Biosociocultural Determinants of Health for ATSI Communities
✨✨ Sociocultural Determinants ✨✨
✨ 1. Social Determinants
| Determinant | Current Status | Mechanisms of Harm | Contribution to Health Gap* |
|---|---|---|---|
| Income & Employment | Median household income ≈ 60% of non-Indigenous; unemployment twice the national rate | Limits access to nutritious food, stable housing, and transport for healthcare | ~14% |
| Education | Year 12 completion: 66% (vs 90% non-Indigenous) | Low health literacy, limited employment options | ~8% |
| Housing | 18% in overcrowded dwellings | ↑ Risk of communicable disease: – Skin infections: Scabies, impetigo, MRSA. – Respiratory infections: Acute otitis media, pneumonia, tuberculosis. – Post-streptococcal complications: ARF, PSGN ↑ Exposure to domestic violence and psychological stress. ↑ Mental health burden (e.g. anxiety, depression) | ~6% |
| Justice System | Incarceration rate: 2,330/100,000 (32% of national prison population) | Family separation, exposure to violence, infectious diseases, disability | — |
AIHW modelling estimates that social determinants account for ~35% of the total gap in health-adjusted life years.
✨ 2. Additional Contributing Factors
- Unemployment, homelessness, financial stress
- Limited access to affordable fresh food, especially in remote areas with only one store
- Transport barriers limiting access to primary and specialist care
- Low health literacy, fear of medication side effects, poor understanding of chronic illness management
- Historical distrust of healthcare, stemming from colonisation and systemic racism
- Cultural and linguistic barriers, including limited GP cultural competence and lack of Aboriginal Health Workers (AHWs)
✨ 3. Environmental & Geographic Determinants
- Remoteness: ~17% live in very remote areas with poor access to health services, nutritious food, and clean water
- Water and sanitation: Ageing infrastructure and drought increase rates of gastroenteritis and skin infections
- Climate change: Increases in heat stress, spread of vector-borne disease, disruption to cultural fire practices
✨ 4. Health System Determinants
- Workforce inequity: <1% of Australian doctors identify as Aboriginal or Torres Strait Islander
- Service availability: Fewer GPs and specialists per capita in remote areas; limited after-hours care
- Cultural safety: Improved outcomes when care is delivered by, or in partnership with, Aboriginal Community Controlled Health Services (ACCHSs)
✨ 5. Historical & Political Determinants
| Factor | Health Impact |
|---|---|
| Colonisation & Dispossession | Loss of land, food systems, and livelihoods; forced relocation to missions and reserves |
| Stolen Generations | Intergenerational trauma, disrupted family attachment, institutional mistrust |
| Assimilation Policies | Suppressed language and culture; eroded cultural determinants |
| Systemic Racism | Inadequate funding, disempowering policies, and lack of Indigenous governance in services |
✨6. Cultural Determinants
| Domain | Key Concepts | Clinical Implications / Tips |
|---|---|---|
| Connection to Country, Language, Kinship & Spirituality | Core to identity and wellbeing; protective against mental illness, substance use, poor nutrition. | Ask where “home” is. Involve Elders/cultural mentors. Support time on Country and cultural leave. |
| Cultural Safety & Racism | Racism (systemic/interpersonal) causes delayed help-seeking, DAMA, distrust. | Apply RACGP cultural safety standards. Use reflective practice, training, anti-racism policies. |
| Cultural Protocols (Men’s/Women’s Business, Kinship, End-of-life) | Gender/kinship define who can discuss health. Sorry Business impacts care. | Offer same-gender clinicians. Clarify decision-makers. Respect Sorry Business. |
| Shame, Privacy & Hospital Fear | “Shame” inhibits open discussion. Hospitalisation causes anxiety due to separation from family/Country. | Reinforce confidentiality. Use telehealth/family escorts. Normalise sensitive health topics. |
| Language & Communication | Up to 60% in NT speak Aboriginal language first. Interpreters underused. | Use accredited Aboriginal interpreters. Allow pauses. Use visual aids and storytelling styles. |
| Holistic Health View | Health = wellbeing of individual + family + community + Country. | Address social determinants (e.g. housing, food). Incorporate cultural strengths in care plans. |
