Barriers and enablers to the provision of alcohol treatment amongAboriginal Australians: A thematic review of five research projects

DENNIS GRAY1, MANDY WILSON1, STEVE ALLSOP1, SHERRY SAGGERS1,EDWARD WILKES1 & CORALIE OBER2

1National Drug Research Institute, Curtin University of Technology, Perth, Australia, and 2Queensland Alcohol and DrugResearch and Education Centre, University of Queensland, Brisbane, Australia

AbstractIntroduction and Aims. To review the results of five research projects commissioned to enhance alcohol treatment amongAboriginal Australians, and to highlight arising from them. Design and Methods. Drafts of the papers were workshoppedby project representatives, final papers reviewed and results summarised. Lessons arising were identified and described.Results. While the impact of the projects varied, they highlight the feasibility of adapting mainstream interventions inAboriginal Australian contexts. Outcomes include greater potential to: screen for those at risk; increase community awareness;build capacity and partnerships between organisations; and co-ordinate comprehensive referral networks and service provision.Discussion. Results show a small investment can produce sustainable change and positive outcomes. However, to optimise andmaintain investment, cultural difference needs to be recognised in both planning and delivery of alcohol interventions; resourcesand funding must be responsive to and realistic about the capacities of organisations; partnerships need to be formed voluntarilybased on respect, equality and trust; and practices and procedures within organisations need to be formalised. Conclusions.There is no simple way to reduce alcohol-related harm in Aboriginal communities. However, the papers reviewed show that withAboriginal control, modest investment and respectful collaboration, service enhancements and improved outcomes can beachieved. Mainstream interventions need to be adapted to Aboriginal settings, not simply transferred. The lessons outlinedprovide important reflections for future research. [Gray D,Wilson M, Allsop S, Saggers S,Wilkes E, Ober C. Barriers andenablers to the provision of alcohol treatment among Aboriginal Australians: A thematic review of five researchprojects. Drug Alcohol Rev 2014;33:482–90]

Key words: alcohol, Aboriginal, screening, brief intervention, treatment.

Introduction

For the past two decades, harmful levels of alcohol andother drug (AOD) use among Aboriginal and TorresStrait Islander peoples have been at least twice those inthe non-Aboriginal population [1,2]. Although consti-tuting about 2.5% of the population [3], in 2011–2012Aboriginal Australians constituted at least 13% of thosereceiving mainstream publicly funded AOD treatment[4]. In response to this long-standing inequity, impor-tant policy initiatives have been developed and a broadrange of treatment and other interventions has beenundertaken by Aboriginal community-controlledorganisations (ACCO) and other groups [5,6].

Several reviews summarise the evidence for effective-ness of alcohol treatment in non-Aboriginal popula-tions [7–9] and treatment guidelines based on themhave been developed [10]. However, these reviews andthose focused specifically on Aboriginal people all con-clude that the evidence base for the effectiveness oftreatment in this population is limited [11–14]. Theirconclusions are reflected by Hunter et al.:

At best there is evidence from controlled trials forsome of the recommended interventions (for Indig-enous people) in non-Indigenous primary care orhospital populations. Such evidence will be cited,with explicit acknowledgement of the uncertainty

Dennis Gray MPH, PhD, Professor and Deputy Director, MandyWilson PhD, Research Fellow, Steve Allsop PhD, Professor and Director, SherrySaggers PhD, Adjunct Professor, Edward Wilkes AOBA, Associate Professor, Coralie Ober RN, DipTchg, GradDip SocSci, AsscDipComWelf,Research Fellow. Correspondence to Professor Dennis Gray, National Drug Research Institute, Curtin University, GPO Box U1987, Perth, WA6845, Australia. Tel: +61 8 9266 1600; Fax: +61 8 9266 1611; E-mail: d.gray@curtin.edu.au

Received 3 October 2013; accepted for publication 20 February 2014.

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Drug and Alcohol Review (September 2014), 33, 482–490DOI: 10.1111/dar.12137

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that remains about their applicability in Indigenouspopulations [11].

Gaps in the evidence base include those related toscreening and assessment, brief interventions (BIs),withdrawal management, pharmacotherapies, psycho-social interventions, relapse prevention and manage-ment, co-existing mental and physical health problems,and integrated case management.

