It's enough to make you sick: the impact of racism on the health of Aboriginal Australians

Mental health consequences of stress and trauma: allostatic load markers for practice and policy with a focus on Indigenous health

OBJECTIVE

Mental health, well-being, and social life are intimately related as is evident from the higher incidence of psychiatric illness in individuals exposed to social stress and adversity. Several biological pathways linking social adversity to health outcomes are heavily investigated in the aims of facilitating early identification and prevention of adverse health outcomes. We provide a practice-orientated overview of the allostatic load model and how it relates to metabolic and cardiovascular comorbidity in psychiatric disorders.

CONCLUSIONS

Allostatic load brings together a set of neuroendocrine, metabolic, immune and cardiovascular biomarkers that are elevated in individuals with adverse early life experiences and are predictive of cardiovascular and metabolic risk in psychiatric illness of critical importance for Indigenous Australians.

Factors Influencing the Health Behaviour of Indigenous Australians: Perspectives from Support People

Disparities between the health of Indigenous and non-Indigenous populations continue to be prevalent within Australia. Research suggests that Indigenous people participate in health risk behaviour more often than their non-Indigenous counterparts, and that such behaviour has a substantial impact on health outcomes. Although this would indicate that reducing health risk behaviour may have positive effects on health outcomes, the factors that influence Indigenous health behaviour are still poorly understood. This study aimed to interview people who support Indigenous groups to gain an understanding of their views on the factors influencing health behaviour within Indigenous groups in Western Australia. Twenty nine people participated in the study. The emergent themes were mapped against the social ecological model. The results indicated that: (1) culture, social networks, history, racism, socioeconomic disadvantage, and the psychological distress associated with some of these factors interact to affect health behaviour in a complex manner; (2) the desire to retain cultural identity and distinctiveness may have both positive and negative influence on health risk behaviour; (3) strong social connections to family and kin that is intensified by cultural obligations, appears to affirm and disrupt positive health behaviour; (4) the separation between Indigenous and non-Indigenous social connection/networks that appeared to be fostered by marginalisation and racism may influence the effect of social networks on health behaviour; and (5) communication between Indigenous and non-Indigenous people may be interrupted by distrust between the groups, which reduces the influence of some non-Indigenous sources on the health behaviour of Indigenous people.

Cultural safety and midwifery care for Aboriginal women - A phenomenological study

BACKGROUND

Aboriginal and Torres Strait islander(1) women face considerable health disparity in relation to their maternity health outcomes when compared to non-Aboriginal women. Culture and culturally appropriate care can contribute to positive health outcomes for Aboriginal women. How midwives provide culturally appropriate care and how the care is experienced by the women is central to this study.

AIM

To explore the lived experiences of midwives providing care in the standard hospital care system to Aboriginal women at a large tertiary teaching hospital.

METHODS

An interpretive Heideggerian phenomenological approach was used. Semi-structured interviews were conducted with thirteen volunteer midwives which were transcribed, analysed and presented informed by van Manen's approach.

FINDINGS

Thematic analysis revealed six main themes: "Finding ways to connect with the women", "building support networks - supporting with and through Aboriginal cultural knowledge", "managing the perceived barriers to effective care", "perceived equity is treating women the same", "understanding culture" and "assessing cultural needs - urban versus rural/remote Aboriginal cultural needs".

CONCLUSION

The midwives in this study have shared their stories of caring for Aboriginal women. They have identified communication and building support with Aboriginal health workers and families as important. They have identified perceived barriers to the provision of care, and misunderstanding around the interpretation of cultural safety in practice was found. Suggestions are made to support midwives in their practice and improve the experiences for Aboriginal women.

Finding Color in Conformity: A Commentary on Culturally Specific Risk Factors for Violence in Australia

This article outlines the current utility of Indigenous culturally specific risk factors for violence and the ramifications for cross-cultural risk prediction. The Indigenous culturally specific violence risk factor literature has provided a rich body of contextual information outlining Indigenous patterns of criminal behaviour. This information has the capacity to facilitate offender responsivity and treatment targets in addition to assisting clinicians identify the presence of risk markers among Indigenous clients. However, if intended for inclusion in risk prediction models, culturally specific risk items then require further quantitative analysis to establish robust associations and probability estimates for recidivistic outcome.

Beyond the Biomedical Paradigm: The Formation and Development of Indigenous Community-Controlled Health Organizations in Australia

This article describes the formation and development of Aboriginal Community-Controlled Health Services in Australia, with emphasis on the Redfern Aboriginal Medical Service in Sydney. These organizations were established in the 1970s by Indigenous Australians who were excluded from and denied access to mainstream health services. The aim of this research was to explore notions of Indigenous agency against a historical backdrop of dispossession, colonialism, and racism. Aboriginal Community-Controlled Health Services act as a primary source of healthcare for many Indigenous communities in rural and urban areas. This study examined their philosophy of healthcare, the range of services provided, their problems with state bureaucracies and government funding bodies, and the imposition of managerialist techniques and strategies on their governance. Essentially, these organizations transcend individualistic, biomedical, and bureaucratic paradigms of health services by conceptualizing and responding to Indigenous health needs at a grassroots level and in a broad social and political context. They are based on a social model of health.

Equity in primary health care delivery: an examination of the cohesiveness of strategies relating to the primary healthcare system, the health workforce and hepatitis C

OBJECTIVE

To suggest ways of increasing the cohesiveness of national primary healthcare strategies and hepatitis C strategies, with the aim of ensuring that all these strategies include ways to address barriers and facilitators to access to primary healthcare and equity for people with hepatitis C.

METHODS

A critical review was conducted of the first national Primary Healthcare System Strategy and Health Workforce Strategy with the concurrent Hepatitis C Strategy. Content relating to provision of healthcare in private general practice was examined, focussing on issues around access and equity.

RESULTS

In all strategies, achieving access to care and equity was framed around providing sufficient medical practitioners for particular locations. Equity statements were present in all policies but only the Hepatitis C Strategy identified discrimination as a barrier to equity. Approaches detailed in the Primary Healthcare System Strategy and Health Workforce Strategy regarding current resource allocation, needs assessment and general practitioner incentives were limited to groups defined within these documents and may not identify or meet the needs of people with hepatitis C.

