What works

There are significant health inequities between Indigenous and non-Indigenous Australians, and the health disadvantages experienced by Indigenous Australians are shaped by the broader social and economic conditions in which they live. In this paper, we review evidence relating to improving Indigenous outcomes and ‘closing the gap’ across a range of key social and economic determinants of health and wellbeing.

For each key determinant area, there are particular issues which contribute towards success, and we have identified these in the relevant chapters. Below are some general issues which are relevant across all determinant areas and characterise successful programs and interventions when taking a social determinants approach. A social determinants approach considers the broad social, political, economic, cultural and environmental context in which people live and the impact these contexts have on health and wellbeing. The causal pathways between social determinants and health are complex and multi-directional. For the programs we have reviewed in each determinant area, establishing direct causal relationships with health outcomes is not possible. It is possible, however, to make causal inferences by linking the program activity with other factors that are known to be associated with improved health. In identifying ‘what works’, we have identified successful (or unsuccessful) elements of programs which, if they improve outcomes for Indigenous people in that particular area, may be associated with long-term benefits for health and wellbeing.

Effective approaches are characterised by the following:

  •  holistic approaches which work with Indigenous people in ways which take into account the full cultural, social, emotional and economic context of their lives, including an awareness of the ongoing legacy of trauma, grief and loss associated with colonisation
  • active involvement of Indigenous communities in every stage of program development and delivery, in order to build genuine, collaborative and sustainable partnerships with Indigenous peoples, and build capacity within Indigenous communities
  • collaborative working relationships between government agencies and other relevant organisations in delivering services and programs, acknowledging the interrelatedness of key social and economic determinants across multiple life domains for Indigenous Australians
  • valuing Indigenous knowledge and cultural beliefs and practices which are important for promoting positive cultural identity and social and emotional wellbeing for Indigenous Australians
  • clear leadership and governance for programs, initiatives and interventions. This includes commitment from high level leadership of relevant organisations and agencies to the aims of reducing Indigenous disadvantage and addressing determinants of health and wellbeing
  • employing Indigenous staff and involving them fully in program design, delivery and evaluation, and providing adequate training, where necessary, to build capacity of Indigenous staff
  • developing committed, skilled staff (Indigenous and non-Indigenous) and providing diversity and cultural awareness training
  • in cases where programs demonstrate success, it is important to provide adequate, sustainable resources for long-term, rather than short-term funding
  • adopting a strengths-based perspective which builds and develops the existing strengths, skills and capacities of Indigenous people
  • clear plans for research and evaluation to identify successful aspects of programs, provide a basis to amend and improve, demonstrate success and build an evidence base to justify allocation of ongoing resources.

What doesn’t work

The evidence reviewed in the paper suggests the following aspects hinder the ability of programs and interventions to be successful in addressing the social determinants of health to reduce health inequities:

  • not involving Indigenous communities in design, delivery and evaluation of programs, and limited consultation with, and opportunities for the participation of Indigenous representatives
  • not training and employing Indigenous staff to contribute towards program implementation and delivery
  • short-term funding and not continuing to fund programs which have demonstrated success – which can contribute towards Indigenous people feeling loss, disappointment and anger at being let down by the system
  • ad-hoc approaches to implementation which may rely upon a handful of people but have no clear leadership or governance
  • not having plans for built-in research, evaluation and monitoring which can build an evidence base and can be used as a basis for advocacy for good practice interventions.

What we don’t know

The following points relate to information ‘gaps’ that restrict our ability to specifically identify ‘what works’ in relation to addressing the social determinants of Indigenous health:

  • Across all of the key determinant areas, there is a lack of high quality, publicly available evaluation data regarding programs and interventions, which limits the ability to identify success associated with such programs.
  • Because social and economic determinants of health are ‘upstream’ or distal causes of population health outcomes that are mediated through a variety of pathways, there are no clear causal links as the relationships are complex and multi-directional.
  • Furthermore, it is difficult to identify which social and economic determinants contribute directly to cause particular health outcomes, or the relative contribution of different social determinants to different health outcomes. This would require extensive multivariate modelling of high quality longitudinal epidemiological data, and is beyond the scope of this issues paper.