Responding to racism: insights on how racism can damage health from an urban study of Australian Aboriginal people

This paper examines responses to racism and the pathways through which racism can affect health and wellbeing for Aboriginal people living in an urban environment. Face-to-face interviews were conducted in 2006/07 with 153 Aboriginal people living in Adelaide, Australia. Participants were asked about their experience of, and responses to, racism, and the impact of these experiences on their health. Racism was regularly experienced by 93% of participants. Almost two thirds of people felt that racism affected their health. Using a thematic analysis with a particular focus on how agency and structure interacted, a number of key reactions and responses to racism were identified. These included: emotional and physiological reactions; and responses such as gaining support from social networks; confronting the person/situation; ignoring it; avoiding situations where they might experience racism; 'minimising' the significance or severity of racism or questioning whether incidents were racist; and consuming alcohol, tobacco and other drugs. A further theme was a conscious decision to not 'allow' racism to affect health. Our study found that most people used more than one of these coping strategies, and that strategies were selected with an awareness of positive and negative health impacts. While individuals demonstrated substantial agency in their responses, there were clear structural constraints on how they reacted and responded. We found that not only was racism potentially detrimental to health, but so too were some responses. However, while some strategies appeared 'healthier' than others, most strategies entailed costs and benefits, and these depended on the meanings of responses for individuals. This paper concludes that initiatives to promote health-protective responses to racism need to consider structural constraints and the overarching goal of reducing systemic racism.     

Disadvantage and discontent: a review of issues relevant to the mental health of rural and remote Indigenous Australians

OBJECTIVE: To provide an overview of the mental health of Aboriginal and Torres Strait Islander residents of rural and remote Australia and to identify associated factors. FINDINGS: Indigenous Australians have higher rates of serious mental disorders and of mental health problems associated with social disadvantage. This disadvantage is greater for Indigenous Australians living outside metropolitan centres. Contrary to romanticised constructions of remote Aboriginal Australia, those living in such settings are not immune to such hardship - which is often unrelenting. The psychological and behavioural problems that emerge as a result are compounded by narrowly focused and inadequate mental health services, with children being particularly vulnerable. CONCLUSION: Indigenous residents of rural and remote Australia experience high levels of mental disorder. Although addressing the predisposing social disadvantage will demand significant whole-of-government investment, ensuring equitable access to effective mental health services is an immediate priority.     

The buffering effects of ethnic density on experienced racism and health

Studies in the United Kingdom (UK) show a consistent inequality between the health of ethnic minorities and that of white people. This is exacerbated by the over-representation of ethnic minorities in deprived areas, which have been associated with poorer infant and child health, chronic disease, and high mortality rates. Ethnic density, defined as the proportion of ethnic minority residents in an area, is generally thought of in relation to the negative impacts of area effects on health. However, it can be considered in terms of social networks and supportive communities, possibly mitigating the detrimental impact of racism on the health of ethnic minority people. This study investigated the ethnic density effect and hypothesised that ethnic minority people who live in areas of high ethnic density would report decreased experienced racism and better health outcomes compared to their counterparts living in areas of low ethnic density. Multiple logistic regressions were conducted using data from the Fourth National Survey of Ethnic Minorities and the 1991 UK Census. Results showed a negative association between ethnic density and psychotic symptomatology, but no evidence of an association between ethnic density and general self-rated health. Findings confirm that the experience of racism is lower in places of higher ethnic density and indicate a tendency for a weaker association between racism and health as ethnic density increases.     