CONCLUSIONS

Actions in the primary healthcare system and health workforce strategies should be extended to additional groups beyond those listed as priority groups within the strategies. Future hepatitis C strategies should outline appropriate, detailed needs assessment methodologies and specify how actions in the broad strategies can be applied to benefit the primary healthcare needs of people with hepatitis C.

"More than skin deep": stress neurobiology and mental health consequences of racial discrimination

Ethnic minority groups across the world face a complex set of adverse social and psychological challenges linked to their minority status, often involving racial discrimination. Racial discrimination is increasingly recognized as an important contributing factor to health disparities among non-dominant ethnic minorities. A growing body of literature has recognized these health disparities and has investigated the relationship between racial discrimination and poor health outcomes. Chronically elevated cortisol levels and a dysregulated hypothalamic-pituitary-adrenal (HPA) axis appear to mediate effects of racial discrimination on allostatic load and disease. Racial discrimination seems to converge on the anterior cingulate cortex (ACC) and may impair the function of the prefrontal cortex (PFC), hence showing substantial similarities to chronic social stress. This review provides a summary of recent literature on hormonal and neural effects of racial discrimination and a synthesis of potential neurobiological pathways by which discrimination affects mental health.

Risk factors and comorbidities for invasive pneumococcal disease in Western Australian Aboriginal and non-Aboriginal people

Australian Aboriginal people have among the highest rates of invasive pneumococcal disease (IPD) worldwide. We investigated clinical diagnosis, risk factors, comorbidities and vaccine coverage in Aboriginal and non-Aboriginal IPD cases. Using enhanced surveillance, we identified IPD cases in Western Australia, Australia, between 1997 and 2007. We calculated the proportion with risk factors and comorbidities in children (<5 years) and adults (=15 years), as well as adults living in metropolitan and non-metropolitan regions. We then calculated the proportion of cases eligible for vaccination who were vaccinated before contracting IPD. Of the 1,792 IPD cases that were reported, 355 (20%) were Aboriginal and 1,155 (65%) were adults. Pneumonia was the most common diagnosis (61% of non-Aboriginal and 49% of Aboriginal adult IPD cases in 2001–2007). Congenital abnormality was the most frequent comorbidity in non-Aboriginal children (11%). In Aboriginal children, preterm delivery was most common (14%). Ninety-one percent of non-Aboriginal and 96% of Aboriginal adults had one or more risk factors or comorbidities. In non-Aboriginal adults, cardiovascular disease (34%) was the predominant comorbidity whilst excessive alcohol use (66%) was the most commonly reported risk factor in Aboriginal adults. In adults, comorbidities were more frequently reported among those in metropolitan regions than those in non-metropolitan regions. Vaccination status was unknown for 637 of 1,082 cases post-July 2001. Forty-one percent of non-Aboriginal and 60% of Aboriginal children were eligible for vaccination but were not vaccinated. Among adults with risk factors who were eligible for vaccination and with known vaccination status, 75% Aboriginal and 94% non-Aboriginal were not vaccinated. An all-of-life immunisation register is needed to evaluate vaccine coverage and effectiveness in preventing IPD in adults.

Aboriginal medical services cure more than illness: a qualitative study of how Indigenous services address the health impacts of discrimination in Brisbane communities

Background

Aboriginal and Torres Strait Islanders persistently experience a significantly lower standard of health in comparison to non-Indigenous Australians. The factors contributing to this disparity are complex and entrenched in a history of social inequality, disempowerment, poverty, dispossession and discrimination. Aboriginal medical services (AMS) provide a culturally appropriate alternative to mainstream medical services as a means to address this health disparity and also advocate for Indigenous rights and empowerment. This study provides a vignette of lay perspectives of Aboriginal and Torres Strait Islanders accessing community and government controlled AMS in Brisbane, Queensland with the intention of identifying self-perceived health determinants to inform the post-2015 international development goals.

Methods

Focus group discussions and semi-structured interviews were held with clients of a government-controlled AMS and an Aboriginal community controlled health service (ACCHS) in order to identify their self-identified essential health needs. Conversations were audio recorded, transcribed verbatim and de-identified for analysis. Common themes were identified to highlight important issues around community health needs, how they can be addressed and what lessons can be extended to inform the post-2015 development goals.

Findings and discussion

Participants acknowledge the complexity of health determinants faced by their peoples. Thematic analysis highlighted the pervasive influence of racism through many perceived health determinants; resulting in reduced healthcare seeking behaviour, unhealthy lifestyles and mental health issues. Participants emphasised the marked health improvements seen due to the establishment of Aboriginal medical services in their communities and the importance of the AMS’ role in addressing the negative effects of discrimination on Indigenous health.

Conclusion

It is concluded from this study that AMS are crucial in addressing the negative impacts of continued discrimination on Indigenous health by providing comprehensive, culturally appropriate, community empowering health services. Such services improve Indigenous healthcare seeking rates, provide invaluable health education services and address mental health concerns in communities and must be supported in order to address health inequalities in Australia. Community driven and culturally informed health services should be encouraged globally to address health disparities.

Examining the potential contribution of social theory to developing and supporting Australian Indigenous-mainstream health service partnerships

Introduction

The substantial gap in life expectancy between Indigenous and non-Indigenous Australians has been slow to improve, despite increased dedicated funding. Partnerships between Australian Indigenous and mainstream Western biomedical organisations are recognised as crucial to improved Indigenous health outcomes. However, these partnerships often experience challenges, particularly in the context of Australia’s race and political relations.

Methods

We examined the relevant literature in order to identify the potential role for social theory and theoretical models in developing and maintaining intercultural partnerships. Having identified relevant theoretical models, terms and possible key words, a range of databases were searched and relevant articles selected for inclusion. An integrative approach brought together theoretical models and practical considerations about working in partnership, to inform our analysis of the literature.

Findings

Considering partnerships between Australian Indigenous and mainstream health organisations as ‘bi-cultural’ is simplistic: rather they are culturally diverse across social and professional levels. As such, partnerships between Australian Indigenous and mainstream health organisations may be better conceptualised as ‘intercultural’, operating across diverse and shifting cultural frames of reference. Theories identified by this review as useful to guide partnerships include power relations, reflexivity and dialogue, borders and strangeness and the intercultural or third space. This paper examines how these theoretical approaches can develop understanding and improve intercultural engagement between mainstream and Australian Indigenous partners in healthcare.

