Transcript Document

What works? The social and economic
determinants of Indigenous health
Engaging with Indigenous communities
What works? The social and
economic determinants of
Indigenous health
Professor Fran Baum
Southgate Institute for Health, Society and
Equity,
Flinders University, Adelaide
Overview
Why social
determinants
are so
important to
health
1
Scope
and
limitations
of the
review
What works
What we
don’t
know
2
3
4
Commission on the Social
Determinants of Health
"(The) toxic combination of
bad policies, economics,
and politics is, in large
measure responsible for the
fact that a majority of people
in the world do not enjoy the
good health that is
biologically possible. Social
injustice is killing people on
a grand scale."
In Australia that includes
Indigenous peoples
Basic logic: what good does it do to treat
people's illnesses/addictions/send them to gaol/
.........
then give them no choice to go back to or no control
over the conditions that made them
sick/addicted/commit crime in the first place?
Social Determinants get
under our skin and cause
diseases and health
inequities …. Chronic stress
is one of crucial pathways
for Indigenous Peoples….
The Biology
of Stress
Wilkinson & Pickett
2009, 86
Biological Pathways 1 …
PERCEIVED
THREAT
FIGHT OR
FLIGHT
REACTION
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THREAT PASSES
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THOSE WITH POWER
Increased production of adrenalin
Increased Heart Rate
Increased BP
More blood directed to muscles
Dilated pupils (eyes)
Less blood to other organs (eg
kidneys, liver)
THOSE WITHOUT POWER


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Increased production of Endorphins, reduced
production of adrenalin
Decreased Heart Rate
Decreased BP
Less blood directed to muscles, muscles relax
Normal pupils (eyes)
More blood to other organs (eg kidneys, liver)
Biological Pathways 2 …
Psych-social Demands (Stressors)
Resistance & Vulnerability Factors
Life events, chronic stress, daily hassles
Coping Responses; Personality; Social Supports
Psycho-biological Stress Response
Neuro-endocrine (brain & hormones)
Cortisol, ACTH, Catecholamines,
Beta- endorphins, Testosterone,
Insulin
Autonomic metabolic
Cardiovascular function, Renal
function, Gastro-intestinal motility, Fat
metabolism, Haemostasis
High BP
Immune
Immunoglobulins, WBCs,
Lymphocyte sub-populations,
Cytokines.
High Cholesterol
Increased risk infection
Increased Heart Rate
Increased risk cancer
Decreased Blood Clotting Time
Insulin resistance
Anxiety
Depression
High BP
Increase heart rate
Diabetes … Heart disease … Stroke … Renal Disease … Infections … Cancer
Source: Marmot & Wilkinson, 1999
How social determinants get into our brains
and cause mental health problems
Lack of control over
work and home life
Living in area
with high
disorder &
lack of safety
Discrimination Social isolation &
Poverty –
(racism, sexism) lack of meaningful
managing on
contacts
low income
Unemployment
Long term
chronic stress
Gendered
violence
Barriers to
seeking mental
health care:
cultural,
financial, class,
gender
Non-permanent
work
Coping by using
substances harmful
to health – alcohol,
tobacco, illegal
drugs
Chronic Disease
Depression, Anxiety
Early childhood not
stimulating maximum
brain development
Indigenous Health Outcomes
Death
Illness
Risk
11 year life expectancy gap – 10
for women, 12 for men
Higher rates of infectious and
chronic disease
Higher rates of risky behaviour driven by
high risk social, economic and cultural
environments
Scope, Frame and limitations of the study
Scope
Frame
Limits
1.
2.
3.
4.
Small budget for review
Rapid appraisal
Focus on Australian literature
Included “grey” literature
1. Social determinants as distal and proximal
determinants
2. Attribution of health & equity impact
1.
2.
3.
