Indigenous Health Research Monitoring, January 2023

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Article Summaries: Subject Areas

Lifestyle and health-promoting behaviours

Association between alcohol restriction policies and rates of alcohol-related harms in remote Australian Aboriginal and Torres Strait Islander communities: A systematic review

Hines, S., Carey, T. A. & Cibich, M. (2022). Association between alcohol restriction policies and rates of alcohol-related harms in remote Australian Aboriginal and Torres Strait Islander communities: A systematic review. JBI Evidence Synthesis, 20(7), 1610‑1637.


Alcohol use has heavy social costs, notably because of the associated health care needs, crimes committed while under the influence and the consequences on childhood development. In Australia, not all Aboriginals and Torres Strait Islanders use alcohol. In fact, their rate of use is lower than in the rest of the Australian population. Those who do drink, however, tend to consume quantities that put them and others at risk of experiencing health consequences. Managing access to alcohol in specific communities is a complex issue, given that various regulations come into play at the local, regional and national levels. Some communities are designated as “dry,” meaning that the sale of alcohol is not allowed. Others place limits on the quantity and type of alcohol available, when it can be purchased and the price. However, the effect of such restrictive policies remains poorly understood.


Study the association between restrictive policies concerning alcohol and the rates of alcohol‑related harms in remote Australian Aboriginal and Torres Strait Islander communities.


A systematic review was conducted using the methodology of the Joanna Briggs Institute. Scientific and grey literature databases were searched for quantitative studies in English published between 1998 and 2020. The quality of the selected publications was evaluated, and a narrative summary prepared.

The population of interest comprised Aboriginals and Torres Strait Islanders subject to alcohol supply restrictions. Alcohol-related harms of interest were: 1) physical injuries, 2) alcohol-related illnesses, and 3) rates of alcohol consumption.

What was learned? 

Thirteen studies were included, with a total of more than 15,800 participants. The studies combined observational and analytical approaches. The effects of restrictive policies were presented by type, namely: 1) total prohibition (three studies) or 2) combined restriction strategies (ten studies), for example restrictions on quantities or business hours. These strategies were in addition to measures already in effect in the communities’ jurisdiction, including the legal age for purchasing alcohol.

From the outset, prohibition was associated with a reduction in alcohol use. However, other unexpected effects also arose: illicit substance use, shifting of use to another community or the illegal import of alcohol. Prohibition does not prevent people from finding and consuming alcohol.
Studies looking at combined measures demonstrate inconsistent results. The three studies reporting data on alcohol use and sales showed unequal reduction. Overall, hospital admissions, including for alcohol-related injuries, decreased in the six studies looking at that type of data. The decrease varied from small and short-lived to a more significant reduction. Seven of the studies presented data concerning assaults, including family and conjugal violence. However, both reductions and increases were observed, making it impossible to reach a conclusion about the effect of restriction policies on such behaviour.

The authors point out that the causes of problematic alcohol use among Australian Aboriginals and Torres Strait Islanders are complex and related to intergenerational trauma and historical disadvantages. Finally, they issued the following recommendations for developing future public policy:

  • Restrictions to a community’s supply of alcohol must be in response to needs identified by members of the community and take into account available resources.
  • Restriction strategies alone may be less effective than combined strategies.


The authors note that the level of evidence in the selected publications was low. Moreover, significant differences in methodology were observed among the studies. It should be emphasized that experimental evidence is difficult or even impossible to obtain in this type of population-based research. In addition, the results presented do not take into consideration the potential difference in needs between Aboriginals living in urban versus regional settings.

Parent wellbeing, family screen time and socioeconomic status during early childhood predict physical activity of Aboriginal and Torres Strait Islander children at ages 8–13

Macniven, R., Stanley, R. M., Biles, B., Dumuid, D., Olds, T., Okely, A. D., Chandler, P. & Evans, J. (2022). Parent wellbeing, family screen time and socioeconomic status during early childhood predict physical activity of Aboriginal and Torres Strait Islander children at ages 8–13. Journal of Science and Medicine in Sport. Not available through open access.


The data used in this article comes from the Longitudinal Study of Indigenous Children, the largest First Nations child cohort study in the world. The study explores compliance with the Australian 24-Hour Movement Guidelines for Children and Young People (5–17 years), which prescribe at least one hour of moderate to intense physical activity every day.


Examine the effect of determinants (sociodemographic, family, community, cultural, parents’ social and emotional wellbeing) during early childhood, specifically Wave 1 (aged 0–5 years) predictors of achieving the recommended levels of physical activity at Wave 9 (aged 8–13 years).


