Introduction
Australia was colonized by the British in 1788 and since then, a difficult relationship has existed between the peoples of Australia and alcohol, currently the most abused substance nationwide.1 Alcohol has been used as currency, a method of social control and a way to define the use of public space; it has also been restricted from purchase by different segments of the population.2 In particular, Australia's Aboriginal and Torres Strait Islander peoples' alcohol use has been the target of social and governmental control since colonization.3
While there is historical and cultural evidence of Aboriginal and Torres Strait Islander people consuming alcohol prior to colonization, consumption increased greatly after the arrival of the British.4 Alcohol was often traded to Aboriginal people by colonists in exchange for labor and sex, which over time led to considerable alcohol-related harm in the context of continued economic and social exclusion, dispossession of lands and disruption of families and culture.5-7
It is important to note that not all Aboriginal and Torres Strait Islander people drink alcohol; in fact, they are approximately 1.3 times more likely to abstain from alcohol entirely than the rest of the Australian population.7 Those who do consume alcohol, however, are more likely than non-Indigenous Australians to consume levels that put them at greater risk of physical, social and economic harms.8 Alcohol-related harms include: deaths due to liver disease, violence and suicide; illnesses such as pancreatitis and some cancers; social harms such as family breakdown, child neglect and crime; and economic harms such as unemployment, debt and loss of social security benefits.5,9 The harms caused by high-risk alcohol consumption also result in a cost to society in terms of health care, lost human capital and the legal system, among others.10
A number of different strategies have been attempted to reduce the harms and costs associated with excessive alcohol consumption in Aboriginal and Torres Strait Islander communities.11,12 These strategies, implemented at federal and state government levels, as well as by individual communities, have been aimed at promoting reduced alcohol consumption or prohibiting consumption entirely.4,13 Strategies to address the problems associated with alcohol misuse can be categorized into three types: harm reduction, demand reduction and supply reduction.14 Harm reduction strategies are those aimed at preventing harm to substance users, rather than the prevention of substance use.15 The primary goal of demand reduction is the prevention of substance use.16 The strategies of interest for this review are categorized as supply reduction strategies; that is, those strategies that aim to reduce the physical availability of alcohol, also known as alcohol restriction policies.
Alcohol restriction policies exist Australia-wide. For example, the legal age to consume alcohol in Australia is 18 years old, and there are various state liquor licensing laws controlling when and where alcohol may be purchased and consumed.17 However, for Aboriginal and Torres Strait Islander Australians, there may be further restrictions on their consumption depending on where they live.18 A large number of communities across Australia are subject to a complex web of alcohol management and/or prohibition regulations.12,19,20 Communities may be designated (or designate themselves) as a "dry area", meaning they are prohibited from possessing or consuming alcohol within that area. There also may be limits on how much alcohol can be purchased, what type and/or when.21,22 Additionally, alcohol may be banned from private premises at the request of the owner or tenant, or from entire communities.22,23
In many places these policies have resulted in a range of unintended consequences.24 In communities where alcohol is entirely prohibited, "drinking camps" sometimes evolve as places outside the community boundaries where alcohol can be consumed freely.25 The distance between these camps and the main community often results in highly intoxicated people traveling various distances back to the community either in cars or on foot, putting themselves and other road users at risk of accidents and death.26 Illegal smuggling and sale of alcohol in dry communities (i.e. "sly-grogging"), and the consequentially inflated prices, increase the percentage of income spent on alcohol and can lead to other financial responsibilities going unattended.27 There is also evidence that illicit alcohol is consumed in greater quantities and with more urgency.20,24,27
Breaches of alcohol restriction laws result in criminal charges/fines or incarceration, leading to further economic and family difficulties.27 Of further concern to law enforcement is the trend in areas of low alcohol availability to substitute other substances, particularly marijuana and methamphetamines, which can also lead to fines and imprisonment in a population that is highly over-represented in prison statistics.20,28 It is estimated that Aboriginal and Torres Strait Islanders are up to 21 times more likely to be imprisoned than non-indigenous Australians. Moreover, they comprise about 30% of female and 20% of male prisoners, despite Aboriginal and Torres Strait Islanders comprising approximately 2% of the Australian population.28 Many incarcerated Aboriginal and Torres Strait Islanders report alcohol and/or illicit drug use as a factor in the offenses for which they were imprisoned.29
The consequences of the restrictions have not been entirely negative. In some communities, there have been significant decreases in hospital transfers for alcohol-related violence and injury, lower rates of child neglect and abuse, and residents report their communities are more peaceful and safe.5,30 School attendance has improved in some communities, and begging has declined.20 It has also been suggested that the locus of control may be an important variable in the success of alcohol prohibitions; if the community itself decided to be alcohol-free, the effects have been positive, at least in the short term. If, however, the prohibition was imposed on the community by a local council, state government or, in the case of the Northern Territory Emergency Response (NTER), the federal government, the effects have been less substantial.31 The NTER imposed a package of interventions on Northern Territory Aboriginal communities, adding income quarantining and bans on pornography to alcohol restrictions, as well as several other measures.32 The range of measures associated with the NTER make it problematic to assign effects to any one of the interventions.