Not systematic review
Often no publicly available evaluation data and
generally not RCTs or systematic approaches
Mainstream programs little evaluation (e.g
Medicare, education, housing)
Osborne, Baum & Brown, 2013
WHAT SOCIAL DETERMINANTS INTERVENTIONS
WORK TO IMPROVE INDIGENOUS HEALTH??
Education pathways to health: employment,
healthy living skills, healthy parenting, valuing
culture
Education success factors:
 High expectations of students
and promoting positive
Indigenous identity
 Community development focus
 ‘Whole of institution’ approach
 Well-trained, high quality
teachers
 Indigenous culture and
knowledge valued
Connection to family, community, culture and
country pathway to health: promotes well-being,
protective of health, social support
Culture success factors:
 Clear planning
 Locally driven and owned by
Indigenous communities
 Elders
 Land and country as means of
healing
 Strengths focus
 Women taking leadership &
governance roles
 Good staff
 Strategic inter-sectoral partnerships
Employment and income pathway to health:
more resources for health and wellbeing
Employment & income success
factors:
 Employment service agencies that have
culturally competent trained staff,
commitment to Indigenous peoples, links
to business, collaborative partnerships
with Indigenous communities, holistic
support
 Income management – controversial and
evidence lacking for success in improving
financial management skills
 Increasing employment opportunities
complex and embedded in history, racism
Housing pathway to health: complex, multidirectional and has large impact on health
especially in remote communities
Housing success factors:
 Standardised method for improving health
hardware
 Local skills
 Collaboration with Indigenous housing
associations
 Preventing homelessness
 Strengths based, holistic case
management
Racism pathway to health: increases stress with
impacts on mental and physical health
Anti-racism success factors:
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Anti-discrimination legislation
Universal interventions across settings
Organisational development (e.g AFL)
Social marketing & Diversity training:
challenge false beliefs; accurate info on
Indigenous culture and impact of racism
on health, emphasise shared values,
involve Aboriginal people in development
and design
Interaction with government systems pathway to
health: treatment in these criminal justice, health
etc. systems impacts directly on health
Changing system success
factors:
 Culturally competent staff and service
delivery
 Indigenous people working in systems
 Holistic, strengths based
 Collaborative partnerships
 Community development approach e.g.
whole of community approach to crime
prevention
 PHC in health system
Health behaviours pathway to health: lifestyles
affect health but they in turn reflect SDH
Health behaviours success
factors:
 Acknowledge impact of broader
determinants of health
 Influence environments e.g. outlets selling
tobacco
 Supply restriction
 Use strong community relationships to
promote healthy lifestyles
 Engage young people in alternative
activities
What we don’t know
Lack of good
evaluation data
• Evaluation culture
weak
• Resistance to
adverse results
rather than interest
in learning
• Mainstream service
evaluation
Casual links
complex
Relative
contribution
• Multi-directional
relationships
• Casual links not
linear or straight
forward
• Hard to say how
much each
determinant
contributes to
health
• Interactive
effect
Lessons from what works
> Mainstream social determinants need to be flexible in order to
respond to needs of Indigenous people
> Cross government co-ordination and collaboration between
government and community sector vital
> Leadership with full commitment to CTG
> Colonisation context: cultural, legacy of trauma and grief need to
inform all action
> Active engagement of Indigenous peoples including employment
of Indigenous staff
> Long term not short term pilot funding
> Strengths based approaches
> Good research and evaluation with adequate funding including
of universal services
Action on SD of Indigenous health requires
that we decide to commit resources
Poverty and inequity is “not a
preordained result of the forces of
nature or the product of a curse of
the deities. But the consequences of
decisions which men and women
take or refuse to take.”
(quoted in Heywood and Altman,
2000, p.173)
Q & A session
Professor Fran Baum
Morning Tea
Engaging with Indigenous Australia –
Exploring effective engagement with
Aboriginal and Torres Strait Islander
communities
Dr Janet Hunt
Fellow, Centre for Aboriginal Economic Policy Research
Research School of Social Sciences
Australian National University
What evidence did I look for?