To address some of these gaps, the (then) AustralianGovernment Department of Health and Ageing fundedthe National Drug Research Institute (NDRI) toconduct a research program aimed at enhancing man-agement of alcohol-related problems among Indig-enous Australians. As part of the program, the NDRIfunded five projects aimed at trialling and/or evaluatingparticular interventions. Literature reviews [15–20] andthe results of these projects [21–27] have been pub-lished separately.The objective of this paper is to reviewthe collective results of the projects, and to highlightlessons arising from them and their implications forimproving treatment services.

Method

This review was conducted in a two-stage iterativeprocess. First, in preparation of the final project reports,two workshops were held and attended by representa-tives of each research team and the NDRI programteam, who reviewed the results and discussed the impli-cations. Comprehensive notes of these discussions pro-vided the basis for recommendations for improvingtreatment services [28] and for the review of the finalpapers.

In the second stage—guided by the notes fromworkshops—the final papers were reviewed and the-matic analyses conducted independently by two of theauthors (D. G. and M. W.). These analyses were com-bined, reviewed and, where appropriate, modified bythe other authors. The following sections include sum-maries of the key publications from each project (seeTable 1) and a discussion of emergent themes.

Results

Training and tailored outreach support for alcoholscreening and BI

The National Drug and Alcohol Research Centre(NDARC) project sought to embed screening and BIsin the practice of four collaborating Aboriginalcommunity-controlled health services (ACCHS) [22].This involved: staff training in use of the screening

questions in patient information and records systems(PIRS) and BIs; providing tailored follow-up support toparticular ACCHSs; and assessing changes in the fre-quency of screening and BIs in the six months pre- andpost-intervention. Screening questions in the PIRS aresimilar to those in Alcohol Use Disorders IdentificationTest (AUDIT)-C [29,30], and training was based onmaterials including those from the ‘Drinkless Program’(a package for use by health practitioners in detectionand treatment of risky drinking) [31].

Despite inter-site variation, overall the percentage ofclients screened increased significantly in the sixmonths post-intervention (9.5% to 19.2%)—a criticalimprovement, as increasing case identification is thefirst step in improving care. Of clients with a validscreen, almost 40% were considered at risk of harm.Impact of the intervention on the provision of BIs wasmore modest. Of clients ‘at risk’ (39 pre, 77 post), thepercentage receiving a BI increased from 28.2% to36.4%. While not statistically significant, in clinicalterms the increase represents some success. Theauthors note other evidence shows that transfer anduptake of interventions is a long-term process, andgiven more time they believe that the number of BIswould further increase. The study demonstrates thepotential of screening in primary health care settingsfor identifying those at risk and providing appropriateservices.

Community intervention in an Aboriginal urban setting

Based on an audit showing few Aboriginal people wereaccessing AOD services, the Sydney South West AreaHealth Service (SSWAHS) project sought to assess thepotential role of ‘community-based education and briefintervention’ in reducing harm [23]. It aimed to do soby screening members of community groups (usingAUDIT); by conducting interactive education sessions(based on ‘Drinkless Program’ materials [31]) toincrease awareness of alcohol-related harms, alcoholguidelines and availability of services; and by feedingback AUDIT scores and providing one-to-one BIs forthose at risk.The number of groups (8) and individuals(58) for whom education sessions were conducted wasmodest and, although 21 (44.7%) had AUDIT scoresindicating potentially problematic drinking, nonesought the option of a BI. The paper identifies processissues (including those relating to production ofresources and recruitment) important in conductingsuch an intervention and provides some qualitativesupport for the approach taken and its potential toincrease awareness (an important end in itself). Theapproach is labour intensive, but the authors suggestpotential economies of funding, staffing and training if

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Table 1. NDRI Enhancement of Treatment Program research paper summaries

Paper and lead agency Aims Methods Key findings

Training and tailored outreachsupport to improve alcoholscreening and BIs in ACCHSs[13]

National Drug and AlcoholResearch Centre (NDARC)

Measure effect of training andoutreach support on deliveryof alcohol screening and BIsin four ACCHSs.

Pre- and post-assessment ofalcohol information recordedin the electronic patientinformation systems of fourACCHSs, 12 months beforeand 6 months after,implementation of anintervention.

Implementing evidence-basedalcohol screening and BI inACCHSs may take time andrequire multiple strategiesspecific to individual services,but has potential forimproving detection of clientswith alcohol problems. Studyprovided modest evidencethat training and outreachsupport can result inimprovements in alcoholscreening in ACCHSs.

The Alcohol Awareness project:community education and BIs inan urban Aboriginal setting [14]

Sydney South West Area HealthService

Conduct pilot study ofcommunity-based educationand BIs in an urbanAboriginal setting.

