Health occupations

Johannes Mulder · Hans Sonneveld

Healthy is one of the seven domains outlined in the Future Healthy Countdown 2030 framework on children and young people's health and wellbeing. The Countdown's framework draws on the Nest, a framework of wellbeing developed by the Australian Research Alliance for Children and Youth.1 In the 2021 iteration of the Nest, a new generation of child and youth voices defined healthy children and young people as those who “have their physical, mental, and emotional health needs met” and “receive appropriate health services, including preventative measures to address potential or emerging physical, emotional and mental health concerns”.1 The physical health and mental health of young Australians continue to benefit from advances in public health, modern medicine, preventive interventions such as vaccination, and a strong universal health care system. However, health inequities remain and the social determinants of health (eg, economic, commercial and structural factors) are strongly at play. Differential outcomes in children's and young people's health and wellbeing are recognised to be “unjust, unnecessary, systematic and preventable”.2 For these reasons, attempts to improve health outcomes in Australia and around the world must ensure that children and young people aged 0–24 years — particularly priority groups (eg, those who are Aboriginal and/or Torres Strait Islander and those living in low income households) — are front and centre of policy decisions aimed at reducing inequities. A broad range of indicators can be used to track the health and wellbeing of young populations. Among these, unhealthy weight (overweight and obesity) and mental health problems and disorders are leading examples of health conditions that remain unacceptably high in young populations globally. These conditions are also inequitably distributed and significant risk factors for wider diseases and disorders across the lifespan.3 Weight problems often begin in the developmental years of childhood and adolescence.4,5 Similarly, half of mental health problems emerge by 18 years of age and almost two‐thirds emerge by 24 years of age.6 Addressing these two health priorities alone would reap major benefits, including improved quality of life and reduced risk of physical disease, with implications within and across generations.3 However, intervening to prevent weight and mental health problems early in the life course necessitates accurate population and clinical data on both of these outcomes, around aspects of public health and health services, ideally from early childhood through to young adulthood (ages 0–24 years). Currently, there is no single survey system in Australia that provides these insights. However, Australia does have three survey systems that could be better integrated to regularly provide an epidemiological profile of the developmental years of Australians. These are the National Health Study (NHS; which collects data on Australians aged 2 years or older), the Australian Child and Adolescent Survey of Mental Health and Wellbeing (which collects data on 4–17‐year‐olds) and the National Study of Mental Health and Wellbeing (which collects data on Australians aged 16 years or older). Broader data capture across each survey system (including measures of social determinants and healthy development) has the potential to provide a more comprehensive and sustainable survey system for tracking the health of young populations. Furthermore, triennial administration of each survey could provide the necessary frequency for “state of the nation” reports that could enhance investments in timely, evidence‐based policy and practice decisions that are intended to improve the health of children and young people across our nation. Tracking data on overweight and obesity in young populations Current generations of children and young people are more likely to live with overweight or obesity than people at the same age in previous generations (Box 1).7 This burden is even greater among particular populations, such as those aged 5–14 years who live in the lowest socio‐economic areas (28%) or are of Aboriginal and/or Torres Strait Islander origin (38%).7 The National Obesity Strategy 2022–2032 has set a target of reducing overweight and obesity in 2–17‐year‐olds by at least 5% by 2030.8 If we are serious about reducing overweight and obesity by 5%, we need to reliably measure weight in young populations and its determinants to track progress and evaluate intervention and policy efforts. High quality and frequently collected data on body mass index (BMI; height and weight) of children and young people are available in the NHS, from in‐person objective measurements taken every three to four years (except in 2020–21 due to the coronavirus disease 2019 [COVID‐19] pandemic).9 The most recent NHS data, from 2017–18, estimated that almost one in four 5–14‐year‐old Australians (24%) and two in five 15–24‐year‐old Australians (41%) were either overweight or obese.7 In the 22 years since data were first collected, in 1995, these rates have risen by 20% for those aged 5–14 years and 46% for those aged 15–24 years (Box 1). We also need to regularly measure key risk factors and protective factors for overweight and obesity, such as physical activity, sleep and nutrition. The National Nutrition and Physical Activity Survey was completed during the period 2011–2012 and is being administered again in 2023 — a decade later.10 We suggest that more frequent data on these key factors are needed to better track the results of previous policy and intervention decisions. Beyond individual factors, we need to