The health status of the Aboriginal and Torres Strait Islanders (hereafter respectfully referred to as Indigenous) peoples in Australia has been significantly improved since the Closing the Gap initiative being a national policy priority for the last 15 years. However, compared with non-Indigenous Australians, Indigenous Australians are 1.7 times as likely to have a disability or restrictive long-term health condition, 2.7 times as likely to experience high or very high levels of psychological distress, and 2.7 times as likely to smoke [1]. Overall, Indigenous Australians have a shorter life expectancy than non-Indigenous Australians [1].

The Australian Institute of Health and Welfare reported [1] that 34% of the health gap was due to social determinants such as education, employment, income, and poorer quality housing, 19% to health risk factors such as smoking, risky alcohol consumption, exercise less, risk of high blood pressure, smoking and obesity, and 47% to health system factors such as institutional racism and difficulty in accessing affordable health services that are nearby.    

The health system factors remain a challenge despite various interventions to improve health services.

The Showcase Day Event

Metro North Health (MNH) in Queensland Australia is the largest Hospital and Health Service (HHS) organization in Australia, with 16 hospitals/services that deliver healthcare to a population approaching 900,000, from north of the Brisbane River to north of Kilcoy. On 6 July 2022, MNH launched its Health Equity Strategy to improve health outcomes and ensure life expectancy parity by 2031 for Aboriginal and Torres Strait Islander peoples [2], which was formulated after 12 months of engagement and consultation with Aboriginal and Torres Strait Islander community groups.

The strategy is an organizational commitment to eliminate institutional racism and improve across the entire health system, including measurable targets in healthy birth weight of babies, reduced suicide with a focus on culturally safe mental health, zero long-waits for planned care, and increased pregnancy education.

On 1 March 2023, after over six months of implementation of the Strategy, MNH held a one-day Aboriginal and Torres Strait Islander Showcase to share the successful stories and lessons learnt from all sectors in MNH.

The areas of successful interventions presented on the Showcase Day covered areas of mental health, women’s health, emergency medicine, cancer screening, access to medication when discharging from the hospital, access to surgery, outpatients care, outreach programs, and cultural safety programs.

Most interventions focused on the health system, including the active engagement of local Indigenous communities and effective connection and transition between primary and tertiary healthcare in both directions.

Two specific examples are presented here to illustrate the above points: emergency medicine and access to surgery.

Example 1: Emergency Department (ED) at Royal Brisbane and Women’s Hospital (RBWH)

The presentation of “Doing things differently for Cultural Safety by embedding a First Nations Senior Health Worker in the Emergency Department at Royal Brisbane and Women’s Hospital” described how the newly employed Indigenous Senior Health Worker used Equity Based Principles to support clinicians and staff education. The co-designed supporting discharge intervention is one of its highlights.

It has been a constant challenge for people to voluntarily discharge themselves from hospital ED against medical advice, including Did Not Wait (DNW) and Left After Treatment Commenced (LATC). With the leadership and support from the Indigenous Senior Health Worker at ED, the content of the intervention included Early Welcome (Identification and Engagement), Information (let us know if you need to go, ED Processes, Options), and Safe Follow-Up (Clinical Screen DNW, Indigenous Health Liaison Officer follow-up, Provide linkages to community care).

Compared with the data in June 2022, in August 2022 (after two months intervention), the DNW and LATC among Indigenous patients at RBWH ED decreased from 8% to 5% and 14% to 6% respectively. 

The immediate outcome also included increased patient satisfaction and decreased hospital re-presentations. It needs to be noted that the RBWH ED was the 2022 Recipient of the AL SPILLMAN AWARD from Australian College of Emergency Medicine (ACEM). This annual award recognizes the outstanding efforts of an ACEM accredited emergency department to ensure cultural safety for Aboriginal and Torres Strait Islander and M?ori patients, visitors, and staff. The award highlights the importance of cultural safety to improve health outcomes for Australian and New Zealand Indigenous communities.

