Transcript Document

What works? The social and economic
determinants of Indigenous health
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 but 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, universal education, public housing)
Osborne, Baum & Brown, 2013
WHAT SOCIAL DETERMINANTS INTERVENTIONS
WORK TO IMPROVE INDIGENOUS HEALTH??
Diversity of
Indigenous
peoples:
cultures, place
of residence
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 intersectoral 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 – Aboriginal
Community Control need to be
supported
Overburden report
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, junk food
 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
Need developmental complex evaluation
> Total impact of policies not just aspects e.g. Northern Territory
intervention impact on empowerment and control which impact
on health
> Interaction between policies – e.g. welfare, housing and health
> Long-term stable policy that can be evaluated
> Participation of recipients of policy and programs in the
evaluation
> Overall goals of policy (e.g. Closing the Gap) and then
determining the proportion different policies contribute
> Policy maker readiness to hear and consider the results
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)
Panel discussion and Q&A session
Professor Fran Baum, Flinders University
Matthew James, Assistant Secretary of the
Evidence and Evaluation Branch of the
Schools, Youth and Evidence Division at the
Department of the Prime Minister and
Cabinet