Conclusions

Rather than viewing partnerships merely as arrangements between disembodied entities, sometimes contractual in nature, they are better seen as activities between people and organisations and essentially dependent on relationships, occurring in an intercultural space that is complex, dynamic and subject to changes in power relations. Theoretical models aiming to understand and improve partnerships indicate the complexity of building and maintaining such partnerships and stress the importance of understanding factors that can strengthen or derail their effectiveness. While the theories presented here are by no means exhaustive, they nonetheless provide a series of entry points through which to engage with the issue and expand the discourse. This approach allows the transformative nature of Australian Indigenous-mainstream ‘culture’ to be explored and understood in its lived expression; rather than relegated to prescriptive categories.

The perspectives of Aboriginal patients and their health care providers on improving the quality of hemodialysis services: a qualitative study

Chronic kidney disease has a higher prevalence in Indigenous populations globally. The incidence of end-stage kidney disease in Australian Aboriginal people is eight times higher than non-Aboriginal Australians. Providing services to rural and remote Aboriginal people with chronic disease is challenging because of access and cultural differences. This study aims to describe and analyze the perspectives of Aboriginal patients' and health care providers' experience of renal services, to inform service improvement for rural Aboriginal hemodialysis patients. We conducted a thematic analysis of interviews with Aboriginal patients (n = 18) receiving hemodialysis in rural Australia and health care providers involved in their care (n = 29). An overarching theme of avoiding the “costly” crisis encompassed four subthemes: (1) Engaging patients earlier (prevent late diagnosis, slow disease progression); (2) flexible family-focused care (early engagement of family, flexibility to facilitate family and cultural obligations); (3) managing fear of mainstream services (originating in family dialysis experiences and previous racism when engaging with government organizations); (4) service provision shaped by culture (increased home dialysis, Aboriginal support and Aboriginal-led cultural education). Patients and health care providers believe service redesign is required to meet the needs of Aboriginal hemodialysis patients. Participants identified early screening and improving the relationship of Aboriginal people with health systems would reduce crisis entry to hemodialysis. These strategies alongside improving the cultural competence of staff would reduce patients' fear of mainstream services, decrease the current emotional and family costs of care, and increase efficiency of health expenditure on a challenging and increasingly unsustainable treatment system.

Improving forensic mental health care for Aboriginal Australians: challenges and opportunities

Mental illnesses constitute a major burden of disease in Aboriginal Australians and Torres Strait Islanders (hereafter Aboriginal Australians), who are also overrepresented in the prison system. A legacy of colonization compounds such prevalence, and is further exacerbated by the persistence of racial discrimination and insensitivity across many sectors, including health. This research completed in a Western Australian forensic mental health setting identifies non-Aboriginal health professionals' support needs to deliver high-quality, culturally-safe care to Aboriginal patients. Data were collected from health professionals using an online survey and 10 semistructured interviews. Survey and interview results found that ongoing education was needed for staff to provide culturally-safe care, where Aboriginal knowledge, beliefs, and values were respected. The findings also support previous research linking Aboriginal health providers to improved health outcomes for Aboriginal patients. In a colonized country, such as Australia, education programmes that critically reflect on power relations privileging white Anglo-Australian cultural dominance and subjugating Aboriginal knowledge, beliefs, and values are important to identify factors promoting or compromising the care of Aboriginal patients and developing a deeper understanding of 'cultural safety' and its clinical application. Organizational commitment is needed to translate the findings to support non-Aboriginal health professionals deliver high-quality care to Aboriginal patients that is respectful of cultural differences.

‘It still leaves me sixty dollars out of pocket’: experiences of diabetes medical care among low-income earners in Perth

Diabetes prevalence is increasing in Australia, and there are stark inequities in prevalence and clinical outcomes experienced by Indigenous people and low socioeconomic groups compared with non-Indigenous and socioeconomically advantaged groups. This paper explores the impact of Indigenous status and socioeconomic disadvantage on the experience of diabetes care in the primary health setting. Data were collected through focus groups and interviews. The sample, comprising 38 participants (Indigenous and non-Indigenous), was recruited from disadvantaged areas in Perth, Australia. Data analysis was mainly deductive and based on a conceptual framework for the relationship between socioeconomic position and diabetes health outcomes. Most participants reported accessing general practitioners regularly; however, evidence of access to dietitians and podiatrists was very limited. Perceived need, cost, lack of information on available services and previous negative experiences influenced health care-seeking behaviour. Complexity and lack of coordination characterised the model of care reported by most participants. In contrast, Indigenous participants accessing an Aboriginal community-controlled health organisation reported a more accessible and coordinated experience of care. Our analysis suggests that Indigenous and socioeconomically disadvantaged people tailor their health care-seeking behaviour to the limitations imposed by their income and disadvantaged circumstances. To reduce inequities in care experiences, diabetes services in primary care need to be accessible and responsive to the needs of such groups in the community.

The pathways from perceived discrimination to self-rated health: an investigation of the roles of distrust, social capital, and health behaviors

Although there has been extensive research on the adverse impacts of perceived discrimination on health, it remains unclear how perceived discrimination gets under the skin. This paper develops a comprehensive structural equation model (SEM) by incorporating both the direct effects of perceived discrimination on self-rated health (SRH), a powerful predictor for many health outcomes, and the indirect effects of perceived discrimination on SRH through health care system distrust, neighborhood social capital, and health behaviors and health conditions. Applying SEM to 9880 adults (aged between 18 and 100) in the 2008 Southeastern Pennsylvania Household Health Survey, we not only confirmed the positive and direct association between discrimination and poor or fair SRH, but also verified two underlying mechanisms: 1) perceived discrimination is associated with lower neighborhood social capital, which further contributes to poor or fair SRH; and 2) perceived discrimination is related to risky behaviors (e.g., reduced physical activity and sleep quality, and intensified smoking) that lead to worse health conditions, and then result in poor or fair SRH. Moreover, we found that perceived discrimination is negatively associated with health care system distrust, but did not find a significant relationship between distrust and poor or fair SRH.

Service providers' perspectives, attitudes and beliefs on health services delivery for Aboriginal people receiving haemodialysis in rural Australia: a qualitative study

OBJECTIVE

Providing services to rural dwelling minority cultural groups with serious chronic disease is challenging due to access to care and cultural differences. This study aimed to describe service providers' perspectives on health services delivery for Aboriginal people receiving haemodialysis for end-stage kidney disease in rural Australia.