measure the key social, structural and commercial determinants of obesity, such as community factors. Community differences in the number of child development risk factors (eg, neighbourhood alcohol availability, school suspension, family conflict and peer bullying) predict significant increases in child weight status (eg, four or more risk factors increase the odds of a child being overweight by 50%) and other outcomes such as poor mental health.11 Broader structural factors offer policy targets that can have far reaching consequences. For example, a tax on sugary sweetened beverages alone is estimated to help reduce obesity rates at the population level by at least 2%.12 To be maximally effective in supporting evidence‐based decision making, we need to find ways of capturing macro level policy settings to help reduce obesogenic environments. Tracking data on mental health difficulties and disorders in young populations Young Australians continue to rate mental health concerns as a major challenge for their generation,13 with some groups dealing with greater burden than others (eg, LGBQTI+ and Aboriginal and Torres Strait Islander children and young people).14,15 Despite this, nationally representative and community data on mental health are collected too infrequently to develop the coherent picture of developmental years that is needed to evaluate current policies and inform approaches to mental health promotion in young populations. Like the NHS, the Australian Child and Adolescent Survey of Mental Health and Wellbeing and the National Study of Mental Health and Wellbeing have the potential to provide a continuous picture of mental health difficulties and disorders across the developmental years. These population representative mental health survey systems collect data on mental health difficulties (distress) and mental disorders (clinical conditions). In the most recent Australian Child and Adolescent Survey of Mental Health and Wellbeing, which was administered a decade ago (during the period 2013–2014), one in five 11–17‐year‐olds (20%) reported high or very high levels of psychological distress using the Kessler 10 Psychological Distress Scale (K10)16 (no equivalent data are available for children younger than 11 years). This compares to almost one in seven 4–17‐year‐olds (14%) who were classified as having a diagnosable mental disorder in the previous 12 months using the Diagnostic Interview Schedule for Children version IV (DISC‐IV).16 The absence of a more recent survey means that there is a striking gap in data for one of the most important public health and health service priorities for children and young people.17 More recent estimates of mental health difficulties are available for those aged 16 years or older in the larger national cohort (2020–2021). However, estimates of psychological distress are presented within wide age bands (16–34 years) which are not likely to represent those aged 16–24 years.18 Tighter age disaggregation is available for mental disorders (rather than mental health distress), with two in five 16–24‐year‐olds (40%) classified as having a mental disorder in the previous 12 months using the Composite International Diagnostic Interview (CIDI).19 In this age group, anxiety and affective disorders have steadily increased since national data were first collected in 1997 (Box 2), while substance use disorders have substantially declined.19,20,21 Driving responsive and accountable action for physical and mental health An important picture of physical health (overweight and obesity) and mental health (distress and disorder) in young populations can be assembled by bringing together data from the NHS, the Australian Child and Adolescent Survey of Mental Health and Wellbeing, and the National Study of Mental Health and Wellbeing. However, these important and high quality survey systems are not currently designed to “talk with each other” and thereby fail to provide a single, coherent picture of health and development in young populations at regular intervals. In addition, there is an important gap in data relating to early childhood and there is no tracking of positive health and developmental outcomes, including good general health, pro‐social behaviour and pro‐environmental behaviour. Yet, measuring the development of these positive types of behaviour has the potential to provide a crucial read on the key attitudes and behaviours that we need to nurture in young populations to ensure kinder, more peaceful societies and a healthier planet into the future. Similarly, the broader social determinants of both positive and problematic outcomes are not assessed. Beyond tracking mental health outcomes, tracking modifiable risk factors and protective factors provides specific targets for public health investments in preventive interventions in addition to health services. For this Countdown series, we suggest connecting these three important Australian survey systems to assemble an early life course national data system capable of providing continuous developmental data (up to age 24 years) on indicators of both physical and mental health. We also suggest more frequent administration of surveys (eg, triennially) with particular attention to measuring the primary social determinants of health and wellbeing and positive measures. Capitalising on the strengths of these national survey systems would address a major gap in data using expertise and infrastructure already in place within a nationally funded system. This could be done in a way that builds on existing assets (adding brief and reliable measures) but does not interfere with the core elements of these surveys which enable