. Sustained action across all sectors is required to address the structural and systemic problems that have resulted in food insecurity in many remote Indigenous communities.
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