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Literature in Australia – especially around regional engagement (16 studies
from 12 diverse regions)
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And in sectors: health, natural resource management, early childhood
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With NGOs and companies, not only governments
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Indigenous engagement in other settler countries (Canada, USA, New
Zealand)
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Engagement with marginalised people and placed–based approaches
What is ‘engagement’?
• ‘Engagement’ is a sustained relationship
between groups of people working towards
shared goals
• There is a spectrum of engagement – from low
to high
The spectrum of engagement
Aboriginal community:
• Has control – defines problem, goals & means
• Has delegated decisions
• Plans jointly
• Advises
• Is consulted
• Receives information
Factors in engagement
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History, culture and language
Indigenous ‘communities’
Scale of engagement – multilayered?
Governance & capacity
Engaging with organisations
Purpose
Timeframes & media
Policy Context
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National policy
National mechanisms
Guidelines
Recent Commonwealth approaches
States & Territories
Remote Australia
Native Title and land rights
UN Declaration on Rights of
Indigenous Peoples
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Article 18: Indigenous peoples have the right to participate in decision
making in matters which would affect their rights, through representatives
chosen by themselves in accordance with their own procedures, as well as
to maintain and develop their own Indigenous decision making institutions.
•
Article 19: States shall consult and cooperate in good faith with the
Indigenous peoples concerned through their own representative institutions
in order to obtain their free, prior and informed consent before adopting and
implementing legislative or administrative measures that may affect them
(UN General Assembly 2007:8).
Australia: Regional studies
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COAG trials (one in each jurisdiction - 7)
Murdi Paaki Regional Assembly (5 studies)
Ngaanyatjarra Regional Partnership (Sullivan)
Noongar – 3 approaches (Barcham)
Fitzroy Futures Forum (ATSI SJC)
Lockhart River Qld (Hagan)
Groote Eylandt & Bickerton Island RPA (Tempo)
What worked
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Leadership
Resources
Participatory processes
Governance & capacity building
Leadership
• High-level government engagement; clear, adaptable
policy framework for WOG, place-based approach.
• Regionally based senior people with decision making
authority & high-level negotiation skills; staff building
trust and respectful relationships.
• Leadership across all levels, governments and
communities. People on the ground willing to try new
approaches and make things work; ‘one size doesn’t fit
all’ communities.
Resources
• Partnership processes themselves resourced: staff to
manage the engagement & follow up decisions made
• Resources available to build partner capacities & to
undertake the programs jointly agreed.
• Having flexible funds for all these purposes
contributes to success.
Participatory Processes
•
Communities were setting the agenda
•
Planning started from community level upwards to regions.
•
There was identification of Aboriginal strengths, assets and
positives; leadership being developed
•
‘Less monitoring and more mentoring’ (Hagan 2009:27)
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Clarity about processes and effective communication.
•
Clarity and agreement about desired outcomes and indicators, and
well-developed plans to achieve them
•
long time frames: people ‘work at their pace and in their spaces’
(Hagan 2009:25); ‘change is chaotic and emergent’ (Hagan 2009:31)
not a linear process.
Governance & capacity building
• Built on existing Indigenous governance structures,
mechanisms and processes wherever possible
• Support and capacity building for communities and
community representatives for engagement with
governments
• Ongoing governance development; processes and
structures designed by Aboriginal people - viewed by
them as legitimate.
• Cultural legitimacy and government funding for regional
governance body for engagement.