international comparisons. Beyond these potential data capture extensions, there is a broader question of data utilisation, particularly concerns about how effectively population data are used. One important barrier to data utilisation relates to the ease with which non‐scientific audiences can make sense of complex, multidimensional data, in ways that lead to clarity about how and when to invest for maximum impact. With this in mind, we further suggest investment in a centralised data visualisation capability that places data on a single platform, to create a single “point of truth” that can be accessed by a broad range of end users. A leading example of this has been developed by the Institute for Health Metrics and Evaluation to visualise Global Burden of Disease estimates. Summary and recommendations The current state of play is summarised in Box 3. We make the following three recommendations around strengthening existing surveillance platforms and building new surveillance capabilities to help improve physical and mental health of young Australians. 1. Track BMI and mental health difficulties and disorders in young populations every three years Continue regular ongoing reporting of physical health, including overweight and obesity (BMI) from the NHS (measured from 2 years of age onward). Integrate child, adolescent and adult mental health and wellbeing survey data to provide a single, coherent picture of the early life course (up to age 24 years). Increase the frequency of mental health survey administration to match the triennial frequency of the NHS to ensure best practice coverage of major shifts in population health. 2. Extend and enrich surveys to assess modifiable developmental determinants Lower the starting age of the Australian Child and Adolescent Survey of Mental Health and Wellbeing to match that of the NHS (from two years of age onward, parent report up to age ten years) to ensure better coverage of young children. Extend the scope of mental health assessment to include brief high level indicators of positive development, including pro‐social and pro‐environmental behaviour. Enrich monitoring with regular population reads on common, modifiable determinants (individual, relational and contextual risk factors, protective factors and structural influences). Continue to ensure oversampling of priority groups and communities to drive more equitable health outcomes based on proportionate universalism.22 3. Invest in platforms that developmentally connect and visualise data Ensure that data can be visualised easily and developmentally (eg, use fine‐grained age disaggregation and community profiles) to ensure optimal data utilisation by governments, researchers and community leaders. Ensure that data on modifiable determinants of positive and problematic health outcomes are likewise easily accessible to optimise intervention planning. Ensure that all data collected are aligned with FAIR (findable, accessible, interoperable and reusable) and Open Science principles for data access and utilisation. We believe that such improvements would build a foundation for responsive and accountable actions towards improving the physical and mental health of young Australians. Box 1 – Proportion of children, adolescents and young adults aged 5–24 years living with overweight or obesity, by birth cohort and age group (measured in 1995, 2007–08 and 2017–18) Source: Adapted from the Australian Institute of Health and Welfare.7 Box 2 – Prevalence of 12‐month mental disorders in young people aged 16–24 years, by time (1997, 2007, 2020–21)* * Original figure produced using the data sources below. Data from 1997 are not directly comparable to data from 2007 and 2020–21 because the 1997 data are based on sampling of Australians aged 18–24 years old (not 16–17 years old) using an earlier version of the Composite International Diagnostic Interview (CIDI). Source: ABS National Study of Mental Health and Wellbeing, measured in 1997, 2007 and 2020–21.19,20,21 Box 3 – Pressing issues and key indicators of physical and mental health of Australians aged 0–24 years What are the two most pressing issues where change could make a real difference by 2030 and why? • Overweight and obesity and common mental health problems (distress and clinical disorders) remain persistently high in young populations, are inequitably distributed, and have major implications both now and for future health and wellbeing. • However, we lack developmental data on these health priorities from early childhood to young adulthood (0–24 years of age), which limits evidence‐informed approaches to prevention and treatment across the early life course. • We suggest connecting three important Australian survey systems to assemble an early life course data system capable of providing continuous developmental data on indicators of both physical and mental health up to age 24 years. What are some of the key indicator measures available and what is lacking? • Key indicators: ‣ prevalence of overweight and obesity in children and young people; ‣ prevalence of mental health difficulties (distress) in children and young people; and ‣ prevalence of mental disorders in children and young people. What is lacking? ‣ data on mental health difficulties (distress) and diagnosable mental disorders in children and adolescents aged 0–24 years (the most recent survey of 4–17‐year‐olds was completed a decade ago in the period 2013–2014); ‣ data on positive development indicators (eg, pro‐social and pro‐environmental behaviour); ‣ data on common, modifiable, social determinants of mental health difficulties and disorders; and ‣ clearly visualised and easily understandable data on weight and mental health across the developmental years. What are the key baseline data on these indicator measures that are available? • Almost one in four 5–14‐year‐olds (24%) and two in five 15–24‐year‐olds (41%) are affected by overweight or obesity (29% in regional and remote areas) (source: National Health Study, 2017–18 financial year).7 • Two in five 16–24‐year‐olds (40%) meet the criteria for a mental disorder (source: National Study of Mental Health and Wellbeing, 2020–21).19