Self-reported data from a parent in 1,181 participant families was collected. Multiple logistic regression analyses examined variables that could influence reaching the goal of an hour or more of physical activity among children aged 8 to 13. A p value of < 0.05 was used to indicate statistical significance.

Variables (parent’s Indigenous status, age, employment situation, place of residence (urban, regional or remote), area-level socioeconomic variable, and main source of income) were chosen based on the social ecological model, its relevance to First Nations and its association with physical activity. The study respected ethical principles concerning communities’ participation and governance.

What was learned? 

  • Among the cohort of 1,181 children, 596 (50.5%) were physically active for at least one hour every day at Wave 9.
  • Achieving the physical activity recommendations at Wave 9 was associated with the following Wave 1 determinants: high parent social and emotional wellbeing, living in remote, regional or low socioeconomic areas, main source of family income not wages/salaries, and little family screen time.
  • Children going to a playground as a family activity and higher perceptions of good places to play in the community—following adjustment for the parents’ Indigenous status and income but not for the region’s socioeconomic level or remoteness—were negatively associated with achieving physical activity recommendations at Wave 9. In other words, the immediate family environment during early childhood may have greater influence on future physical activity than do community characteristics.
  • These results contradict what is usually observed among non-Indigenous families in Australia and other high-income countries. However, the results corroborate data that associates a high socioeconomic status with a low level of physical activity for children in low- and medium-income countries.
  • Family screen time during early childhood is associated with the child having a lower level of future physical activity, a predictable result but the first of its type concerning Australian Aboriginals and Torres Strait Islanders.
  • These results are also the first to quantify the relationship between cultural engagement and the level of physical activity in children, in keeping with qualitative data on the positive role of culture and its broader protective effects on physical activity and health.


The authors point out an inherent limitation of the question used in the study about achieving physical activity recommendations. Whereas the guidelines focus on moderate to intense physical activity, the study question does not define this intensity. As a result, the study data must be interpreted cautiously in terms of compliance with recommendations in the Australian 24-Hour Movement Guidelines for Children and Young People.

Inequalities and social determinants of health

Using concept mapping to define Indigenous Housing First in Hamilton, Ontario

Firestone, M., Zewge-Abubaker, N., Salmon, C., McKnight, C. & Hwang, S. W. (2022). Using Concept Mapping to Define Indigenous Housing First in Hamilton, Ontario. International Journal of Environmental Research and Public Health, 19(19), 12374.


In Ontario, nearly three quarters of the Indigenous population live in urban areas. One of every 15 Indigenous people in urban centres is homeless, compared with 1 in 128 for the general population.

For Indigenous people living in urban areas, barriers to housing access include poverty, discrimination, mental health problems and intergenerational trauma resulting, in particular, from experiences in residential schools and with the child welfare system.

The effectiveness of the Indigenous Housing First approach, which supports and prioritizes access to permanent housing, has been shown to reduce chronic homelessness among people with mental illness. Provincial and federal programs featuring this approach have been put in place.


Evaluate the Indigenous Housing First program managed by Indigenous people in Hamilton, Ontario, in order to fill a knowledge gap about best practices in addressing homelessness as experienced by Indigenous population.


This research is part of a broader study aimed at describing the Indigenous values and principles of the Indigenous Housing First model and at evaluating their influence on the experience of users. A collaboration agreement was reached between the research team and Indigenous partners, and an ethical assessment of the project was conducted.

A concept mapping approach was selected for its inclusive and participatory nature. This method uses participant statements to generate graphic representations and illustrate associations among the main ideas. Program employees were invited to three concept mapping activities. Thirteen of the fourteen employees participated in at least one of the activities.

At the outset, a brainstorming activity was organized to generate statements based on the following sentence: “Delivering Housing Services involves the following component or service….” The statements were then ranked by the participants according to importance and feasibility. Finally, the participants interpreted the conceptual maps and graphic representations generated from the data collected.

What was learned? 

Six clusters emerged from an analysis of the 65 statements arising out of the brainstorming activity. Within the clusters, each statement was ranked according to importance and feasibility. The clusters listed below are ranked by importance and feasibility from one (most) to six (least).

  • Fostering Change: The program supports users with basic needs such as housing and food. Rank: 6th in importance and 1st in feasibility.
  • Daily Practices: The staff organizes activities and provides services on a daily basis, including personal support, referrals and planning. Rank: 5th in importance and 4th in feasibility.
  • Program Uniqueness: The program provides services geared to the specific needs of the homeless Indigenous population while respecting their ways of knowing and doing. Rank: 4th in importance and 5th in feasibility.
  • Spiritual Practices: The program ensures access to culturally relevant services such as ceremonies, teaching and traditional practices. Rank: 2nd in importance and 2nd in feasibility.
  • Partnerships and Agency Support: The program develops relationships with partners and other stakeholders, such as property owners. Rank: 3rd in importance and 6th in feasibility.
  • Team’s Professional Skills: Employees support one another and see to the wellbeing of the entire team. Rank: 1st in importance and 3rd in feasibility.

