How do these factors affect the use of primary health care services?
Individual and family level factors and experiences
A recent review of the literature on the cultural determinants of health for Aboriginal and Torres Strait Islander people showed that family/community, country and place, cultural identity and self-determination all have strong protective effects on health and wellbeing (Verbunt et al. 2021).
The link between self-reported perceptions or experiences of racism and poorer physical and mental health is well established (Kelaher et al. 2014). Racism can lead to reduced access to resources that are associated with good health outcomes, such as education, employment, housing and medical care. Studies have also found a strong association between experiences of racism and ill-health, psychological distress, mental health conditions and risk behaviours such as substance use (Paradies et al. 2015; Priest et al. 2011).
The Mayi Kuwayu Study of Aboriginal and Torres Strait Islander Wellbeing contained a number of questions about respondents’ experiences of everyday discrimination, with 42% reporting no discrimination, 48% low discrimination and 11% moderate to high discrimination (Thurber et al. 2021). Those who reported no discrimination experienced better overall health; however, the authors found statistically significant associations between experiences of everyday discrimination and poorer outcomes across several domains, including:
- social and emotional wellbeing (SEWB) outcomes – frequent experience of pain, low life satisfaction, low happiness, high or very high psychological distress, doctor-diagnosed anxiety, doctor-diagnosed depression
- culture and identity outcomes – feeling low control over life; feeling torn between cultures; feeling disconnected from culture; choosing not to identify as Aboriginal and/or Torres Strait Islander in the Census, or within study, work, Centrelink, or real estate contexts
- health behaviours – smoking, gambling, alcohol dependence
- health outcomes – poor/fair general health, doctor-diagnosed heart disease, high cholesterol, high blood pressure, diabetes.
A number of studies have shown that experiences of racism in the health system also led to delays in seeking and receiving health care (Aspin et al. 2012; Baba et al. 2014; Ben et al. 2017; Durey and Thompson 2012).
Socioeconomic factors can affect health and health status in a number of ways, including through access to financial and social resources, psychosocial factors and health behaviours. A recent AIHW analysis indicates that social determinants of health explain 35% of the total health gap between Aboriginal and Torres Strait Islander people and non‑Indigenous Australians, with household income and employment/hours worked explaining 14% and 13% of the gap, respectively (AIHW 2024b). Higher levels of income are associated with higher levels of health service use and with better overall health (AIHW 2023a; Ou et al. 2010, 2011).
Location factors
There are variations across Australia in the location of health services, so where people live affects how easy or difficult it is to access services in general (and timely, affordable and culturally responsive services in particular).
Modelling of how Aboriginal and Torres Strait Islander people’s local access to Aboriginal and Torres Strait Islander specific PHCOs varies geographically across Australia found that this type of care appears to be well positioned relative to the geographic distribution of the Aboriginal and Torres Strait Islander population (AIHW 2023a); however, it also identified 29 medium-sized areas estimated to have at least 200 Aboriginal and Torres Strait Islander people who had no Aboriginal and Torres Strait Islander specific PHCO available within a 1-hour drive and relatively poor access to GP services in general. Lack of access to transportation has also been reported as a significant barrier to accessibility of care (Nolan-Isles et al. 2021).
Health system characteristics
The health system includes several levels – the individual workers with whom Aboriginal and Torres Strait Islander people engage, the characteristics of the organisation/facility, and higher level policy/funding requirements.
How the health system is funded (and subsequent costs to patients/clients), where services and providers are located, and the capacity of local providers to deliver culturally responsive and appropriate care directly affects the ability of Aboriginal and Torres Strait Islander people to access and use that care (Coombes et al. 2018; Pearson et al. 2020). For example, Beks and colleagues (2023) found that ACCHOs are often constrained from being responsive to local community needs by systemic rules. When an organisation wanted to implement a mobile clinic, one of the challenges was that MBS home care items could not be used to pay for visits because of the MBS funding rules for that item.
There is considerable evidence on systemic factors that affect not only the ability of Aboriginal and Torres Strait Islander people to access primary health care but also the ways in which the system can be more responsive in delivering health care to Aboriginal and Torres Strait Islander people. Nolan-Isles et al. (2021) identified 6 themes across 3 communities as being of critical importance (as either opportunities or barriers) – which are consistent with the findings of other studies (for example, Coombes et al. 2018). These themes were:
- improved coordination of health care
- better communication between providers and patients
- trust in providers and cultural safety
- importance of prioritising health care by Aboriginal and Torres Strait Islander people
- importance of reliable, affordable and sustainable care
- distance and transport availability.
It is important to note that ACCHOs in particular (Box 2.1) and other IAHP-funded services were developed and are funded to tackle these issues specifically.
Box 2.1: Role of ACCHOs
ACCHOs are primary health care services operated by local Aboriginal and Torres Strait Islander communities, and controlled through locally elected boards. They deliver comprehensive, holistic and culturally appropriate health care to their communities, particularly in areas where mainstream health services have failed to engage and empower their communities. The first ACCHO opened in Sydney in 1971; now there are over 140 ACCHOs operating more than 300 clinics across Australia (NACCHO 2024).
Over half of the full-time equivalent positions (FTEs) in the ACCHOs who reported to the 2022–23 OSR were Aboriginal and Torres Strait Islander people, making ACCHOs collectively one of the largest employers of Aboriginal and Torres Strait people in Australia.
ACCHOs respond to the health-care needs of Aboriginal and Torres Strait Islander people in a variety of ways; for example by:
- delivering culturally meaningful chronic disease care that other models of primary care do not (Wyber et al. 2023)
- providing specialised clinical care to Aboriginal and Torres Strait Islander people for conditions that are uncommon in other populations in Australia
- promoting the psychosocial health and wellbeing within the community.
ACCHOs also directly and indirectly respond to the social determinants of health, and drive change, such as by:
- reducing institutional racism
- meeting the social and cultural needs of their communities
- reducing inequities that disadvantage Aboriginal and Torres people
- providing training for Aboriginal and Torres Strait Islander staff to obtain qualifications (Pearson et al. 2020).
Having the option of attending ACCHOs is important to Aboriginal and Torres Strait Islander people who feel more comfortable using services where culturally safe care is delivered (Pearson et al. 2020), where they can talk to health professionals who understand that health is not only about physical health but a ‘whole-of-person’ concept, and where they have access to health providers who are themselves Aboriginal and Torres Strait Islander people (NACCHO 2021).
Through its focus on prevention, early intervention and comprehensive care, ACCHOs have reduced barriers to access health care and are improving individual health outcomes for Aboriginal and Torres Strait Islander people (Panaretto et al. 2014). During the COVID-19 pandemic, responses by Aboriginal and Torres Strait Islander communities were commended worldwide as a demonstration of how self-determination can achieve optimal health outcomes for Indigenous populations (Dudgeon et al. 2023).
For more details on the model of Aboriginal and Torres Strait Islander Community Controlled Comprehensive Primary Health Care, see NACCHO’s Core Services and Outcome Framework (NACCHO 2021).
The following section of this chapter provides an overview of the variables selected from the 2018–19 NATSIHS. It begins by outlining the ‘outcome’ variables (primary health care variables), before presenting a detailed discussion of the independent variables and their distributions (the distribution of the primary health variables are presented in Availability of services in local areas.