Community-based groupsoffered interactive alcoholeducation session (n = 9) andscreened 47 (81%)participants. Screening foralcohol use conducted priorto education. Scoresquantified and resultreturned to participant postsession. Confidentialfeedback and one-on-one BIsoffered.

While labour intensive, theprocess reached a number ofindividuals in need ofassistance with alcohol. Studyhighlighted low awareness ofdrinking guidelines andtreatment options amongparticipants, however,illustrated thatcommunity-based approacheshave potential to raiseawareness and promotediscussion around drinkingwith community members.

‘Can I have a Walan Girri?’ Thedevelopment of anIndigenous-led model of servicedevelopment and delivery forproblematic alcohol use amongstIndigenous people in theAustralian Capital Territory [15]

Winnunga Nimmityjah AboriginalHealth Service (Winnunga)

Design, implement andevaluate a culturallymediated case managementmodel including SBI andreference to country forACCHS clients experiencingproblematic alcohol use.

Review of existing models forintegrated assessment, careplanning, care delivery andcare review. Pre-testquantitative staff survey oftraining needs (n = 34).Development of casemanagement instrumentincluding complementarypolicy and proceduraldocuments and staff trainingpackage.

High staff turnover delayeddevelopment and inhibitedimplementation ofinstrument and evaluation ofeffectiveness during studyperiod. Despite this, findingsillustrated that, with goodpartnerships, capacitybuilding and clearprocedures, comprehensivecase management can bedeveloped and adapted forlocal contexts.

The Grog Mob: lessons from theevaluation of a multi-disciplinaryalcohol intervention forAboriginal clients [16]

Central Australian AboriginalCongress (Congress)

Trial and evaluate anon-residential treatmentprogram offeringpharmacotherapy,psychological and socialsupport for Aboriginal clientswith alcohol problems.

Process and outcomeevaluation involvingqualitative interviews withprogram staff and keystakeholders (n = 32), andquantitative review of clientcontact and outcome data(n = 49).

Identified process-related issuesincluding staff recruitmentand retainment, and need forflexibility in programapplication. Limitedconclusions could be drawnon client outcomes due tosmall numbers. Nonetheless,evaluation demonstratedfeasibility of project andevidence of high demand forit.

Aboriginal-mainstreampartnerships: exploring thechallenges and enhancers of acollaborative servicearrangement for Aboriginalclients with substance relatedissues [17]

Aboriginal Drug and AlcoholService

Explore factors that challengedand/or enhanced agovernment-initiatedpartnership between oneAboriginal and fourmainstream servicesproviding alcoholrehabilitation and supportservices to Aboriginal clients.

Semi-structured qualitativeinterviews with staff (n = 16).Collection of observationaldata. Partnership forum todiscuss findings and resolveidentified issues.

Identification of several keyissues impacting on thepartnership includingcultural, historical, structuraland personal considerations.Enhancers included thepotential for maximisingtreatment options forAboriginal clients.

ACCHS, Aboriginal Community-Controlled Health Services; BI, brief intervention; NDRI, National Drug Research Institute.

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it became a routine element of service provision. Never-theless, the issue of cost-effectiveness requires furtherinvestigation.

An Indigenous-led model of service developmentand delivery

The objective of the project conducted jointly byWinnunga Nimmityjah Aboriginal Health Service andthe National Centre for Epidemiology and PopulationHealth was to develop a comprehensive, culturallymediated, case-management and care-planning tool—incorporating alcohol screening and BI—including spe-cific questions about ‘belonging’ and ‘country’ designedto facilitate client engagement with the health service.This tool became known as Walan Girri (Wiradjuri for‘strong future’) [24].

Prior to implementation, a survey was undertaken toassess staff training needs, and a training programdeveloped. However, post-test evaluation of the trainingprogram was precluded by high staff turnover. Staff andmanagement turnover, changes in membership of theresearch team, and the way Walan Girri evolved led toprolonged development and implementation. This andlow numbers meant outcome evaluation could not becompleted within the project time frame. Nevertheless,on the basis of the trial, Walan Girri is now being usedwithin Winnunga and the descriptive case study of theproject provides several broadly applicable lessons,including the importance of partnerships, capacitybuilding and the formalisation of procedures; issuesraised by staff turnover; and small numbers of researchparticipants. Importantly, it also led to an Aboriginalteam member completing a PhD project to validatescreening measures incorporated into Walan Girri [32].