DESIGN

Semistructured interviews, thematic analysis

SETTING

A health district in rural New South Wales, Australia

PARTICIPANTS

Using purposive sampling, 29 renal and allied service providers were recruited, including nephrologists, renal nurses, community nurses, Aboriginal health workers, social workers and managers. Six were Aboriginal and 23 non-Aboriginal.

RESULTS

Improving cultural understanding within the healthcare system was central to five themes identified: rigidity of service design (outreach, inevitable home treatment failures, pressure of system overload, limited efficacy of cultural awareness training and conflicting priorities in acute care); responding to social complexities (respecting but challenged by family obligations, assumptions about socioeconomic status and individualised care); promoting empowerment, trust and rapport (bridging gaps in cultural understanding, acknowledging the relationship between land, people and environment, and being time poor); distress at late diagnosis (lost opportunities and prioritise prevention); and contending with discrimination and racism (inherent judgement of lifestyle choices, inadequate cultural awareness, pervasive multilevel institutionalised racism and managing patient distrust).

CONCLUSIONS

Service providers believe current services are not designed to address cultural needs and Aboriginality, and that caring for Aboriginal patients receiving haemodialysis should be family focused and culturally safer. An Aboriginal-specific predialysis pathway, building staff cultural awareness and enhancing cultural safety within hospitals are the measures recommended. Increasing patient support for home haemodialysis may improve health and the quality of care outcomes.

Complex impact of remoteness on the incidence of myocardial infarction in Aboriginal and non-Aboriginal people in Western Australia

OBJECTIVE

To determine the impact of remoteness on Aboriginal and non-Aboriginal myocardial infarction incidence rates in men and women of different ages.

DESIGN

Descriptive study.

SETTING

Western Australia.

PARTICIPANTS

Incident cases of myocardial infarction in Western Australia from 2000-2004 identified from person-linked files of hospital and mortality records. Analysis was undertaken for Aboriginal and non-Aboriginal populations, separately and combined, by broad age group, sex and remoteness.

MAIN OUTCOME MEASURE

Incidence of myocardial infarction.

RESULTS

In the combined analysis, age-standardised incidence was significantly higher for men in very remote areas (rate ratio 1.31: 95% confidence interval (CI), 1.19-1.45) and in women in both regional (rate ratio 1.12: 95% CI, 1.01-1.20) and very remote (rate ratio 2.05: 95% CI, 1.75-2.41) areas. Aboriginal rates were substantially higher than non-Aboriginal rates in all substrata. Compared with metropolitan people, regional Aboriginal men and very remote non-Aboriginal men aged 25-54 years had significantly higher incidence rates. For the remaining rural strata, there was either no geographical disadvantage or inconclusive findings.

CONCLUSIONS

Non-metropolitan disadvantage in myocardial infarction rates is confirmed in regional areas and women in very remote areas. This disadvantage is partly explained by the high rates in Aboriginal people. Non-metropolitan dwellers are not uniformly disadvantaged, reflecting the interplay of the many factors contributing to the complex relationship between myocardial infarction incidence and sex, age, Aboriginality and residence. Aboriginal Western Australians in all regions and young non-Aboriginal men living in very remote areas need to be targeted to reduce disparities in myocardial infarction.

Patterns and correlates of self-reported racial discrimination among Australian Aboriginal and Torres Strait Islander adults, 2008-09: analysis of national survey data

Background

There is now considerable evidence that racism is a pernicious and enduring social problem with a wide range of detrimental outcomes for individuals, communities and societies. Although indigenous people worldwide are subjected to high levels of racism, there is a paucity of population-based, quantitative data about the factors associated with their reporting of racial discrimination, about the settings in which such discrimination takes place, and about the frequency with which it is experienced. Such information is essential in efforts to reduce both exposure to racism among indigenous people and the harms associated with such exposure.

Methods

Weighted data on self-reported racial discrimination from over 7,000 Indigenous Australian adults participating in the 2008–09 National Aboriginal and Torres Strait Islander Survey, a nationally representative survey conducted by the Australian Bureau of Statistics, were analysed by socioeconomic, demographic and cultural factors.

Results

More than one in four respondents (27%) reported experiencing racial discrimination in the past year. Racial discrimination was most commonly reported in public (41% of those reporting any racial discrimination), legal (40%) and work (30%) settings. Among those reporting any racial discrimination, about 40% experienced this discrimination most or all of the time (as opposed to a little or some of the time) in at least one setting. Reporting of racial discrimination peaked in the 35–44 year age group and then declined. Higher reporting of racial discrimination was associated with removal from family, low trust, unemployment, having a university degree, and indicators of cultural identity and participation. Lower reporting of racial discrimination was associated with home ownership, remote residence and having relatively few Indigenous friends.

Conclusions

These data indicate that racial discrimination is commonly experienced across a wide variety of settings, with public, legal and work settings identified as particularly salient. The observed relationships, while not necessarily causal, help to build a detailed picture of self-reported racial discrimination experienced by Indigenous people in contemporary Australia, providing important evidence to inform anti-racism policy.

Association between perceived discrimination and racial/ethnic disparities in problem behaviors among preadolescent youths

OBJECTIVES

We examined the contribution of perceived racial/ethnic discrimination to disparities in problem behaviors among preadolescent Black, Latino, and White youths.

METHODS

We used cross-sectional data from Healthy Passages, a 3-community study of 5119 fifth graders and their parents from August 2004 through September 2006 in Birmingham, Alabama; Los Angeles County, California; and Houston, Texas. We used multivariate regressions to examine the relationships of perceived racial/ethnic discrimination and race/ethnicity to problem behaviors. We used values from these regressions to calculate the percentage of disparities in problem behaviors associated with the discrimination effect.

RESULTS

In multivariate models, perceived discrimination was associated with greater problem behaviors among Black and Latino youths. Compared with Whites, Blacks were significantly more likely to report problem behaviors, whereas Latinos were significantly less likely (a "reverse disparity"). When we set Blacks' and Latinos' discrimination experiences to zero, the adjusted disparity between Blacks and Whites was reduced by an estimated one third to two thirds; the reverse adjusted disparity favoring Latinos widened by about one fifth to one half.

CONCLUSIONS

Eliminating discrimination could considerably reduce mental health issues, including problem behaviors, among Black and Latino youths.