Care for chronic conditions for indigenous Australians: Key informants’ perspectives on policy

BackgroundThe WHO's 2002 global report, Innovative Care for Chronic Conditions proposes a comprehensive framework for health systems to meet the challenges posed by chronic conditions. This paper uses the policy environment component of the WHO framework as a lens through which to examine key informants’ perspectives on the management and prevention of chronic conditions in rural and remote Aboriginal communities in Australia.MethodsTwenty one semi-structured telephone interviews were conducted with a purposive sample of stakeholders, including senior commonwealth, state/territory and regional public servants and health service staff. All of the interviews were audio recorded, from which written summaries were produced. These summaries were then content analysed to build a composite picture of this area.FindingsThe results indicate substantial success in developing national and sub-national strategies and refining funding and reporting arrangements. But much work remains to be done in strengthening partnerships, developing and retaining the workforce, and further shifting the focus from acute to chronic conditions.ConclusionsThis paper provides a snapshot of the main policy issues, as identified by key informants, facing chronic disease management in rural and remote Indigenous communities in Australia. It has the potential to contribute to new national policy directions in Indigenous health.     

If the land's sick, we're sick:* the impact of prolonged drought on the social and emotional well-being of Aboriginal communities in rural New South Wales

Objective: To report Aboriginal communities' views of how prolonged drought in rural NSW has affected their social and emotional well‐being, and of possible adaptive strategies. Design: Content analysis of issues, priorities and adaptive strategies raised in semistructured community forums. Setting: Rural centres across NSW. Participants: Aboriginal people, service providers and other stakeholders. Voluntary participation by invitation with consent to record discussions. Results: Three themes (containing six issues) emerged: (i) impacts on culture (harm to traditional family structure, culture and place; bringing shame to culture); (ii) sociodemographic and economic impacts (skewing of the population profile; loss of livelihood and participation; aggravation of existing socioeconomic disadvantage); and (iii) loss. In addition to continuing well‐being programs that were already successful, proposed adaptive strategies were: capturing the spirit of Aboriginal knowledge and traditions; knowing your land; and Aboriginal arts. Conclusion: Prolonged drought presented substantial and unique adversity for rural NSW Aboriginal communities, compounding existing, underlying disadvantage. Drought‐induced degradation of and, sometimes, the necessity to leave traditional land drove people apart and disrupted Caring for Country activities. Some people reported despair at not being able to discharge cultural obligations. At the same time, the drought prompted increased love of and concern for land and a renewed enthusiasm for expressing connectedness to land through all forms of art. Modern Aboriginal and wider community well‐being programs helped frame a response to drought alongside traditional Aboriginal dreaming and cultural approaches to emotional health and well‐being.     

Wabishki Bizhiko Skaanj: a learning pathway to foster better Indigenous cultural competence in Canadian health research

ObjectiveIn Canada, Indigenous people experience racism across diverse settings, including within the health sector. This has negatively impacted both the quality of care that Indigenous people receive as well as how research related to Indigenous populations is conducted. Therefore, an Indigenous-led council at a kidney research network, in partnership with other key stakeholders, sought to create a learning pathway that aims to distill the racism that Indigenous people face, and build cultural competence, within the health sector.ParticipantsThe learning pathway was designed for researchers, health care providers, patient partners and administrators.SettingVarious components of the pathway are established trainings in healthcare and research settings at provincial and national levels. Provincially, some components are implemented in British Columbia, Alberta, Saskatchewan, Manitoba and Ontario.InterventionThe pathway, called Wabishki Bizhiko Skaanj (meaning “White Horse” in Anishinaabemowin), involves six key steps: a culturally tailored blanket exercise that walks participants through the history of local Indigenous Nations/peoples; a more detailed online training program (San’yas); a series of webinars on Indigenous research ethics and protocols; an educational booklet about engaging Knowledge Keepers in research, as well as sharing details about their traditional knowledge and culture; two certification programs about Indigenous ownership of data; and a “book club,” wherein the conversation of racism—and the goal for finding solutions—is continually discussed.OutcomesWabishki Bizhiko Skaanj is working to build cultural competence in the Canadian health sector.ImplicationsThis learning pathway has the potential to address racial disparities across the country and improve health outcomes for Indigenous peoples.     