A multidisciplinary alcohol intervention forIndigenous clients

The ‘Grog Mob’ project—conducted by CentralAustralian Aboriginal Congress (Congress), a largeACCHS—aimed to trial and evaluate a referral systemand provision of three streams of care (medical, psycho-logical and social) for clients with alcohol-related prob-lems [25]. Evaluation was based on documentary data,key stakeholder interviews and review of client healthrecords. Limited data precluded strong conclusionsabout client outcomes, but process evaluation identifiedissues arising out of implementation, including prob-lems of staff recruitment and training and the need forflexibility in implementation. Nevertheless, the evalu-ation demonstrated that the project was feasible andthat strong demand for it existed. On this basis, theproject has received ongoing funding from both theNorthern Territory and Australian Governments.

An Aboriginal–mainstream partnership

The project conducted in Perth by Aboriginal Alcoholand Drug Service (AADS) is a case study exploringfactors challenging or enhancing an Aboriginal–mainstream partnership for the provision of counselling,withdrawal management and residential rehabilitationfor Aboriginal clients [26]. The partnership—enteredinto at the behest of a government funding agency—wasbetween AADS, a non-Aboriginal withdrawal centre,and two mainstream residential treatment facilities (atwhich 12 dedicated Aboriginal beds were purchased).The case study was based on semi-structured interviewswith 16 staff members from the partner organisations.

The partnership was fraught with tension and theauthors describe a range of structural, historical, cul-tural and personal factors—compounded by clientcomplexity and the ‘paternalism of the fundingagency’—which challenged the partnership and theintervention. Nevertheless, both Aboriginal and non-Aboriginal informants saw the potential of such part-nerships. A key lesson arising from the project is that tobe successful such partnerships must be voluntary,equitable, accountable and based on trust.

Discussion

The projects raise a range of issues and here we con-sider the most salient and the lessons arising fromthem.

Additional resources have impact

The projects demonstrate that modest additionalresources can produce change and enhance outcomes.A small amount of additional resources led to increasedcapacity to deliver services; improved case identifica-tion; increased client engagement; improved intera-gency and community collaboration; and developmentof more appropriate assessment tools and resources. Asthese became embedded in service provision, the initialinvestment has continued to have a positive effect andthe success of the NDARC and Congress projects ledto the allocation by government agencies of additionalfunds, two and 36 times greater, respectively, than theoriginal investment of about $250 000 in each project.

The importance of culture

The papers demonstrate that interventions effective innon-Aboriginal communities cannot simply be imple-mented in Aboriginal settings without consideration ofcultural differences. The AADS paper shows thatACCOs are not simply the equivalent of mainstreamhealth services managed by Aboriginal communities.

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ACCOs, their practices and values reflect the groupsthat established them and which they serve. These cul-tural elements affect the relationships between Aborigi-nal and mainstream organisations, implementation ofspecific interventions within ACCOs, and patient–practitioner relationships. Concern with the initialengagement of patients with a service, which conditionsfuture interactions, is a key element in the developmentof Walan Girri; recognition of cultural differences iscentral to modifications to the AUDIT and ‘Drinkless’materials by the SSWAHS team; and the clash of cul-tural values and failure to recognise differences, high-lighted in the AADS study, demonstrates how provisionof quality care can be undermined. Strategies for goingbeyond rhetoric and ensuring the operationalisation ofculture in psychotherapeutic practice are outlined in areview by Smith and others and these have broad appli-cability in the Aboriginal AOD field [33].

The potential of screening and BI

The potential for screening and BIs among AboriginalAustralians has long been recognised. They areincluded in the Medicare Benefits Schedule’s ‘HealthAssessment for an Aboriginal andTorres Strait IslanderAdult’ (Item 715) [34]. With qualifications, use ofAUDIT and BIs is recommended in Aboriginal-specificalcohol treatment guidelines and a guide to preventivehealth assessment of Aboriginal people [13,35]. Inaddition, either AUDIT or AUDIT-C is included intwo of the PIRS commonly used in ACCHSs. Never-theless, a number of issues relating to screeningand BIs in Aboriginal settings have been identified[13,36–41].

Questions have arisen about the length of theAUDIT and to address this, in non-Aboriginal popu-lations, abbreviated versions have been tested in bothclinical and community-survey settings [30,42]. Theresults show that AUDIT-C is effective in identifyingthose drinking at hazardous levels and that a singlequestion on consumption from the AUDIT (‘Howoften do you have six or more drinks on one occasion?’)is also useful in identifying those who drink at hazard-ous levels [30].