No Time Like The Present: Determinants Of Intentions To Engage In Bystander Anti-Racism On Behalf Of Indigenous Australians

The present study explored whether variables previously shown to relate to pro-social attitudes and behaviours could be applied to the intention to engage in bystander anti-racism on behalf of Indigenous Australians. 149 non-Indigenous participants were asked to indicate how likely they were to engage in bystander anti-racism in response to an ‘everyday’ racial discrimination scenario presented within an online survey. Being female, older, and politically left leaning correlated with bystander anti-racism intentions, as did higher levels of collective guilt, anger, empathic concern and lower levels of prejudice. Regression analysis revealed that being older and having higher levels of empathic concern predicted the intention to engage in bystander anti-racism. While it may seem rational that the ability to feel for the plight of another (empathic concern) is necessary for bystander anti-racism to ensue, older individuals may feel more competent in their ability to effectively intervene.

Perceived discrimination and physical health among HIV-positive Black and Latino men who have sex with men

We conducted the first study to examine health correlates of discrimination due to race/ethnicity, HIV-status, and sexual orientation among 348 HIV-positive Black (n = 181) and Latino (n = 167) men who have sex with men. Participants completed audio computer-assisted self-interviews. In multivariate analyses, Black participants who experienced greater racial discrimination were less likely to have a high CD4 cell count [OR = 0.7, 95 % CI = (0.5, 0.9), p = 0.02], and an undetectable viral load [OR = 0.8, 95 % CI = (0.6, 1.0), p = 0.03], and were more likely to visit the emergency department [OR = 1.3, 95 % CI = (1.0, 1.7), p = 0.04]; the combined three types of discrimination predicted greater AIDS symptoms [F (3,176) = 3.8, p < 0.01]. Among Latinos, the combined three types of discrimination predicted greater medication side effect severity [F (3,163) = 4.6, p < 0.01] and AIDS symptoms [F (3,163) = 3.1, p < 0.05]. Findings suggest that the stress of multiple types of discrimination plays a role in health outcomes.

Making the invisible visible: are health social workers addressing the social determinants of health?

This study explored the ways in which health social workers (HSW) address the social determinants of health (SDH) within their social work practice. Social workers (n = 54) employed at major hospitals across Toronto had many years of practice in health care (M = 11 years; SD = 10.32) and indicated that SDH were a top priority in their daily work; with 98% intentionally intervening with at least one and 91% attending to three or more. Health care services were most often addressed (92%), followed by housing (72%), disability (79%), income (72%), and employment security (70%). Few HSW were tackling racism, Aboriginal status, gender, or social exclusion in their daily practice.

Socioeconomic disparities in the mental health of Indigenous children in Western Australia

Background

The burden of mental health problems among Aboriginal and Torres Strait Islander children is a major public health problem in Australia. While socioeconomic factors are implicated as important determinants of mental health problems in mainstream populations, their bearing on the mental health of Indigenous Australians remains largely uncharted across all age groups.

Methods

We examined the relationship between the risk of clinically significant emotional or behavioural difficulties (CSEBD) and a range of socioeconomic measures for 3993 Indigenous children aged 4–17 years in Western Australia, using a representative survey conducted in 2000–02. Analysis was conducted using multivariate logistic regression within a multilevel framework.

Results

Almost one quarter (24%) of Indigenous children were classified as being at high risk of CSEBD. Our findings generally indicate that higher socioeconomic status is associated with a reduced risk of mental health problems in Indigenous children. Housing quality and tenure and neighbourhood-level disadvantage all have a strong direct effect on child mental health. Further, the circumstances of families with Indigenous children (parenting quality, stress, family composition, overcrowding, household mobility, racism and family functioning) emerged as an important explanatory mechanism underpinning the relationship between child mental health and measures of material wellbeing such as carer employment status and family financial circumstances.

Conclusions

Our results provide incremental evidence of a social gradient in the mental health of Aboriginal and Torres Strait Islander children. Improving the social, economic and psychological conditions of families with Indigenous children has considerable potential to reduce the mental health inequalities within Indigenous populations and, in turn, to close the substantial racial gap in mental health. Interventions that target housing quality, home ownership and neighbourhood-level disadvantage are likely to be particularly beneficial.

Reducing the health disparities of Indigenous Australians: time to change focus

Background

Indigenous peoples have worse health than non-Indigenous, are over-represented amongst the poor and disadvantaged, have lower life expectancies, and success in improving disparities is limited. To address this, research usually focuses on disadvantaged and marginalised groups, offering only partial understanding of influences underpinning slow progress. Critical analysis is also required of those with the power to perpetuate or improve health inequities. In this paper, using Australia as a case example, we explore the effects of ‘White’, Anglo-Australian cultural dominance in health service delivery to Indigenous Australians. We address the issue using race as an organising principle, underpinned by relations of power.

Methods

Interviews with non-Indigenous medical practitioners in Western Australia with extensive experience in Indigenous health encouraged reflection and articulation of their insights into factors promoting or impeding quality health care to Indigenous Australians. Interviews were audio-taped and transcribed. An inductive, exploratory analysis identified key themes that were reviewed and interrogated in light of existing literature on health care to Indigenous people, race and disadvantage. The researchers’ past experience, knowledge and understanding of health care and Indigenous health assisted with data interpretation. Informal discussions were also held with colleagues working professionally in Indigenous policy, practice and community settings.

Results

Racism emerged as a key issue, leading us to more deeply interrogate the role ‘Whiteness’ plays in Indigenous health care. While Whiteness can refer to skin colour, it also represents a racialized social structure where Indigenous knowledge, beliefs and values are subjugated to the dominant western biomedical model in policy and practice. Racism towards Indigenous patients in health services was institutional and interpersonal. Internalised racism was manifest when Indigenous patients incorporated racist attitudes and beliefs into their lived experience, lowering expectations and their sense of self-worth.

Conclusions

Current health policies and practices favour standardised care where the voice of those who are marginalised is often absent. Examining the effectiveness of such models in reducing health disparities requires health providers to critically reflect on whether policies and practices promote or compromise Indigenous health and wellbeing - an important step in changing the discourse that places Indigenous people at the centre of the problem.

Strategic approaches to enhanced health service delivery for Aboriginal and Torres Strait Islander people with chronic illness: a qualitative study

BACKGROUND

Aboriginal and Torres Strait Islander people with chronic illness confront multiple challenges that contribute to their poor health outcomes, and to the health disparities that exist in Australian society. This study aimed to identify barriers and facilitators to care and support for Aboriginal and Torres Strait Islander people with chronic illness.

