Tackling the clinical, social, cultural, communication, and research determinants of health together
The news on Indigenous health is not all bad. We know that lack of progress in Closing the Gap is unacceptable,1 and attention has turned to social determinants as the principal barriers to Indigenous health equity, as highlighted in this and previous issues of the MJA by Michael Marmot.2,3 As in this issue of the Journal, however, we can reflect on the past not only as an admonishment, but also as guide to moving forward in a coherent manner.
Georges and his colleagues4 explore data on life expectancy at birth for Indigenous Australians in the Northern Territory, describing remarkable improvements over the past 50 years. Life expectancy for non-Indigenous Australians has, of course, also improved during this period to about the same degree in absolute terms, but the proportional improvements for Indigenous Australians — albeit starting from a much lower base — have been particularly strong for Indigenous women, for whom the life expectancy gap has narrowed. This progress should not obscure the fact that gaps remain, but the improvement in Indigenous life expectancy is a major achievement, largely attributable to dedicated contributions by health care professionals across diverse geographic and social settings.
Hart and his co-authors5 thoughtfully examine education as an agent of gap reduction, noting that reducing disparities between Indigenous and non-Indigenous Australians requires that many social determinants outside the immediate influence of clinical care be considered. We may not, however, overlook the impact that clinicians have on improving the health of Indigenous people, and it is on practical clinical approaches that this issue of the Journal focuses.
Social determinants of health not only include living conditions, poverty, education, and employment, but also self-esteem, racism, and power relationships. Clinicians can have a direct impact on these latter factors, sometimes through relatively simple yet pervasive interventions, particularly in the areas of cultural safety and communication. Laverty and colleagues6 show how we can move from sometimes superficial recognition of cultural safety to embedding culturally safe practices by applying nationally consistent standards, implemented through education and accreditation processes. Equally significant is that many non-Indigenous health professionals are still unable to communicate effectively with Indigenous people across a range of health care settings. Two linguists bring their expertise to the question of improving clinical environments by delving into the nature of communication gaps and providing simple bridges to cross them,7 and by reminding us of the rich solutions available from the arts, which is presented as the natural custodian of language and communication competence.8 Waran and colleagues indicate that lessons can also be learned from Indigenous cultures, reporting that Indigenous Australians are much more likely to die in their home environment — undeniably preferable to dying in an institution — than non-Indigenous people.9
In their insightful narrative review of cardiac care of Indigenous Australians, Walsh and Kangaharan provide a detailed guide on how to deliver quality care in settings constrained by social determinants.10 They note that much of their approach is based not on formal analyses of practice, but is derived from the experience of a deep and long commitment to Indigenous clinical care. Their work is an example of the impact clinicians can have in improving the health of Indigenous people. Similar analyses in areas such as sexual and mental health are needed, and would be welcomed for publication in the MJA.
Evidence-based practice is the foundation of informed clinical care, but data on Indigenous health and health care are limited; more research is urgently required. Increased funding by various sources and the research efforts of diverse organisations and institutions have increased the volume of literature on Indigenous health in recent years, much of it published in this Journal. Some of the articles in this issue are formal scientific investigations, such as the investigation by Lucaszyk and her co-authors of the different patterns of hospitalisations for falls among Indigenous and non-Indigenous people.11 In a different type of investigation, Comino and colleagues present an important report on the general health of a cohort of urban Aboriginal children (from birth to 7 years) in Sydney, one of the few longer term follow-up studies undertaken with best practice methods for research in an Aboriginal community.12
There is a dilemma in Indigenous health research: the resources, expertise and personnel needed for a study of strong cultural acceptability are not readily compatible with one that satisfies the usual criteria for scientific rigour and quality of evidence. Meta-analyses of interventional studies that could inform best practice in health care for Indigenous Australians are wanting, and the MJA looks forward to a time when sufficient published studies are available for the Journal to be able to receive such submissions. The Journal will continue to place a high priority on both culturally appropriate research and scientific rigour. Bringing the two together remains a challenge that must be met; Braunack-Meyer and Gibson13 make a start in this direction with their discussion of important aspects of the inclusion of members of minority groups in research trials.
This issue of the MJA showcases state of the art information on social determinant, clinical, and research facets of Indigenous health care that will need to be considered when developing cohesive approaches for successfully reducing the gap in health outcomes from a clinician’s perspective. In editing the issue, we have enjoyed witnessing the depth of commitment by Australian and international authors to this endeavour, and we commend to you the important information these writers have presented.
Provenance: Commissioned; not externally peer reviewed.
- 1. Australian Government, Department of the Prime Minister and Cabinet. Closing the Gap: Prime Minister’s report 2017 [website]. Canberra, 2017. http://closingthegap.pmc.gov.au/ (accessed Apr 2017).
- 2. Marmot M. Social determinants and the health of Indigenous Australians. Med J Aust 2011; 194: 512-513.
- 3. Marmot MG. Dignity, social investment and the Indigenous health gap. Med J Aust 2017; 207: 20-21.
- 4. Georges N, Guthridge SL, Li SQ, et al. Progress in closing the gap in life expectancy at birth for Aboriginal people in the Northern Territory, 1967–2012. Med J Aust 2017; 207: 25-30.
- 5. Hart MB, Moore MJ, Laverty M. Improving Indigenous health through education. Med J Aust 2017; 207: 11-12.
- 6. Laverty M, McDermott DR, Calma T. Embedding cultural safety in Australia’s main health care standards. Med J Aust 2017; 207: 15-16.
- 7. Amery R. Recognising the communication gap in Indigenous health care. Med J Aust 2017; 207: 13-15.
- 8. Phipps A. “Has he eaten salt?”: communication difficulties in health care. Med J Aust 2017; 207: 23-24.
- 9. Waran E, Zubair MY, O’Connor N. The gap reversed: a review of site of death in the Top End. Med J Aust 2017; 207: 39.
- 10. Walsh WF, Kangaharan N. Cardiac care for Indigenous Australians: practical considerations from a clinical perspective. Med J Aust 2017; 207: 40-46.
- 11. Lukaszyk C, Harvey LA, Sherrington C, et al. Fall-related hospitalisations of older Aboriginal and Torres Strait Islander people and other Australians. Med J Aust 2017; 207: 31-35.
- 12. Comino EJ, Elcombe E, Jalaludin BB, et al. The general health of a cohort of Aboriginal children (0–7 years) in Sydney. Med J Aust 2017; 207: 37-38.
- 13. Braunack-Meyer AJ, Gibson OR, for the CREATE Methods Group. Including minority populations in research: we must do better. Med J Aust 2017; 207: 22-23.
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.