Results of the NDARC project suggest that use ofeither AUDIT-C or the single consumption question isalso effective in Aboriginal settings and is preferable touse of the full AUDIT as a screening tool.While seem-ingly at odds with SSWAHS’s report that they success-fully used the full AUDIT, SSWAHS was conductingscreening and alcohol awareness education in commu-nity groups especially convened for the purpose withoutthe distraction of pressing health problems and busyclinic schedules. In such situations, the full AUDIT can

provide a more nuanced assessment with the potentialfor more appropriate intervention.

ACCHS clients have reportedly had difficulty under-standing some of the AUDIT questions that have hadto be clarified and reworded [36,37]. Questions in thePIRS used by the ACCHSs in the NDARC study aresimilar to, but do not follow, the wording recommendedin the AUDIT manual. The SSWAHS team modifiedthe wording of the questions ‘to suit the client group’—and give some examples of this. This is consistent withthe AUDIT manual, which notes questions may needto be adapted to specific languages, cultures and stand-ards [29], and is appropriate given the documenteddifferences between Standard and Aboriginal varietiesof English [43].

Ascertainment of consumption levels is an issue, withfew people (Aboriginal or otherwise) having a clearunderstanding of the concept of a ‘standard drink’ andthe amounts poured or consumed as ‘a drink’ generally.The SSWAHS team simply recorded ‘the number ofdrinks reported by participants’, judging that potentialloss of specificity ‘. . . would be outweighed byincreased comfort for subjects in completing thesurvey’ [23]. While a practical solution in a clinical (asopposed to a research) setting, it would be useful toattempt to quantify what is lost.

The SSWAHS paper raises the broader issue of com-munity understanding of alcohol-related harm andoptions for addressing it. Although the total number ofpeople screened was small, they tended to consumealcohol episodically at high levels, had little knowledgeof current drinking guidelines and knew little aboutinterventions other than residential treatment. Thissuggested that mass media campaigns have had littleimpact, lack of knowledge of other interventions pre-cluded their uptake and screening itself has a poten-tially significant role in raising awareness.

Partnerships in research in research and practice

Partnerships are a key element in reducing alcohol-related harm among Aboriginal Australians [5], andeach of the papers addresses this issue. All involvedcollaboration between AOD service providers anduniversity-based research centres. In four instances,providers took the lead roles and, in the other, aresearch centre did so but based on previously estab-lished relationships with ACCHSs. As a consequence,the projects tackled issues of relevance to the serviceproviders themselves.

The AADS paper highlights structural, historical,cultural and personal impediments to effective partner-ships. The partnership itself was involuntary (at leastfrom the perspective of AADS) and emerged from afunding agency decision. It reflected unequal power

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relations between the funding agency and the non-Aboriginal partners on the one hand and AADS on theother, creating an atmosphere of distrust. This wascompounded by poor knowledge among partners ofeach other’s services; divergent views regarding staffskills and competencies, including the relative impor-tance of clinical and cultural competencies; communi-cation difficulties; staff turnover; and the paternalism ofthe funding agency. Despite these challenges, most staffsaw the value of partnerships, with the qualification thatthey be voluntary, equitable, accountable and based ontrust, and that they engender community control.

In contrast, the Winnunga paper describes collabora-tion between researchers and health service staff builtupon: existing relationships; strong community control,ownership and management of the project; and consul-tation with staff on implementation of the intervention.Similarly, the partnership between SSWAHS, the Uni-versity of Sydney and ACCHSs was successful becauserelationships between partners had developed over aconsiderable period prior to the current project. Suchresearch collaborations might be less fraught than thosebetween service providers, as the parties are not incompetition as providers often are.

A positive outcome of the program process was theclose network established between practitioners andresearchers. Staff from each of the projects met at work-shops in which they shared ideas in the development ofresearch proposals and reports. They also shared train-ing on screening and BIs and project materials. Thiscollegiate approach to project development and thefunding of projects was particularly suited to research inACCOs not established primarily to conduct researchand led to significant improvements in research design,process and outcomes. As such, the model provides anefficient complement to research funding throughbodies such as the NHMRC, the processes of which aretime-consuming, challenge resources and processeswithin small ACCOs, and require considerable workwith little likelihood of success.