METHODS

Face-to-face in-depth interviews were conducted with Aboriginal and Torres Strait Islander people with diabetes, chronic heart failure or chronic obstructive pulmonary disease (n-16) and family carers (n = 3). Interviews were transcribed verbatim and the transcripts were analysed using content analysis. Recurrent themes were identified and these were used to inform the key findings of the study.

RESULTS

Participants reported both negative and positive influences that affected their health and well-being. Among the negative influences, they identified poor access to culturally appropriate health services, dislocation from cultural support systems, exposure to racism, poor communication with health care professionals and economic hardship. As a counter to these, participants pointed to cultural and traditional knowledge as well as insights from their own experiences. Participants said that while they often felt overwhelmed and confused by the burden of chronic illness, they drew strength from being part of an Aboriginal community, having regular and ongoing access to primary health care, and being well-connected to a supportive family network. Within this context, elders played an important role in increasing people's awareness of the impact of chronic illness on people and communities.

CONCLUSIONS

Our study indicated that non-Indigenous health services struggled to meet the needs of Aboriginal and Torres Strait Islander people with chronic illness. To address their complex needs, health services could gain considerably by recognising that Aboriginal and Torres Strait Islander patients have a wealth of cultural knowledge at their disposal. Strategies to ensure that this knowledge is integrated into care and support programs for Aboriginal and Torres Strait Islander people with chronic illness should achieve major improvements.

Closing the gap in a regional health service in NSW: a multi-strategic approach to addressing individual and institutional racism

Building a culturally safe and respectful organisation that genuinely addresses individual and institutional racism is a substantial and complex undertaking. Achieving this outcome requires sustained commitment and a comprehensive strategy, including the active involvement of Aboriginal stakeholders. This paper describes the journey of a large regional health organisation in NSW. A multi-strategic approach is broadly described, with three strategies explored in depth. These are: staff education and training; leadership; and consultation, negotiation and partnerships. Challenges are discussed in the context of promising progress and an ongoing commitment to this important organisational goal.

Research on discrimination and health: an exploratory study of unresolved conceptual and measurement issues

OBJECTIVES

Our goal in this study was to better understand racial and socioeconomic status (SES) variations in experiences of racial and nonracial discrimination.

METHODS

We used 1999 and 2000 data from the YES Health Study, which involved a community sample of 50 Black and 50 White respondents drawn from 4 neighborhoods categorized according to racial group (majority Black or majority White) and SES (≤ 150% or > 250% of the poverty line). Qualitative and quantitative analyses examined experiences of discrimination across these neighborhoods.

RESULTS

More than 90% of Blacks and Whites described the meaning of unfair treatment in terms of injustice and felt certain about the attribution of their experiences of discrimination. These experiences triggered similar emotional reactions (most frequently anger and frustration) and levels of stress across groups, and low-SES Blacks and Whites reported higher levels of discrimination than their moderate-SES counterparts.

CONCLUSIONS

Experiences of discrimination were commonplace and linked to similar emotional responses and levels of stress among both Blacks and Whites of low and moderate SES. Effects were the same whether experiences were attributed to race or to other reasons.

Questioning the General Self-Esteem Vaccine: General Self-Esteem, Racial Discrimination, and Standardised Achievement Across Indigenous and Non-Indigenous Students

Psychological research and the popular media culture have repeatedly noted that self-esteem positively contributes to life satisfaction and performance indicators across a large variety of domains. However, while varying measures of self-esteem may be argued to have a positive influence on outcome measures, increasing evidence suggests that perceptions of racial discrimination may also have a negative impact across a wide variety of outcomes. The current investigation used structural equation modelling techniques to examine the potential impact of Indigenous and non-Indigenous Australian students' General Self-Esteem and their perceptions of racial discrimination on spelling and maths achievement. Results indicated that General Self-Esteem displayed little or no significant relations with the performance measures, yet perceived racial discrimination significantly and negatively predicted both spelling and maths achievement for the Indigenous and non-Indigenous students. In addition, no significant latent interaction between General Self-Esteem and perceived discrimination was identified, raising questions for the self-protective properties of General Self-Esteem, at least for achievement outcomes.

The DRUID study: racism and self-assessed health status in an indigenous population

Background

There is now considerable evidence from around the world that racism is associated with both mental and physical ill-health. However, little is known about the mediating factors between racism and ill-health. This paper investigates relationships between racism and self-assessed mental and physical health among Indigenous Australians as well as potential mediators of these relationships.

Methods

A total of 164 adults in the Darwin Region Urban Indigenous Diabetes (DRUID) study completed a validated instrument assessing interpersonal racism and a separate item on discrimination-related stress. Self-assessed health status was measured using the SF-12. Stress, optimism, lack of control, social connections, cultural identity and reactions/responses to interpersonal racism were considered as mediators and moderators of the relationship between racism/discrimination and self-assessed health status.

Results

After adjusting for socio-demographic factors, interpersonal racism was significantly associated with the SF-12 mental (but not the physical) health component. Stress, lack of control and feeling powerless as a reaction to racism emerged as significant mediators of the relationship between racism and general mental health. Similar findings emerged for discrimination-related stress.

Conclusions

Racism/discrimination is significantly associated with poor general mental health among this indigenous population. The mediating factors between racism and mental health identified in this study suggest new approaches to ameliorating the detrimental effects of racism on health. In particular, the importance of reducing racism-related stress, enhancing general levels of mastery, and minimising negative social connections in order to ameliorate the negative consequences of racism.

The DRUID study: exploring mediating pathways between racism and depressive symptoms among indigenous Australians

PURPOSE

Racism is an important determinant of mental and physical health for minority populations. However, to date little is known about the relationship between racism and ill-health outside of the U.S. or the causal pathways between racism and poor health. This paper focuses on the relationship between racism and depression in a non-U.S. indigenous population, including examination of novel mediators and moderators.

METHODS

One hundred and eighty-five adults in the Darwin Region Urban Indigenous Diabetes study responded to a validated instrument assessing multiple facets of racism. Depressive symptoms were assessed using the Centre for Epidemiologic Studies Depression Scale. Stress, optimism, lack of control, social connections, cultural identity and reactions/responses to interpersonal racism were considered as possible mediators and moderators in linear regression models.