Kate Lycett · Georgie Frykberg · Peter S Azzopardi · Joyce Cleary · Susan M Sawyer · John W Toumbourou · Tim Slade · Craig A Olsson

The Lancet commission on culture in health1 identified positive cultural connections as key to achieving equity in health and wellbeing for all people; however, action towards culture in health has remained largely neglected. The intent of this article is not to debate any singular aspect of culture, identity, Indigeneity, or indeed Indigenous cultural identity, but to promote the application of a human rights and cultural lens across social determinant‐informed policy making, to facilitate positive health impacts and nurture and maintain wellbeing. “Positive sense of identity and culture” is one of seven domains considered in the MJA supplement on the Future Healthy Countdown 2030. While culture and identity is of importance to all people, it is especially relevant to children and adolescents given it is during early life that culture and identify are formed.2 Childhood and adolescence are also where individuals are exposed to, and where they can shape, the social determinants of health.3 Moreover, in this article, we argue that positive cultural practices and a strong sense of identity are protective factors for child and adolescent wellbeing (Box 1). Culture In its broadest sense, culture is said to be the whole complex of distinctive spiritual, material, intellectual and emotional features that characterise a society or social group. It includes not only the arts and languages but also modes of life, the fundamental rights of the human being, value systems, traditions, and beliefs. A loss of any cultural foundation is a loss to humankind.5 Importantly, culture is not static, it is fluid and adaptive, changing with time and geography and incorporating new events and exposures. In Australia, and around the world, various policies have perpetuated the systematic denial of the basic human rights of Indigenous peoples and other marginalised and vulnerable groups. These ongoing experiences of colonisation, exclusion and discrimination are critical to understanding the contemporary determinants of poor health that Aboriginal and Torres Strait Islander people (and other populations) continue to experience.6,7 Conversely, cultural policies and culture in policies aim to protect, stimulate and enrich each people's identity and cultural heritage, and establish absolute respect for and appreciation of cultural minorities and the other cultures of the world.5 Identity The definition of identity is a fluid, complicated and unclear concept that nonetheless plays a central role in ongoing debates.8 In very simple terms, it can be described as a sense of belonging that derives from shared origins or characteristics.9 We identify in many ways — according to gender, religion, geography, culture, hobbies, ethnicities, language groups — and how we identify, or how we attempt to build an identity for ourselves, is complex and multifaceted. For those who identify as Indigenous there are additional layers and complexities, including social and political discourse on identity and cultural belonging — the claims and counter claims, legal criteria imposed by colonisers, community gatekeepers and individuals who do not know the difference between heritage and legitimate Indigenous cultural ancestry and all of the responsibilities that come with such a privilege.10,11 Despite the tension and confusion, there is also growing evidence to confirm that a positive sense of cultural identity is a protective factor and supports the process of resilience.12,13 Further, identity is not only dependent upon individual status, but on community level and collective perspectives and connections. For Aboriginal and Torres Strait Islander peoples, identity is based on a cultural sense of self grounded within a collectivist perspective that views the self as inseparable from, and embedded within, family and community.14 Wellbeing Health and wellbeing are complex concepts and there is no clear consensus across or within cultures as to how these constructs should be defined.15,16 In broad terms, wellbeing is a good or satisfactory condition of existence; a state characterised by health, happiness and prosperity; a positive outcome that is meaningful for people. At a minimum, it includes the presence of positive emotions and moods (eg, contentment, happiness), the absence of negative emotions (eg, depression, anxiety), satisfaction with life, fulfilment, and positive functioning (social, economic). As outlined by national reference and working groups,17,18 there are nine guiding principles that underpin social and emotional wellbeing (Box 2); these include recognition of the centrality of kinship, cultural diversity, and Aboriginal strengths. Indigenous wellbeing is an inclusive concept that encompasses physical, psychological, social and cultural aspects, both individual and collective. Issues core to Indigenous wellbeing also include connection to one another and to the environment and natural world. For children and adolescents — as for all people — wellbeing is deeply impacted by the intergenerational impacts of