Gender differences in the dialysis treatment of Indigenous and non‐Indigenous Australians

Objective: Access to dialysis treatment and the types of treatments employed in Australia differs by Indigenous status. We examined whether dialysis treatment utilisation in Indigenous and non‐Indigenous Australians also differs by gender. Methods: Using registry data we evaluated 21,832 incident patients (aged ≥18 years) commencing dialysis, 2001–2013. Incidence rates were calculated and multivariate regression modelling used to examine differences in dialysis treatment (modality, location and vascular access creation) by race and gender. Results: Dialysis incidence was consistently higher in Indigenous women compared to all other groups. Compared to Indigenous women, both non‐Indigenous women and men were more likely to receive peritoneal dialysis as their initial treatment (non‐Indigenous women RR=1.91, 95%CI 1.55–2.35; non‐Indigenous men RR=1.73, 1.40–2.14) and were more likely to commence initial treatment at home (non‐Indigenous women RR=2.07, 1.66–2.59; non‐Indigenous men RR=1.95, 1.56–2.45). All groups were significantly more likely than Indigenous women to receive their final treatment at home. Conclusions: Contemporary dialysis treatment in Australia continues to benefit the dominant non‐Indigenous population over the Indigenous population, with non‐Indigenous men being particularly advantaged. Implications for Public Health: Treatment guidelines that incorporate a recognition of gender‐based preferences and dialysis treatment options specific to Indigenous Australians may assist in addressing this disparity.     

Social determinants in the sexual health of adolescent Aboriginal Australians: a systematic review

While research indicates that Aboriginal and Torres Strait Islander adolescents may be at increased risk of some sexually transmitted infections, there is limited information about factors that may place these young people at more risk of adverse sexual health than their non‐Indigenous counterparts. Current research has tended to focus on surveillance‐type data, but there is an increasing need to understand social determinants of sexual health risk. This systematic review assessed the evidence of social determinants impacting on Aboriginal and Torres Strait Islander adolescents’ sexual health in Australia. Published, English‐language literature was searched across key databases from 2003 to 2015. Fourteen studies were included in the qualitative synthesis. Findings suggest that social determinants such as access to healthcare, poverty, substance use, educational disadvantage, sociocultural context, gender inequalities, status and identity, and social disadvantage impacted on Indigenous adolescents’ sexual behaviours and sexual health risk. Evidence from the literature included in the review suggests that peer education may be an acceptable and appropriate approach for addressing such issues. There remains a need for programmes and services to be community‐developed and community‐led, thus ensuring cultural appropriateness and relevance. However, there is also a significant need for such programmes to be effectively and rigorously evaluated with data that goes beyond surveillance, and seeks to unpack how sexual norms are experienced by Indigenous adolescents, particularly outside of remote Australia – and how these experiences act as either risk or protective factors to good sexual health and positive social and emotional well‐being.     

Advance Australia fair: social democratic and conservative politicians' discourses concerning Aboriginal and Torres Strait Islander Peoples and their health 1972-2001

This paper reports research undertaken as part of a larger project in which we examined whether and how values and beliefs communicated by Australian politicians have shaped decades of health policy and influenced health outcomes for Aboriginal and Torres Strait Islander Peoples of Australia. To first characterise those values and beliefs we analysed the public statements of the politicians responsible nationally for the health of Aboriginal and Torres Strait Islander Peoples 1972-2001, using critical discourse analysis. We found that four discourses, communicated through words, phrases, sentences and grammatical structures, dominated public statements over the study period. These four discourses focused on the competence and capacity of Aboriginal and Torres Strait Islander Peoples to "manage"; matters of control of and responsibility for the health of Aboriginal and Torres Strait Islander Peoples; Aboriginal and Torres Strait Islander Peoples as "Other"; and the nature of the "problem" concerning the health of Aboriginal and Torres Strait Islander Peoples. Analysis of the discursive elements contributing to shaping these four discourses is reported in this paper.     

Identifying psychosocial mediators of health amongst indigenous Australians for the Heart Health Project

Objective. The Heart Health Project is an ongoing community-directed health promotion programme encompassing the collection of health-related data and interventions promoting cardiovascular health. Following research which has emphasised the importance of psychological factors including mastery, or personal control, in mitigating cardiovascular health outcomes, this qualitative study explored whether such constructs were relevant from Indigenous perspectives, or whether there were other, more meaningful and relevant psychosocial factors identified by participants that should be incorporated into models of Indigenous health and which could be effective targets for change.