Staffing

The difficulties of recruiting qualified staff, high staffturnover rates in the AOD field in general, and theAboriginal field in particular, have been highlighted[44,45] and four of the five papers discuss the negativeimpacts of these. In theWinnunga case, staff turnover ledto abandonment of a plan to conduct a post-interventionevaluation survey and the other four projects highlightintra- and inter-service difficulties as a consequence ofthese factors. In the Congress project, resignation of asenior therapist and difficulty in recruiting a replace-ment delayed implementation and constrained collabo-ration with other agencies. Similarly, the SSWAHS team

reported that staff turnover (among factors such asfunerals, illness and other external events) in their ownagency and their partner groups significantly delayedrecruitment of participants; and the AADS paper iden-tified staff turnover as a major challenge to the imple-mentation of partnership arrangements. While theseproblems are not easily resolved, they can be amelioratedby planning for such contingencies and, as both theWinnunga and AADS papers suggest, by developingformalised program procedures to minimise disruptionand loss of ‘corporate knowledge’ if staff move on.

All the projects emphasise the need for appropriatestaff development. As the NDARC andWinnunga proj-ects highlight, this should be provided to staff at allorganisational levels. Furthermore, as exemplified bythe SSWAHS, AADS and Winnunga projects, thisshould go beyond the simple provision of technicalskills to include awareness of the broader and culturalcontexts in which intervention takes place.

Short-term projects

The length of the overall program was constrained bythe funding period, and initially, it was planned toconduct the individual projects over a 12-monthperiod. However, all projects exceeded this. Thisproblem was acute when, as in the case of the Congressand SSWAHS projects, program structures and referralnetworks had to be established and new staff recruited.

The short-term nature of projects exacerbates otherproblems. The difficulty of recruiting qualified staff(particularly in rural and remote areas) is compoundedwhen agencies can offer only short-term employmentcontracts. Furthermore, over short terms, delays neces-sitated by recruitment, training, establishing collabora-tive relationships and gaining community acceptancehave proportionately greater impact. This problem isnot unique to research projects and the adverse effectsof short-term funding and reporting cycles hasbeen highlighted elsewhere [46] and, in the case ofAboriginal-specific AOD interventions, the number ofshort-term funded projects has increased [6].

Formalisation

Clearly defined management structures and procedureshave been identified as elements of best practice in theprovision of Aboriginal AOD services [44]. The papershighlight this and the need to formalise processeswithin organisations. In the AADS project, problemsarose because of the failure to embed working arrange-ments and commitments in policy and procedures. Inthe Winnunga case, development of a formal screeninginstrument, commitment by management and atten-tion to the concerns and training of staff led to

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improved client engagement with the service. Embed-ding screening questions and providing training led tosignificant increases in the number of patients screenedin the four ACCHSs in New South Wales. In addition,within Congress, the formalisation of a comprehensive,structured case management system apparently led toimproved access to care.

Ethical and rigorous Aboriginal health research

Each project illustrates the challenges and rewards ofconducting rigorous and ethical Aboriginal healthresearch. Jamieson et al. provide a useful review of theemerging literature in this area, and principles to guideresearch [47]. Issues discussed earlier, including smallsamples due to recruitment difficulties, modified studyprotocols and extended timelines, along with the some-times equivocal results consequent on these limitations,are characteristic of many similar studies in Australiaand overseas. Concerns about the impact of thesefactors on the scientific rigour of the research need tobe balanced by the overriding importance of Aboriginalcontrol of the research process—from the identificationof the research topic and building the capacity of Abo-riginal researchers to dissemination and implementa-tion of results [48]. Each of the projects described herehas attempted to address these issues.

Conclusion

There is no simple way of reducing alcohol-relatedharm in Aboriginal communities. It must be based onAboriginal control, addressed on a number of levels andincorporate tested approaches.The extensive evidence-based literature on interventions to reduce alcohol-related harm cannot simply be transferred fromnon-Aboriginal to Aboriginal settings. Interventionsneed to be adapted to those settings and the best pro-cesses for doing so need to be identified. The smallprojects reported upon in this review are a significantstep in this direction and show that important improve-ments can be made with modest investment and acollaborative approach, especially one that respect-fully and collegiately explores the relevance of evidenceand expertise for Aboriginal people, services andcommunities.

Acknowledgements

We wish to thank organisations and staff members whoparticipated in each of the projects conducted as part ofthe ‘Enhancing the management of alcohol-relatedproblems among Indigenous Australians’ program.The program and the individual research projects werefunded by a grant to the NDRI from the (then)

Australian Government Deparmtnet of Health andAgeing.The NDRI at Curtin University is supported byfunding from the Australian Government under theSubstance Misuse Prevention and Service Improve-ment Grants Fund.

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