discriminatory policies and practices, and the resultant trauma, grief, violence, diminished family and community cohesion, cultural dislocation, and socio‐economic disadvantage.19 Indigenous resilience Resilience may be defined as the capacity to cope with, and bounce back after, the ongoing demands and challenges of life, and to learn from them in a positive way.20 This includes positive adaptation despite adversity, or a class of phenomena characterised by good outcomes despite serious threats to adaptation or development.21 Resilience may also be considered as adaptation over time, “a dynamic process involving an interaction between both risk and protective processes, internal and external to the individual … of varying degrees of impact, and … at varying points in development”.22 The exploration of resilience is a powerful and culturally relevant construct. Cultural resilience is the capacity of a community or cultural system to absorb disturbance and reorganise while undergoing change, in order to retain key elements of structure and identity that preserve its distinctness.8,22,23 Iris Heavyrunner and other educators proposed additional cultural protective factors, cultural resources for resilience — symbols and proverbs from common language and culture, traditional child rearing philosophies, religious leadership, counsellors and elders.24 Social determinants of health We understand the social determinants of health to mean the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.25 It is widely accepted that health inequities arise from these social, material and political circumstances in which people live, and the systems put in place to deal with ill health.26 Marmot has also observed that the health gap between Indigenous and non‐Indigenous Australians “bespeaks large social inequalities”.27 However, addressing only social determinants will continue to fail Indigenous Australians. The social determinants of health are deeply situated within a deficit context. Although important in the pathway between cultural discrimination, marginalisation and poor health, a social determinants approach in isolation risks reinforcing this deficit perspective, emphasising poorer health outcomes for those from lower socio‐economic populations, with lower educational attainment, long term unemployment and welfare dependency, and intergenerational disadvantage.28 Cultural determinants of health and wellbeing Indigenous peoples the world over have long understood that positive cultural practices are protective, and can build resilience, particularly in children and young people. The United Nations and its affiliated agencies have considered culture in the context of community development, creating toolkits and indicators to measure impacts of culture on development and social outcomes,29,30 but have not connected culture to health outcomes. The lead author of this article (NB) has been working for many years to articulate and develop a framework for the cultural determinants of health using a strengths‐based approach that acknowledges that stronger connections to culture and country build stronger individual and collective identities, a greater sense of self‐esteem, resilience, and improved outcomes across the social determinants of health, including education, economic stability and community cohesion. A positive sense of self, inclusive of domains across culture, spirituality, politics and social engagement, is a key factor in strengths‐based approaches and positive trajectories across the life course. A growing body of evidence demonstrates that the protection and promotion of traditional knowledge, family, culture and kinship contribute to community cohesion and personal resilience.4,11,17 Further, cultural links and practices — for example, extended family, access to traditional land, revitalisation of traditional languages, learning dance and story, and understanding traditional roles and responsibilities — are protective factors that improve resilience against emotional and behavioural problems.31 To illustrate this approach, NB developed a conceptual framework (Box 3) reflective of the Articles of the United Nations Declaration on the Rights of Indigenous Peoples, proposing that these cultural determinants underpin social determinants.32 The original framework has been expanded to consider examples of implementation and measurement of these cultural determinants and is presented in Box 4.33 Both frameworks were presented at the United Nations Permanent Forum on Indigenous Issues. Relevance and utility A combined social and cultural determinants approach recognises that there are multiple, complex drivers of wellbeing and ill health, many of which lie outside of the health sector, and which therefore require a collaborative, inter‐sectoral approach. Indigenous perspectives and practices also hold the promise of benefiting mainstream systems and enabling positive social determinant impacts for all. Lessons learned through experience in Indigenous health and politics (nationally, regionally, globally) reinforce that Indigenous perspectives, values and practices can enrich our professions, communities and policy environments far beyond the limits of Indigenous services. What we do as Indigenous communities, parents, clinicians, educators and knowledge holders may be freely gifted if the systems and services are ready to embrace truth telling, understand the context, and honour the gift. To reinforce the message — Indigenous rights are human rights. The cultural determinants are just as relevant to culturally and linguistically diverse groups, LGBTQIA+ people, refugees and non‐Indigenous communities as