Design. The study fits within the broader participatory action research design of the Heart Health Project. Data comprised 30 in-depth interviews with members of a rural Aboriginal community in south-eastern Australia to identify psychosocial factors relevant to their health. Interviews were semi-structured and carried out by two interviewers, one Aboriginal and one non-Aboriginal. Qualitative analysis using QN6 software resulted in a number of salient themes and sub-themes. These are summarised using extracts from the data.

Results/Conclusions. Five major themes and 15 sub-themes emerged from data analysis. The findings indicated that while a sense of control may be one factor impacting on health and health behaviours, there were other factors that participants spoke about more readily that have specific relevance to the social and cultural context of Indigenous health. These included history, relationship with mainstream and connectedness. These may be worthy of further empirical investigation and are likely to assist in the design of community health promotion interventions for Aboriginal people.     

Learning from the past,looking to the future: Exploring our place with Indigenous Australians

This paper aims to explore ways in which we as occupational therapists in Australia can participate in enabling a different and better future for all Australians. In doing so, it is necessary to explore our history and our cultures, both individually and collectively as a profession, and to understand the ways in which these shape who we are and what we do. As occupational therapists, we have valuable knowledge and skills that have the potential to contribute in a positive way to the health and educational outcomes of Indigenous Australians. As a profession operating in Australia, we also have a responsibility to reach this potential. This paper aims to present some of these contributions and to provide examples of practical and culturally safe ways in which we can take action.     

Implementing the Institute of Medicine definition of disparities: an application to mental health care

OBJECTIVE: In a recent report, the Institute of Medicine (IOM) defines a health service disparity between population groups to be the difference in treatment or access not justified by the differences in health status or preferences of the groups. This paper proposes an implementation of this definition, and applies it to disparities in outpatient mental health care. DATA SOURCES: Health Care for Communities (HCC) reinterviewed 9,585 respondents from the Community Tracking Study in 1997-1998, oversampling individuals with psychological distress, alcohol abuse, drug abuse, or mental health treatment. The HCC is designed to make national estimates of service use. STUDY DESIGN: Expenditures are modeled using generalized linear models with a log link for quantity and a probit model for any utilization. We adjust for group differences in health status by transforming the entire distribution of health status for minority populations to approximate the white distribution. We compare disparities according to the IOM definition to other methods commonly used to assess health services disparities. PRINCIPAL FINDINGS: Our method finds significant service disparities between whites and both blacks and Latinos. Estimated disparities from this method exceed those for competing approaches, because of the inclusion of effects of mediating factors (such as income) in the IOM approach. CONCLUSIONS: A rigorous definition of disparities is needed to monitor progress against disparities and to compare their magnitude across studies. With such a definition, disparities can be estimated by adjusting for group differences in models for expenditures and access to mental health services.     

A bibliometric analysis of research on Indigenous health in Australia, 1972-2008

Objective: To determine the growth patterns and citation volume of research publications referring to Indigenous health in Australia from 1972 to 2008 compared to seven selected health fields. Methods: Web of Science was used to identify all publications (n=820) referring to the health of Indigenous Australians authored by Australian researchers, 1972 to 2008. Citations for each publication were also captured. Growth was compared with selected health fields as well as with overall Australian research publications. Results: Research publications referring to Indigenous health, while remaining relatively small in number, grew at an average annual rate of 14.1%, compared with 8.2% across all fields of Australian research. The growth rate shown was equal second highest in our seven categories of health and medical research. However, Indigenous publications were cited significantly less than the Australian average. Conclusions: While there has been positive growth in publications referring to Indigenous health, the attention paid to this research through citations remains disappointingly low. Implications: Given that research concentration and impact can be an index of how seriously a nation considers a health problem, the low visibility of Australian research examining Indigenous health does not demonstrate a level of concern commensurate with the gravity of Indigenous health problems. Further investigation for the reasons for lower citations may identify potential intervention strategies.