RESULTS

Interpersonal racism was significantly associated with depression after adjusting for socio-demographic factors (β = 0.08, p < 0.001). Lack of control, stress, negative social connections and feeling ashamed, amused or powerless as reactions to racism were each identified as significant mediators of the relationship between racism and depressive symptoms. All examined mediators together accounted for 66% of the association between interpersonal racism and depressive symptoms.

CONCLUSIONS

This study demonstrates that racism is associated with depressive symptoms in an indigenous population. The mediating factors between racism and depressive symptoms identified in this study suggest new approaches to ameliorating the detrimental effects of racism on health.

Ethnic discrimination prevalence and associations with health outcomes: data from a nationally representative cross-sectional survey of secondary school students in New Zealand

BACKGROUND

Reported ethnic discrimination is higher among indigenous and minority adult populations. There is a paucity of nationally representative prevalence studies of ethnic discrimination among adolescents. Experiencing ethnic discrimination has been associated with a range of adverse health outcomes. NZ has a diverse ethnic population. There are health inequalities among young people from Māori and Pacific ethnic groups.

METHODS

9107 randomly selected secondary school students participated in a nationally representative cross-sectional health and wellbeing survey conducted in 2007. The prevalence of ethnic discrimination by health professionals, by police, and ethnicity-related bullying were analysed. Logistic regression was used to examine the associations between ethnic discrimination and six health/wellbeing outcomes: self-rated health status, depressive symptoms in the last 12 months, cigarette smoking, binge alcohol use, feeling safe in ones neighbourhood, and self-rated school achievement.

RESULTS

There were significant ethnic differences in the prevalences of ethnic discrimination. Students who experienced ethnic discrimination were less likely to report excellent/very good/good self-rated general health (OR 0.51; 95% CI 0.39, 0.65), feel safe in their neighbourhood (OR 0.48; 95% CI 0.40, 0.58), and more likely to report an episode of binge drinking in the previous 4 weeks (OR 1.77; 95% CI 1.45, 2.17). For all these outcomes the odds ratios for the group who were 'unsure' if they had experienced ethnic discrimination were similar to those of the 'yes' group.Ethnicity stratified associations between ethnic discrimination and the depression, cigarette smoking, and self-rated school achievement are reported. Within each ethnic group participants reporting ethnic discrimination were more likely to have adverse outcomes for these three variables. For all three outcomes the direction and size of the association between experience of ethnic discrimination and the outcome were similar across all ethnic groups.

CONCLUSIONS

Ethnic discrimination is more commonly reported by Indigenous and minority group students. Both experiencing and being 'unsure' about experiencing ethnic discrimination are associated with a range of adverse health/wellbeing outcomes. Our findings highlight the progress yet to be made to ensure that rights to be free from ethnic discrimination are met for young people living in New Zealand.

Dimensions of perceived racism and self-reported health: examination of racial/ethnic differences and potential mediators

BACKGROUND

Many details of the negative relationship between perceived racial/ethnic discrimination and health are poorly understood.

PURPOSE

The purpose of this study was to examine racial/ethnic differences in the relationship between perceived discrimination and self-reported health, identify dimensions of discrimination that drive this relationship, and explore psychological mediators.

METHODS

Asian, Black, and Latino(a) adults (N=734) completed measures of perceived racial/ethnic discrimination, self-reported health, depression, anxiety, and cynical hostility.

RESULTS

The association between perceived discrimination and poor self-reported health was significant and did not differ across racial/ethnic subgroups. Race-related social exclusion and threat/harassment uniquely contributed to poor health for all groups. Depression, anxiety, and cynical hostility fully mediated the effect of social exclusion on health, but did not fully explain the effect of threat.

CONCLUSIONS

Our results suggest that noxious effects of race-related exclusion and threat transcend between-group differences in discriminatory experiences. The effects of race-related exclusion and threat on health, however, may operate through different mechanisms.

Oral health and social and emotional well-being in a birth cohort of Aboriginal Australian young adults

Background

Social and emotional well-being is an important component of overall health. In the Indigenous Australian context, risk indicators of poor social and emotional well-being include social determinants such as poor education, employment, income and housing as well as substance use, racial discrimination and cultural knowledge. This study sought to investigate associations between oral health-related factors and social and emotional well-being in a birth cohort of young Aboriginal adults residing in the northern region of Australia's Northern Territory.

Methods

Data were collected on five validated domains of social and emotional well-being: anxiety, resilience, depression, suicide and overall mental health. Independent variables included socio-demographics, dental health behaviour, dental disease experience, oral health-related quality of life, substance use, racial discrimination and cultural knowledge.

Results

After adjusting for other covariates, poor oral health-related items were associated with each of the social and emotional well-being domains. Specifically, anxiety was associated with being female, having one or more decayed teeth and racial discrimination. Resilience was associated with being male, having a job, owning a toothbrush, having one or more filled teeth and knowing a lot about Indigenous culture; while being female, having experienced dental pain in the past year, use of alcohol, use of marijuana and racial discrimination were associated with depression. Suicide was associated with being female, having experience of untreated dental decay and racial discrimination; while being female, having experience of dental disease in one or more teeth, being dissatisfied about dental appearance and racial discrimination were associated with poor mental health.

Conclusion

The results suggest there may be value in including oral health-related initiatives when exploring the role of physical conditions on Indigenous social and emotional well-being.

The effect of perceived discrimination on the health of immigrant workers in Spain

BACKGROUND

Discrimination is an important determinant of health inequalities, and immigrants may be more vulnerable to certain types of discrimination than the native-born. This study analyses the relationship between immigrants' perceived discrimination and various self-reported health indicators.

METHODS

A cross-sectional survey was conducted (2008) amongst a non-random sample of 2434 immigrants from Ecuador, Morocco, Romania and Colombia in four Spanish cities: Barcelona, Huelva, Madrid and Valencia. A factorial analysis of variables revealed three dimensions of perceived discrimination (due to immigrant status, due to physical appearance, and workplace-related). The association of these dimensions with self-rated health, mental health (GHQ-12), change in self-rated health between origin and host country, and other self-reported health outcomes was analysed. Logistic regression was used adjusting for potential confounders (aOR-95%CI). Subjects with worsening self-reported health status potentially attributable to perceived discrimination was estimated (population attributable proportion, PAP %).