they are to Indigenous peoples. The guiding principles are self‐determination, freedom from discrimination, freedom from assimilation, and collective rights. If we, as a nation, want our children to be physically, emotionally and psychologically healthy, to be generous, kind and resilient, to be active social and economic participants, and if we hope to mitigate their risk of vulnerability to antisocial influences or radicalisation, then we need to work harder to ensure they know that they are loved, supported, heard. Positive cultural practices are protective factors against toxic stress, health risk, mental health, and behavioural issues. Moving towards a more sensitive measure of wellbeing The Human Development Index is a tool developed by the United Nations to measure and rank countries’ levels of social and economic development based on four criteria: life expectancy at birth; mean years of schooling; expected years of schooling; and gross national income per capita.34 A key question is whether these truly reflect and measure what is most relevant to people, including Indigenous peoples. Using economic parameters does not capture how people feel about their lives; for example, the quality of their relationships, their positive emotions and resilience, the realisation of their potential, or their overall satisfaction with life. Further, wellbeing approaches acknowledge that money is not the answer, and that macro‐economic measures such as gross domestic product do not comprehensively capture or reflect what ordinary people perceive about the state of their own lives. Hence the need to develop less traditionally mainstream measures and indicators to reflect progress toward improved social and cultural determinants of health — metrics that better capture how people feel about cultural identity, cultural connections, language reclamation, and Indigenous content in mainstream curricula. Box 1 – Aragung buraay: culture, identity and positive futures for Australian children What are the most pressing issues where change could make a real difference by 2030 and why? Policies have perpetuated the systematic denial of the basic rights of Indigenous peoples and other marginalised groups, including cultural practice and identity. Positive cultural practices and a strong sense of identity are protective factors for child and adolescent wellbeing that we urgently need to foster through intentional policies. Indigenous perspectives and practices also hold the promise of benefiting mainstream systems and enabling positive social determinant impacts for all. What are some of the key indicator measures available? Currently available national indicators of cultural wellbeing are limited. Those that are available are: ‣ Cultural pride: Proportion of children and adolescents who are proud of their culture (measured in the National Aboriginal and Torres Strait Islander Social Survey [NATSISS] for Indigenous youths aged 18–24 years). This measure should be included in regular national surveys such as the National Health Survey to be inclusive of all children. ‣ Language: Proportion of Indigenous 10–24‐year‐olds who speak a few words or more of Indigenous language, included in the NATSISS. ‣ Racism: Proportion of Indigenous 10–14‐year‐olds attending school who are bullied or treated unfairly because they are Indigenous, and the proportion of Indigenous people 15–24 years of age who felt discriminated against in previous 12 months. These are included in the NATSISS and are therefore currently specific to Indigenous people. These are measures that should be included in regular national surveys such as the National Health Survey to be inclusive of all children. ‣ Impact: The impacts of cultural wellbeing and toxic exposures such as racism on health and wellbeing are many. One indicator is suicide mortality for children and adolescents (aged 10–24 years) reported in 5‐year age bands.4 A measure that is needed is: Aboriginal and Torres Strait Islander education content for all children — this can be measured by the number of states/territories that have Aboriginal and Torres Strait Islander education content for all children as part of the core education curriculum. Box 2 – Nine guiding principles that underpin social and emotional wellbeing Health as holistic The right to self‐determination The need for cultural understanding The impact of history in trauma and loss Recognition of human rights The impact of racism and stigma Recognition of the centrality of kinship Recognition of cultural diversity Recognition of Aboriginal strengths Created by Social Health Reference Group;17 adapted from Swan and Raphael.18 Box 3 – The cultural determinants of health and wellbeing32 Referencing the United Nations Declaration on the Rights of Indigenous Peoples and other human rights instruments, the cultural determinants of health and wellbeing include, but are not limited to: Self‐determination Freedom from discrimination Individual and collective rights Freedom from assimilation and destruction of culture Protection from removal/relocation Connection to, custodianship and utilisation of country and traditional lands Reclamation, revitalisation, preservation and promotion of language and cultural practices Protection and promotion of traditional knowledge and Indigenous intellectual property Understanding of lore, law and traditional roles and responsibilities Box 4 – Implementation and measurement examples of the cultural determinants of health and wellbeing33 Cultural determinants Human rights instrument/s Domain Sector/service examples Indicator/measure examples Self‐determination UDHR; UNDRIP Human rights, law and justice, social