A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and JBI Database of Systematic Reviews and Implementation Reports was conducted and no current or underway systematic reviews on this specific topic were identified. A review published in 2016 examined the impacts of changes to liquor store trading hours, covering all geographic and social groups, thus issues particular to Aboriginal and Torres Strait Islander Australians were not investigated in detail.33 Gray et al. evaluated supply reduction strategies as part of their review on alcohol misuse interventions; however, this work was published in 2000 and so cannot be regarded as current evidence.34 More recently, a systematic review of Indigenous community-led alcohol control interventions was published in 2017 that examined communities from a range of nations, but this review did not examine government-imposed interventions and did not include unpublished studies.35
Therefore, the objective of this review is to examine the association between alcohol restriction policies and rates of alcohol-related harms in Australian Aboriginal and Torres Strait Islander communities.
Review question
What is the association between alcohol restriction policies, such as alcohol management plans, and the rate of alcohol-related harm in Aboriginal and Torres Strait Islander communities in Australia?
Inclusion criteria
Participants
This review will consider studies that include Australian Aboriginal and Torres Strait Islander peoples living in communities subject to alcohol control policies.
Intervention
This review will consider studies in which participants are living in communities subject to alcohol restriction or prohibition, due to the imposition of alcohol management plans or other alcohol restriction policies.
Outcomes
The primary outcome of interest to this review is physical alcohol-related harm. Harm may be physical injuries (whether due to assaults or accidents), which are measured as hospital admissions, Royal Flying Doctor Service (RFDS) attendance and transfers, or reported assaults, including intimate partner or family violence. Harm may also be reported in rates of alcohol-related illnesses, measured as hospital admissions for conditions primarily attributed to alcohol consumption. The secondary outcome of interest will be rates of alcohol consumption, measured as alcohol sales per person or as self-reported consumption.
Types of studies
This review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports, and descriptive cross-sectional studies for inclusion. Only studies published in English will be included, as it is the primary language of publication for Australian studies. Studies published from 1998 to the present will be included, as current rather than historic alcohol management practices are of core concern to this review.
Methods
The proposed systematic review will be conducted in accordance with JBI methodology for systematic reviews of etiology and risk.36
Search strategy
The search strategy will aim to locate both published and unpublished studies. An initial limited search of CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and index terms used to describe the articles were used to develop a full search strategy for MEDLINE (see Appendix I). The search strategy, including all identified keywords and index terms will be adapted for each included information source with the assistance of a research librarian. The reference lists of all studies selected for critical appraisal will be screened for additional studies.
Information sources
The databases to be searched include: APAIS-ATSIS: Australian Public Affairs Information Service - Aboriginal and Torres Strait Islander (Informit), ATSIHealth: Aboriginal and Torres Strait Islander Health, Australian Indigenous HealthInfoNet, Australian Institute Health and Welfare (AIHW), CINAHL (EBSCOhost), CINCH-ATSIS, Embase, Global Health, Health & Society (Informit), Indigenous Australia (Informit), Lowitja Institute Literature Search, MEDLINE (Ovid), PsycINFO, and PsycEXTRA.