Groote Eylandt RPA
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Ministerial support
Community driven partnership
ALC – strategic approach
Community $ and leverage,
plus other funds
• Collaboration & trust
• Vision & high level leadership
• Effective implementation
Groote Eylandt RPA
• Needs more integrated plans
and pooled funding
• Better alignment across govts
• More streamlined &
collaborative processes at
local level
Replicable? Key success factors
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Equality between partners & authority to proceed
Community needs, aspirations the driving force
Objectives, priorities shared by all parties
Detailed planning & negotiation from outset
Principles of operation - touchstone for
partnership operations
• Adequate resourcing & long time frame
• Responsive & efficient management
What didn’t work
• Government arrangements
• Communities’ capacities
• Relationships
Government arrangements
• Different jurisdictions and departments with
differences never resolved
• High-level government goals not adequately
translated into specific plans and actions
• Organisational cultures discouraged flexibility
and risk taking
• Insufficient focus on relationship building
• No streamlined, flexible funding
Communities’capacities
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•
Communities with weaker capacity to engage with
government, or cynical about the ability of
governments to change; little government support
for community learning/capacity building.
Community-level governance problems impeded
their leaders’ ability to engage effectively with
governments.
Relationships
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Insufficient participation, sense of shared ownership
by Indigenous people in decision-making
No genuinely shared objectives, performance
indicators or benchmarks, or data for M & E
Government agencies weren’t clear about roles and
responsibilities in the partnership arrangements
Government limitations not made clear to
Indigenous partners from the outset
What works: sectoral findings
• Long term relationships based on trust
• Working within a framework of Aboriginal-driven
decision making
• Power inequalities are addressed–strong mutual
accountabilities
• Culturally competent staff
• Shared responsibility and accountability for
shared objectives
What didn’t work? Example from Coastal
zone decision-making (Rockloff & Lockie 2006)
- Aboriginal people’s lack of financial & technical resources
- Inequity re participation in meetings unpaid
- Aboriginal people expected to attend bureaucratic meetings,
with set agendas, & discuss issues through a ‘western’ lens
- Little confidence that listened to & knowledge respected
- Govt agencies & others failed to acknowledge considerable
diversity among Aboriginal people (3 distinct cultural groups
with own languages, customs, aspirations etc.)
Solutions?
• Indigenous people agenda-setting
• Capacity building – support (financial & other) for
Aboriginal involvement; modification of processes &
structures
• Cultural awareness training for government
• Ensuring Aboriginal specific views are respected,
recorded; investing in relationships and communication
based on equality, openness, & respect for each other’s
values
• Supporting the development of Aboriginal governance
structures (starts to challenge the power inequalities)
What works: Relationships
• Responding to Indigenous history, cultures and
social dynamics
• Valuing skills and knowledge of community
organisations and Indigenous people
• Clarity about purpose and relevant scale for
engagement
• Engagement needs to relate to Indigenous
concepts of wellbeing (not just COAG targets)
What works: Relationships
• Long-term relationships of trust, respect and
honesty
• Accessible, ongoing communication and
information
• Effective governance and capacity - Indigenous
& among governments
• Appropriate timeframes
What works: Participatory processes
• Indigenous agency & decision-making from the
outset
• an Indigenous-driven process with government
as facilitator/enabler
• builds on existing community governance
structures and Indigenous strengths and assets
• an empowering process - small achievements
towards mutually agreed longer term goals
What works: Participatory Processes
• Recognition of power inequalities - sincere attempts to
share power, through agreements
• Transparency of decision making processes and agreed
conflict resolution mechanisms
• Strong mutual accountability relationships in agreements
• A high degree of clarity about desired outcomes,
indicators
• Clearly defined roles and responsibilities in agreements
and partnerships, some continuity of personnel
• Parties engage in joint planning of monitoring and
evaluation to meet rights and needs of each
What works: Governance & leadership
• Effective and legitimate Indigenous governance
arrangements
• Strong and strategic Indigenous leadership
• Indigenous leadership resourced & supported for
engagement
• Very high level leadership, flexibility, and secure,
adequate resources within governments
• Honesty about resource (or other) limitations; set
achievable goals
• Culturally competent staff able to build trusting
relationships
What works: Governance & leadership
• Investment in strengthening the governance of both
Indigenous and government partners for effective
partnership working
• Building on existing community organisations and
governance structures
• Governments have capacity to respond to Indigenous
priorities with pooled and flexible funding arrangements
Q & A session
Dr Janet Hunt