Alcohol-Related Violence among the Australian Aboriginal and Torres Strait Islanders of the Northern Territory: Prioritizing an Agenda for Prevention-Narrative Review Article

Abstract

Alcohol - related violence among Australian Aboriginal and Torres Strait Islanders (also called as “Indigenous”) is a major public health concern in Northern Territory of Australia. There is dearth of epidemiological data that link three contributing epidemics: alcohol misuse, violence, and trauma in the Northern Territory. In this review, we aimed to concentrate on how these epidemics intersect among the Indigenous people in the Northern Territory. In our descriptive review, we have searched published papers, publicly available government and health department reports web sites reporting relevant data on these three risk factors in the Northern Territory. The high rate of family and domestic violence and assaults in the Australian Territory indicates an increased correlation with high risk alcohol use compared to unintentional injuries. Heavy drinking pattern and harmful use of alcohol among Indigenous people are more likely to be associated with the incidence of violent assaults and physical injuries in the Northern Territory. We are trying to emphasize our understanding of co-occurring risk factors on the alcohol - violence relationship and urging a need for interventional approaches to reduce the public health issues in the Northern Territory.

Introduction

High risk drinking is a global problem results 2.5 million deaths each year (1). The hazardous alcohol drinking often not only causes significant problems for those who drink, but also creates a huge health impact across society. In 2004, alcohol use disorders have been ranked by the WHO as the 17th leading risk factor for contributing 4 to 6% of the global burden of disease and injury for all ages (2, 3). A binge drinking person can put others at risk of traffic accidents or violent behavior, or harmfully affect co-workers, relatives, friends or strangers (1). Harmful use of alcohol is often associated with medical conditions, injuries, accidents, violence and crime (2, 4, 5) and results in high economic costs to the health care sector and to society (6). In Australia, alcohol is considered as a part of the social lives of young people and alcohol consumption on private premises has been informally regulated and influenced by social agreement however there is no legal minimum drinking age among Australians (7, 8). Australians have been severely affected in some way by a strangers drinking, the numbers estimated approximately 10 million (9). Harmful use of alcohol in the Australian society is contributing 62% of all police attendances, 73% of assaults, 77% of street offences, 40% of domestic violence incidents and 90% of late-night calls (10). Harmful consumption of alcohol is very high among the Australian Indigenous people in the remote communities. Alcohol - related conflicts among the remote Indigenous people are still continuing and contributing to physical abuse and violent assaults (11). Furthermore, alcohol-related domestic violence and homicides are consistently and substantially noticed to be higher in Indigenous people in rural and remote communities than urban areas (12).

Northern Territory is a federal Australian state and has higher proportion of Indigenous people than any other states and territories (32%) (13). The Indigenous people in the Northern Territory are frequently facing enormous negative impact of harmful alcohol use. Our recent review and research studies pointed out that a strong relationship existing among three co-occurring risk factors namely alcohol misuse, violence and trauma among the Indigenous people of the Northern Territory (14–16).

The purpose of this review is to summarize the most significant public health concern of the Australian Indigenous people residing in the Northern Territory. Although, there have been some advances in health services for Indigenous victims of alcohol issues, violence and trauma, there has been a lack of Northern Territory government responses. Swift attentions to prevent this alcohol-related violence against the Indigenous women and children is warranted now and an urgent remedial actions to designing and implementing multifaceted interventional approaches must be directed by Australian and Northern Territory political, social and economic forces.

Methods

Our research team has used published studies and reports (primarily past 10 years) as well as grey literature written in English for the preparation of this manuscript. Russel and his colleagues pioneered intersection of mutually occurring risk factors, alcohol misuse, interpersonal violence and HIV infection in South Africa. They have explored reinforcing epidemics such as substance abuse, violence and AIDS (SAVA) among pregnant women and highlighted dire need for multi-faceted interventional approaches (17). Similarly, our review paper examines relationship among three epidemics (risk factors): substance abuse misuse, violence, and trauma (SAVT) among the Indigenous people residing in the Northern Territory. Our understanding on casual and frequent interplay between co-occurring epidemics and their significant influence to each other has progressed over time among the remote Indigenous people of Northern Territory. The inclusion criteria kept in line with the narrative nature of the review. Exclusion criteria were applied, with the intention on removing articles that focused on the diagnosis, treatment, and screening of long-term medical effects of alcohol and case studies.

Results and Discussion

Crucial interplay of risk factors among Indigenous people

Prevention of violence and aggressive attitude is purely relying on the basic understanding of co-occurring risk factors and intersecting processes that would help to design the suitable evidence based interventional approaches to address these risk factors and tailoring these preventing approaches to cater the specific needs of local communities (18).

Impact of alcohol use

Per capita consumption of alcohol in the Northern Territory found to be higher than the Australia, estimating the consumption of person over the age of 14 was 15.1 liters of pure alcohol per year in the NT, which is one and a half times higher than the Australian average (19). The rate of episodic alcohol consumption among the Indigenous adults in the Northern Territory was 49.2%. The alcohol consumption rates were 63.5% of Indigenous men and 14.8% of Indigenous women in 2008. Indigenous men reportedly consumed harmful use of alcohol at hazardous level (14.8%) than non-remote areas (10.4%) (20). Darwin (capital city of the Northern Territory) is considered as “capital of alcoholism” because alcohol sales and consumption is always very high in this city and national and international tourists visit this place year around to explore tropical forests and enjoy unique weather pattern. The Indigenous people residing in the remote communities have to travel to Darwin health facilities to access basic services. Culturally fuelled sharing is very common attitude among the Australian Indigenous people. As a result, they may tend to stay with their families and relatives in an urban house (21). Under this circumstance, the overcrowded house continues to act as venues for alcohol abuse and domestic violence. Indigenous Australians suffer high rates of unemployment (22) and they were not actively engaged in the Australian labor market due to high alcohol abuse, illness, disability or lack of market opportunities. These mutually occurring risk factors often collectively or separately contribute to alcohol-related violence among the Indigenous people.