inclusion Aboriginal Community Controlled Health sector The number of new and established Aboriginal Community Controlled Health Services Freedom from discrimination ICERD; ICESCR Politics, service delivery, social policy, law and justice 3AQ (availability, accessibility, acceptability and quality framework) culturally safe services Zero tolerance policies and legal protections (Commonwealth, states and territories) Decreased number of complaints to Australian Human Rights Commission Individual and collective rights UNDRIP; ICCPR Law and justice, employment, economics, social policy Citizenship, cultural rights, human rights Some knowledge cannot be individually owned (eg, genetic/biological information) Australia incorporates Articles of international human rights instruments into domestic legislation Constitutional reform — does not allow Commonwealth to enact racist legislation Compulsory research agreements that ensure legal and ethical protections, addressing self‐determination, priority setting, benefit sharing Freedom from assimilation and destruction of culture ILO Convention (No. 169) on Indigenous and Tribal Peoples; ICCPR Law and justice, service delivery, social policy, politics, education Inclusive policies and resourcing Education reform National curriculum in primary and secondary schools addressing history, Indigenous culture, local language, local teachers Policy impact assessments Political representation Repatriation of historically held collections Protection from removal/relocation CRC; ICERD; UNDRIP Law and justice, service delivery Birthing Dialysis Education Ongoing removal of children Develop a model of service delivery, funded to provide co‐located primary, secondary and tertiary services The number of Aboriginal Community Controlled Health Services supported to provide comprehensive co‐located care (eg, midwife‐led antenatal and birthing clinics in regional/remote areas) Aboriginal Community Controlled Health Services as child protection hubs/champions Connection to, custodianship and utilisation of country and traditional lands ILO Convention; ICESCR; Convention on Biological Diversity Native title and land rights, environment Formal acknowledgement and validation of cultural knowledge and practices Upscaling Indigenous enterprises Increased number of rangers and trainees Micro‐financing initiatives/opportunities Expedited native title determinations Heritage and National Park orders Reclamation, revitalisation, preservation and promotion of language and cultural practices CRC; ICESCR Education, employment Australian Institute of Aboriginal and Torres Strait Islander Studies Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council Language education courses Employment of cultural educators Funded local cultural education initiatives Network of cultural immersion schools Protection and promotion of traditional knowledge and Indigenous intellectual property ILO Convention; Universal Declaration on Bioethics and Human Rights Law and justice, ethics International human rights instruments and agencies UNPFII, ECOSOC, UNESCO Domestic legislation (Commonwealth) Ethical guidelines and legal protections — custodianship of traditional/cultural language, songs, stories, images, designs, biological material Authority to negotiate benefit Understanding of lore, law, traditional roles and responsibilities UNDRIP Education Strong, resilient Surviving in difficult environments Strict social structures, clear social roles Need platforms for protection, promotion, revitalisation of traditional knowledge and practices Engaging and remunerating traditional healers Cultural education networks CRC = Convention on the Rights of the Child; ECOSOC = Economic and Social Council; ICCPR = International Covenant on Civil and Political Rights; ICERD = International Convention on the Elimination of All Forms of Racial Discrimination; ICESCR = International Covenant on Economic, Social and Cultural Rights; ILO = International Labour Organization; UDHR = Universal Declaration of Human Rights; UNDRIP = United Nations Declaration on the Rights of Indigenous Peoples; UNESCO = United Nations Educational, Scientific and Cultural Organization; UNPFII = United Nations Permanent Forum on Indigenous Issues.

Ngiare Brown · Peter S Azzopardi · Fiona J Stanley

Natasha Reid · Leonard C Gray

Deborah Gleeson · James Scheibner · Dianne Nicol

University departments of rural health are Commonwealth‐funded to improve recruitment and retention of the rural allied health and nursing (including midwifery) workforce, primarily through student placements. We examined publications by university departments of rural health that were focused on allied health and nursing students undertaking placements in rural Australia, to understand the characteristics, main findings and implications of the research conducted. Interprofessional learning was a key feature of placements and placement education, although other activities such as community engagement added to placement experiences. Factors such as quality supervision and being involved in the community contributed to a positive placement experience and increased rural practice intention. Tracking studies showed a relationship between rural placements, rural practice intention and rural practice. Rural placements occurred across a variety of settings and in locations consistent with the policy framework. Embedding university departments of rural health in rural communities enabled staff to build relationships and increase placement capacity.

Sandra M Walsh · Vincent L Versace · Sandra C Thompson · Leanne J Browne · Sabina Knight · David M Lyle · Geoff Argus · Martin Jones