In short, participants ranked the Spiritual Practices and Team’s Professional Skills clusters as being both the most important and most feasible for improving practices aimed at addressing homelessness as experienced by Indigenous population.


The small sample size limits the possibility of generalizing the results and any data analysis of subgroups. A larger number of participants would have contributed to achieving data saturation.

Promotion of wellbeing and mental health

Culturally grounded strategies for suicide and alcohol risk prevention delivered by rural Alaska Native communities: A dynamic wait-listed design evaluation of the Qungasvik intervention

Allen, J., Charles, B., Fok, C. C. T., Lee, K., Grogan‐Kaylor, A., Qungasvik Team & Rasmus, S. (2022). Culturally grounded strategies for suicide and alcohol risk prevention delivered by rural Alaska Native communities: A dynamic wait‐listed design evaluation of the Qungasvik intervention.  American Journal of Community Psychology. 1-14.


The suicide mortality rate among Alaska Natives aged 15 to 24 is 7.4 times that of the general population of the same age in the United States. The suicide rate in the remote southwest region of Alaska has been increasing for several years. Actual suicide attempts among Alaska Natives often occur during alcohol use.

The Yup'iks are the largest group of Alaska Natives. Qungasvik (Tools for Life) is an intervention based on strengths and resilience intended for young Yup'iks living in a rural area. Qungasvik addresses colonial disruptions to the ancestral Yup'ik way of life through four strategies: 1) local Indigenous control, 2) an Alaska Natives cultural model of change, 3) Indigenous theory‑driven implementation and 4) an Indigenous approach to knowledge development.


Evaluate the effectiveness of Qungasvik as a suicide and alcohol prevention strategy for young Yup'iks aged 12 to 18 by:

  • Examining the effect of the intervention on three intermediate outcomes on the individual, family and community levels;
  • Measuring, two years after the intervention, the growth of two ultimate (dependent) outcomes that act as a suicide and alcohol protective factor.


At the time of the intervention, importing and possessing alcohol were illegal in the four participating communities. The sample comprised 239 young people (49% girls and 51% boys with an average age of 14.9). The tribal council in each community approved the study.

The study used an experimental methodology, with the approach based on a dynamic wait-listed community-level trial. In this type of approach, all participants receive the intervention but at a precise randomly predetermined moment, imitating the delivery of interventions in an actual services context. At various measurement points, it is possible to compare participants who have received the intervention with those who have not yet.
Five multidimensional measurements coherent with Yup'ik culture were used. Three are intermediate outcomes:

  • Individual characteristics (gathering with family and friends, becoming a role model);
  • Family characteristics (cohesion, expressiveness, affection, parents as models);
  • Community characteristics (opportunities, connection with elders, community role models, support).

Two are ultimate outcomes:

  • Reflective processes about the consequences of alcohol;
  • Reasons for life.

Two other outcomes were used: pre-existing community support and dose, i.e. the level of participation in intervention activities. To evaluate the effects of the intervention, the authors created Bayesian linear mixed models and reported their results within a 95% credibility interval. The models also included the effects of time, gender and age.

What was learned? 

Compared with the baseline situation, the level of participation in the intervention activities was associated with improvement in ultimate outcomes but not in intermediate outcomes. Unlike a low-dose intervention, a high-dose intervention led to increased reasons for life and reflective processes about the consequences of alcohol. As for the intermediate outcomes, only family characteristics were strengthened: young people who received less community support and boys in general showed greater improvement in those characteristics.

The results provided an evidentiary database for developing suicide and alcohol prevention strategies among young Alaska Natives living in rural areas.


The authors note that interpretation of the data is limited by the experiment conditions. The start date was not randomized in the fourth community, which was added to the study after it was underway. Likewise, a selection bias may have influenced the results. Psychometric limitations are present due to the interrelationship between individual and family characteristics. Furthermore, individual activities were more attended and more often conducted than were family activities. Finally, the binary conception of gender is an additional limitation.

If you are experiencing distress, you can call the Hope for Wellness Help Line (1-855-242-3310) or chat online. This service is available 24/7 for Indigenous people in Canada.

Other resources are available, consult a list of helplines by region.

The inclusion of articles presented in this monitoring newsletter does not represent their endorsement by the Institut. Professional judgment remains essential in assessing the value of these articles for your work. You can also consult the Methodology for Indigenous Health Research Monitoring.