Impact of violence

Family and Domestic violence: The terms “family and domestic violence” are often used to illustrate the relationship between the victim and the perpetrator. Family and domestic violence can be narrowly defined (e.g. intimate partner violence) or broadly defined (e.g. people living in the same house) (23). High rates of family violence are more common in the remote Indigenous communities. Significant proportion of alcohol-related violence occur at private residential locations of the Indigenous people whereas the venue of alcohol-related violence for non-Indigenous people happens at licenced premises (hotels and night-clubs)(12, 24).

Violence against Indigenous women: The occurrence rate of violence is the highest in poor communities, particularly women with less education and poor economic facilities are at an increased risk for victimization (17). Australian Indigenous women to be hospitalised due to family violence are 35 times higher than non-Indigenous women (25). This national wide data indicated high violence rates against Indigenous women. In the Northern Territory, the rate hospital admission for Indigenous men due to violence was 1627 admissions per 100,000 populations and for Indigenous women due to violence was 1829 per 100,000. The rates were 13.5 times (Indigenous men) and 40 times (Indigenous women) higher than the rate for non-Indigenous populations(26). The data pointed out that violence against Indigenous women in the Northern Territory was higher than the Australian rates. Violence against Indigenous women is partly or completely fuelled by harmful use of alcohol. The rate alcohol-related violence or violent incidents occurred at 52% in the Northern Territory(26). The physical abuse, especially assaults against Indigenous women is often committed by heavy drunk husband in the remote Northern Territory communities (16). Even the Northern Territory government and Department of Children and Families (27, 28) have frequently promoted many initiatives and propaganda to control this particular problem, violence against Indigenous women in Australia has been poorly reported because the Indigenous women in the remote communities often refuse to report violent men for fear of family breakup, further retaliation and the belief that perpetrators may die in custody (27, 28).

Violence against Indigenous children: culturally fuelled sharing ethos attribute to overcro-wding in the Indigenous communities of the Northern Territory. When overcrowded house continues to act as venue for alcohol misuse, women and children in particular premise are severely impacted due to alcohol-related violence and family fights. Children in the remote communities often face at risk from visitors with alcohol misuse and overcrowded conditions that may disrupt their education and wellbeing. In response to these circumstances, Indigenous children may leave their home (29). Indigenous youth are often overrepresented in detention centre due to high levels of abuse and/or neglect (30).

Impact of assaults and trauma

Alcohol is considered as the highest contributors to the global burden of disease, particularly account for 3.8 % of all deaths and 4.6 % of all disability-adjusted life years being attributable to alcohol (2). Alcohol consumption is accounted for approximately 250 deaths and 11,000 hospitalizations among young people aged 15-24 years (31). While only 32% of the population is Indigenous, 60% of all facial fractures seen are in Indigenous patients in the Northern Territory and 89% of these are a result of interpersonal violence (32). The close family members and friends involved in the harmful use of alcohol may face great risk for alcohol-related assaults in the overcrowded houses. Apart from private residential locations, the bushes or private homes or parks or narrow pathways are the primary venues for the Indigenous assaults. Alcohol-fuelled violence leads to facial trauma among the Indigenous population (33). Furthermore, costs of alcohol purchase are often financed by the Australian government centrelink allowances (financial support paid by the Australian government to the unemployed). These “paydays” commonly every other Thursday and often considered as heavy drinking day for Indigenous people in the Northern Territory. They absolutely spent their allowances on that day itself and relied on other friends and relatives to supports for their necessary expenses leading to conflicts and assaults.

Recommendations for prevention

Heavy drinking is severely impacting the remote Indigenous communities of the Northern Territory causing more social, economic and physical damages. This public health and wellbeing issues could be prevented by changing the harmful drinking pattern of Indigenous people in the Northern Territory. There is no single interventional approach that could potentially be recommended due to complex nature of evidences. There are many approaches including face-to-face, one-session, motivational interviewing-style brief interventions, focusing on harm minimization and all with long-term follow-up (34). Hospital based intervention is another suggested approach (14) whereas health department policy makers and government must consider to introduce brief interventions in the hospital setting. Health professional in the hospital setting are trained to deliver these interventions (34). Some studies recommend that culturally appropriate interventions would prevent a wide range of social and economic issues that are urgently needed to alleviate Indigenous violence and assaults attributed harmful use of alcohol (14, 15, 16, 35).

Limitation and future directions

Our review did not follow any systematic review methodologies. Therefore, it has its own limitations. However, there is an increased media interest on high risk alcohol use among the Indigenous people and associated violence and trauma in the Northern Territory and consistent rising incidences in the Indigenous communities of the Northern Territory are solid and not a relic of data gathering practices. Further funded research will be needed to investigate the feasibility and suitability of these interventional approaches in the Northern Territory.

Conclusion

Indigenous communities of the Northern Territory are facing huge negative impacts of alcohol. It is really surprising to note the high rates of violence and assaults among the Indigenous people in one of the richest countries of the world. The Northern Territory government and the Department of Health need to take an urgent action to prevent this this major public health concern.

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.