| Historical & Intergenerational Trauma | Trauma from colonisation, removals, marginalisation leads to distress and mistrust. | Use trauma-informed care. Build trust. Promote resilience. Ensure emotional/cultural safety. |
| Kinship Responsibilities & Sorry Business | Family obligations take priority over appointments or treatment. | Ask about cultural duties. Offer flexibility and outreach if needed. |
| Traditional Healing & Bush Medicine | Use of Ngangkari and bush medicine remains common. | Respect traditional treatments. Coordinate care with consent. Acknowledge healer roles. |
| Time Orientation & Flexibility | Time viewed relationally; strict punctuality may conflict with cultural norms. | Offer flexible scheduling, group/walk-in appointments, SMS reminders, community outreach. |
| Service Access & Transport Barriers | Challenges: distance, cost, literacy, health system complexity. | Link with ACCHOs, Indigenous Liaison Officers, transport schemes. Simplify processes. |
✨✨ Biomedical Determinants ✨✨
1. Genetic & Biological Factors
| Point | What the evidence actually shows | Bottom-line contribution |
|---|---|---|
| Classic “disease genes” | The largest GWAS in Aboriginal Australians (1 263 participants) found a single significant signal for acute rheumatic fever/rheumatic heart disease in the HLA class II region. Effect sizes were modest and explain only a fraction of risk. Menzies Institute for Medical Research | Small. No “Indigenous gene” explains the much higher chronic-disease burden. |
| “Thrifty gene” hypothesis | Originally proposed to explain diabetes in several Indigenous populations. Decades of candidate-gene and GWAS work have failed to identify any high-frequency “thrifty” alleles with large effects; most experts now regard it as unproven. | Minor at best — social and environmental factors dominate. |
| Thrifty phenotype / epigenetic programming | Maternal under-nutrition, stress and hyperglycaemia alter fetal DNA-methylation and histone marks at metabolic and inflammatory genes. Emerging epigenomic work in First Nations cohorts links these changes to earlier onset of type 2 diabetes, CKD and CVD. | Moderate — interacts strongly with post-natal environment. |
| Gene–environment interplay | Genetic variants may slightly modify susceptibility (e.g. HLA for ARF, APOL1 for kidney disease in some populations) but they act within the context of housing, nutrition, infection load and health-care access. | Adds nuance rather than driving the gap. |
2. Demographic structure
- Median age: First Nations Australians ≈ 24 years versus 38 years for the total Australian population. Australian Parliament House
- Implications
- Higher proportions of pregnancies, childhood infections, injury, youth mental-health presentations.
- However, even age-standardised rates of chronic and infectious disease remain 2–3 times higher, so the younger age profile does not explain the bulk of the burden.
2. Modifiable Risk Factors
- Tobacco use, poor diet, physical inactivity, harmful alcohol use
- Chronic stress and racism → chronic cortisol elevation (allostatic load)
Chronic Disease Burden
| Pathway | Scientific explanation |
|---|---|
| Foetal & early-child “programming” | High rates of low birth weight and maternal under-nutrition activate thrifty phenotype adaptations (reduced β-cell mass, altered insulin signalling) → ↑ lifetime risk of T2DM, CVD. |
| Intergenerational trauma & chronic stress | Sustained HPA-axis activation, epigenetic methylation of inflammatory and metabolic genes, and adverse childhood experiences contribute to hypertension, metabolic syndrome and mental-health comorbidity. |
| Behavioural risk factors shaped by environment | Daily smoking still 3× national rate; energy-dense diets, low physical-activity infrastructure, and alcohol misuse—all coping responses to disadvantage—drive obesity, NAFLD, CVD and certain cancers. |
| Post-infectious sequelae | Recurrent GAS skin/throat infection → RHD; PSGN → CKD; chronic otitis media → hearing loss → poorer education/employment (feedback loop). |
| Under-resourced primary prevention | Lower participation in health assessments, cancer screening and pharmacological primary prevention; later-stage presentation of chronic illnesses. |
Overall, the total burden of disease in 2018 was 2.3 times that of non-Indigenous Australians; mental/substance use disorders, CVD, diabetes and chronic kidney disease are the leading contributors.