RESULTS

73.3% of men and 69.3% of women immigrants reported discrimination due to immigrant status. Moroccans showed the highest prevalence of perceived discrimination. Immigrants reporting discrimination were at significantly higher risk of reporting health problems than those not reporting discrimination. Workplace-related discrimination was associated with poor mental health (aOR 2.97 95%CI 2.45-3.60), and the worsening of self-rated health (aOR 2.20 95%CI 1.73- 2.80). 40% (95% CI 24-53) PAP of those reporting worse self-rated health could be attributable to discrimination due to immigrant status.

CONCLUSIONS

Discrimination may constitute a risk factor for health in immigrant workers in Spain and could explain some health inequalities among immigrant populations in Spanish society.

Racism as a determinant of social and emotional wellbeing for Aboriginal Australian youth

OBJECTIVE

To explore the associations between self-reported racism and health and wellbeing outcomes for young Aboriginal Australian people.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional study of 345 Aboriginal Australians aged 16-20 years who, as participants in the prospective Aboriginal Birth Cohort Study, were recruited at birth between 1987 and 1990 and followed up between 2006 and 2008.

MAIN OUTCOME MEASURES

Self-reported social and emotional wellbeing using a questionnaire validated as culturally appropriate for the study's participants; recorded body mass index and waist-to-hip ratio.

RESULTS

Self-reported racism was reported by 32% of study participants. Racism was significantly associated with anxiety (odds ratio [OR], 2.18 [95% CI, 1.37-3.46]); depression (OR, 2.16 [95% CI, 1.33-3.53]); suicide risk (OR, 2.32 [95% CI, 1.25-4.00]); and poor overall mental health (OR, 3.35 [95% CI, 2.04-5.51]). No significant associations were found between self-reported racism and resilience or any anthropometric measures.

CONCLUSIONS

Self-reported racism was associated with poor social and emotional wellbeing outcomes, including anxiety, depression, suicide risk and poor overall mental health.

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.

Racism and health among urban Aboriginal young people

Background

Racism has been identified as an important determinant of health but few studies have explored associations between racism and health outcomes for Australian Aboriginal young people in urban areas.

Methods

Cross sectional data from participants aged 12-26 years in Wave 1 of the Victorian Aboriginal Health Service's Young People's Project were included in hierarchical logistic regression models. Overall mental health, depression and general health were all considered as outcomes with self-reported racism as the exposure, adjusting for a range of relevant confounders.

Results

Racism was reported by a high proportion (52.3%) of participants in this study. Self-reported racism was significantly associated with poor overall mental health (OR 2.67, 95% CI 1.25-5.70, p = 0.01) and poor general health (OR 2.17, 95% CI 1.03-4.57, p = 0.04), and marginally associated with increased depression (OR 2.0; 95% CI 0.97-4.09, p = 0.06) in the multivariate models. Number of worries and number of friends were both found to be effect modifiers for the association between self-reported racism and overall mental health. Getting angry at racist remarks was found to mediate the relationship between self-reported racism and general health.

Conclusions

This study highlights the need to acknowledge and address racism as an important determinant of health and wellbeing for Aboriginal young people in urban areas of Australia.

Owning solutions: a collaborative model to improve quality in hospital care for Aboriginal Australians

Well-documented health disparities between Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) and non-Aboriginal Australians are underpinned by complex historical and social factors. The effects of colonisation including racism continue to impact negatively on Aboriginal health outcomes, despite being under-recognised and under-reported. Many Aboriginal people find hospitals unwelcoming and are reluctant to attend for diagnosis and treatment, particularly with few Aboriginal health professionals employed on these facilities. In this paper, scientific literature and reports on Aboriginal health-care, methodology and cross-cultural education are reviewed to inform a collaborative model of hospital-based organisational change. The paper proposes a collaborative model of care to improve health service delivery by building capacity in Aboriginal and non-Aboriginal personnel by recruiting more Aboriginal health professionals, increasing knowledge and skills to establish good relationships between non-Aboriginal care providers and Aboriginal patients and their families, delivering quality care that is respectful of culture and improving Aboriginal health outcomes. A key element of model design, implementation and evaluation is critical reflection on barriers and facilitators to providing respectful and culturally safe quality care at systemic, interpersonal and patient/family-centred levels. Nurses are central to addressing the current state of inequity and are pivotal change agents within the proposed model.

Racism, social resources and mental health for Aboriginal people living in Adelaide

BACKGROUND

This paper examines whether reported experience of racism by Aboriginal people living in Adelaide is negatively associated with mental health, and whether social resources ameliorate the mental health effects of racism.

METHODS

Face-to-face structured and semi-structured interviews were conducted with 153 Aboriginal people. Data on self-reported experiences of racism (average regularity of racism across a number of settings, regular racism in at least one setting), social resources (socialising, group membership, social support, talking/expressing self about racism), health behaviours (smoking, alcohol), socio-demographic (age, gender, education, financial situation) and mental health (SF-12 measure) are reported. Separate staged linear regression models assessed the association between the two measures of racism and mental health, after accounting for socio-demographic characteristics and health behaviours. Social resource variables were added to these models to see if they attenuated any relationship between racism and mental health.

RESULTS

The two measures of racism were negatively associated with mental health after controlling for socioeconomic factors and health behaviours. These relationships remained after adding social resource measures. Non-smokers had better mental health, and mental health increased with positive assessments of financial situation.

CONCLUSION AND IMPLICATIONS

Reducing racism should be a central strategy in improving mental health for Aboriginal people.

Improving access to hard-to-reach services: a soft entry approach to drug and alcohol services for rural Australian Aboriginal communities

Australian Aboriginal communities are concerned about drug- and alcohol-related harms in their communities. There are a significantly higher proportion of substance problems experienced by Aboriginal Australians than non-Indigenous Australians. Ways to address these problems are limited by racial barriers to mainstream services, especially in the rural context. Soft entry was an approach designed to increase Aboriginal Australians' access to Drug & Alcohol (D&A) services. The approach was designed to put control over when and how D&A interventions were delivered in the hands of the community and individuals within it by giving them ready access to a human services worker with specialist knowledge. Quantitative and qualitative evaluation methods found that soft entry substantially increased the number of Aboriginal and non-Aboriginal women accessing drug and alcohol services. It fundamentally shifted the power relationship between counselors and community, providing opportunities to develop a non-stigmatizing trustful rapport to facilitate discussion of harmful substance use. The challenges for drug and alcohol counselors were the slow unpredictability of the approach and the need for highly skilled and responsive communication techniques. However, the factor most likely to improve access to services, once trust is developed, is regular and frequent attendance at the service delivery site.