Sources of unpublished studies and gray literature to be searched include: ProQuest Dissertations and Theses, MedNar, EBSCO Open Dissertations, Open Access Theses and Dissertations, and Trove.
Study selection
Following the search, all identified citations will be collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA), and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for this review. Potentially relevant studies will be retrieved in full and their citation details imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the final systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.37
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers at the study level. Methodological quality appraisal will occur at the outcome level in the review using standardized critical appraisal instruments from JBI for experimental and quasi-experimental, descriptive and observational studies.36,38 Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in narrative form and in a table. All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible). Included studies of lower quality will be identified in the analysis and subgroup analysis conducted, where possible.
Data extraction
Data will be extracted from papers included in the review using the standardized data extraction tools in JBI SUMARI by two independent reviewers.36 The data extracted will include specific details about the exposure of interest including different exposure categories if applicable, populations, study methods and outcomes or dependent variables of significance to the review question and specific objectives. Confounding factors documented by the included studies will also be extracted to provide context to the findings. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Data synthesis
Studies will, where possible, be pooled in statistical meta-analysis using RevMan 5.3.5 (Copenhagen: The Nordic Cochrane Centre, Cochrane). Effect sizes will be expressed as either odds ratios for dichotomous data or weighted (standardized) mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Risk ratios, odds ratios, and/or hazard ratios will be pooled where appropriate. A random effects model will be used to conduct meta-analyses as the direction of effects in observational studies is difficult to assess with certainty.39 Heterogeneity will be assessed initially by visual inspection of the forest plot, then statistically using the standard Chi-squared and I2 tests. If there is statistically significant heterogeneity, a narrative synthesis or graphical representation will be undertaken.
Subgroup analyses will be conducted where there are sufficient data to investigate differences in effects for communities where alcohol control was chosen by the community and for those where it was imposed upon them by governments. Sensitivity analyses will be conducted to test the effects on the analysis of studies of poorer methodological quality. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation, where appropriate. A funnel plot will be generated using RevMan 5.3.5 to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed, where appropriate.
Assessing certainty in the findings
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence will be followed and a Summary of Findings (SoF) will be created using GRADEpro (McMaster University, ON, Canada). The SoF will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision, and risk of publication bias of the review results. The outcomes reported in the SoF will be: physical injuries, alcohol-related illnesses and rates of alcohol consumption.
Funding
The Centre for Remote Health, Alice Springs is funded by the Commonwealth Department of Health under the Rural Health Multidisciplinary Training Program to improve the health status of populations in rural and remote areas. The funding body has had no involvement in the conduct of this review.
Acknowledgments
The Centre for Remote Health wishes to respectfully acknowledge the past and present traditional custodians of the land on which we work, the Arrernte people. It is a privilege to be standing on Arrernte country.
Appendix I: Search strategy
MEDLINE Ovid
1. SOUTH AUSTRALIA/ or Australia.mp. or AUSTRALIA/ or WESTERN AUSTRALIA/
2. northern territory.mp. or Northern Territory/
3. new south wales.mp. or New South Wales/
4. queensland.mp. or QUEENSLAND/
5. victoria.mp. or VICTORIA/
6. tasmania.mp. or TASMANIA/
7. 1 or 2 or 3 or 4 or 5 or 6
8. Alcohol Drinking/ or Alcoholic Intoxication/ or Alcoholism/ or Alcohol-Related Disorders/ or alcohol misuse.mp.
9. alcohol prohibition.mp. or Temperance/
10. alcohol control.mp. or Public Policy/ or Health Policy/
11. Harm Reduction/ or "Drug and Narcotic Control"/ or supply reduction.mp.
12. 9 or 10 or 11
13. 8 and 12
14. "aboriginal and torres strait islander".mp.
15. Oceanic Ancestry Group/ or aboriginal.mp.
16. indigenous.mp.
17. 14 or 15 or 16
18. 7 and 13 and 17
References