| Condition | Notes |
|---|---|
| Type 2 Diabetes | Screen all ATSI adults ≥18 years (non-Indigenous: AUSDRISK ≥40 y every 3 years) |
| Chronic Kidney Disease | Up to 10× higher incidence |
| Cardiovascular Disease | Premature atherosclerosis; driven by diabetes, HTN, obesity, dyslipidaemia |
| Cancer | ↑ Lung (40% smoking), ↑ Cervical (late screening), ↑ Liver (alcohol, Hep B/C, NAFLD) |
Infectious Disease Burden
Pathways to a Higher Infectious-Disease Burden
| Pathway | Evidence & effect |
|---|---|
| Crowding + inadequate sanitation | Directly increases transmission of GAS, scabies, influenza, RSV, tuberculosis and diarrhoeal pathogens. RHD registries show 78 % of Australian cases occur in Indigenous people. |
| Climate & geography | Tropical humidity favours GAS/skin infections; extremes of heat impair food storage & sleep, worsening immunity. |
| Health-system barriers | Fewer AMS (Aboriginal Medical Services) per capita in very-remote areas; workforce shortages → later antibiotic therapy for sore throats/skin sores. |
| Comorbid chronic disease | Diabetes, CKD and under-nutrition suppress immune responses and prolong carriage. |
| Historically lower vaccination coverage | (now largely closed but some lag in remote NT/WA communities) → periodic measles, influenza, pertussis clusters. |
Interaction between Infectious & Chronic Pathways
- Early, untreated infections seed chronic pathology (ARF→RHD; hepatitis B→cirrhosis/HCC).
- Chronic diseases (T2DM, CKD) in turn increase infection risk, creating a reinforcing cycle.
| Condition | Key Points |
|---|---|
| Scabies & Impetigo | Precursor to GABHS infection → ARF, PSGN |
| Otitis Media | Chronic tympanic perforations in ~50% of children |
| Streptococcal Infections | Highest global ARF rates (~250–300/100,000 children) |
| TB, Leprosy | Related to poverty, overcrowding; screen with nerve function test if suspect leprosy |
| Trachoma | Treat with azithromycin stat; hygiene essential |
| Conjunctivitis | Swab for MCS + Chlamydia; consider gonococcus |
| Worms | Hookworm causes anaemia; deworm every 6 months |
| MRSA | TMP-SMX preferred over flucloxacillin |
| Fungal Infections | Common tinea; requires antifungal treatment |
| STIs / PID | High prevalence; routine screening critical |
✨ Vaccination in ATSI Communities
| Vaccine | Schedule |
|---|---|
| BCG | At birth in high-risk areas |
| Meningococcal B | 2, 4, 12 months (+ 6 months for high-risk) |
| Pneumococcal (13v, 23v) | 6 months, 4 years, 9 years; then 50, 51, 56 years |
| Hepatitis A | 18 months and 4 years |
| Influenza | Annual from 6 months |
| Shingrix | Start at 50 years (2 doses, 2–6 months apart) |
✨ Child and Adolescent Health Issues
- Paediatric: Low birth weight, FTT, recurrent infections, chronic anaemia
- Adolescent: High rates of mental illness, early pregnancy, STIs, substance misuse (e.g. cannabis, solvents)
✨ Mental Health and Suicide
- Suicide rates 2–3× higher than non-Indigenous Australians
- Contributing factors: intergenerational trauma, incarceration, racism, substance use, and lack of culturally safe care
✨Domestic and Family Violence
- Hospitalisation rates for assault are significantly higher for ATSI women
- Pregnancy is a recognised period of heightened risk
→ Warning signs: late antenatal care (>28 wks), abdominal/genital trauma
→ Always assess safety along with smoking, alcohol, nutrition
✨✨ Clinical Practice Priorities ✨✨
- Respect cultural protocols (e.g. men’s/women’s business)
- Build trust; acknowledge historical trauma
- Use plain, jargon-free language; confirm understanding
- Collaborate with AHWs and ACCHSs
- Consider social context (housing, food, transport)
- Proactive screening: diabetes, CKD, hearing, STIs, mental health
- Ensure immunisation is up to date with ATSI-specific schedules
✨✨Explaining the Health Disparity ✨✨
Why the disparity with non-Indigenous (“white settler”) Australians?
- Colonisation created the baseline disadvantage – dispossession and forced dependency dismantled established economies and food systems.
- Cascading social inequality – unequal schooling, employment, housing and justice‐system bias perpetuate poverty and stress.
- Structural racism in systems – health, education and justice services were designed without Indigenous governance, leading to cultural unsafety and lower utilisation.
- Inter-generational trauma – neuro-biological and socio-economic impacts are transmitted across generations.
- Under-investment – per-capita health spending within the universal system is lower once remoteness costs are excluded, and social programmes are chronically short-term.
✨✨ Take-home mnemonic – “BIO-SOCIAL-CULTURAL-PLACE”✨✨
Biology & behaviours → Income/education/employment → Overcrowding & housing
Stress of racism → Out-of-reach services → Cultural connection (protective)
Inter-generational trauma → Access to justice → Location & environment
Political history → Land dispossession → ACCHS strength → Climate & water → Empowerment/self-determination