Example 2: Pre-surgery Health and Wellness Check for Aboriginal and Torres Strait Islander People from Indigenous & Multicultural Health Team, Patient Flow Services at RBWH

The team presented the current challenge that conventional westernized pre surgical admission preparation only includes the necessary clinical/technical details but fails to adequately address Aboriginal and Torres Strait Islander people’s social and emotional wellbeing which describes a person’s connection to land, sea, culture, spirituality, family and community and its impact on health.

The situation at RBWH is the unacceptable high levels of Indigenous patient-initiated surgery cancellations rates (Day of surgery and within 24 hours of surgery) changed from bad to worse, it increased by 49.1% from 2018 to 2019. There was no dedicated pathway to support Indigenous patients on their surgical care journey.

The intervention to address this challenge is composed of the following elements: Develop the partnership among RBWH Surgical & Perioperative Services, Patient Flow Services and Aboriginal & Torres Strait Islander services; Collaboratively analyze the root causes that have led to the high rates of patient-initiated cancellations; Build a culturally appropriate and engaging pre surgery assessment tool and care pathway.

With the leadership of nurse navigators for Indigenous patients, the activities of the intervention included: Advocate for the health and wellbeing of our Indigenous patients; Contact Indigenous patients booked for surgery both seven and three days from surgery, to ensure the patient is appropriately prepared and healthy enough to attend surgery; Identify at-risk patients to navigate through complex health system; Facilitate early referral and connections to the right services to support them on their surgical care journey; Increased preoperative communication, a comprehensive wellness check and aim to mitigate day of surgery (DOS) cancellations and operative delays.

The initial evaluation showed that compared with the same time period in previous year, there was a 45.5% decrease in patient-initiated cancelations, 33.3% decrease in Fail to Attend, and 82.4% decrease in patients calling to cancel the surgery.

The successful stories presented at the Aboriginal and Torres Strait Islander Showcase day are from interventions and innovations in a wide range of health areas. However, there are shared elements among all of them. These are vital insights for future interventions aiming to improve the health system factors and to Close the Gap for Indigenous peoples in Australia, and potentially in other countries.

Our personal reflection and critical analysis of the shared elements among the successful interventions found that the success could be due to the following key areas: 1) the strong organizational leadership in healthcare and local communities; 2) the sustainable financial commitment; 3) the enthusiastic and culturally competent healthcare staff; and 4) the evidence-based practice approach. We will elaborate the first and the third elements with details in the following discussion, as financial sustainability and evidence-based approach are common knowledge among the researchers and practitioners in this area.

The strong organizational leadership in healthcare has been demonstrated by the vigorous process of developing the MNH Health Equity Strategy and its implementation plan, including the solid commitment from MNH CEO, the Heads of different departments such as Emergency Medicine, Mental Health and Psychiatry, and Surgery. Their leadership and determination to make progress in improving Indigenous access to affordable healthcare are so visible in all of the presentations on the Showcase Day.   

The strong leadership from the local Indigenous communities has been equally important. Without the local community leaders, there would be no partnership, no active engagement with the community people. It has been well known that “for the people and by the people” approach is fundamental for any intervention to be successful, which is not different among the Indigenous communities. A recently published scoping review identified the importance of Indigenous community engagement and the recommendations for proper engagement via partnerships, study approval, and adapting to the local context [3].

Regarding the enthusiastic and culturally competent healthcare staff, it was deeply impressive to see the MNH staff, especially the Indigenous staff, who presented their activities and findings from their interventions. They are the front-line “fighters” against the institutional racism. Racism plays a vital role in the health gap between Indigenous and Non-Indigenous Australians. For example, the analysis of an Australian national longitudinal data showed that racism has a significant negative impact on Indigenous children, including sleep difficulties and asthma [4].

The MNH staff are also “advocators” for the Indigenous patients and their families, and “helpers” to look after the patients, not only in caring their physical and mental illness but also in transport and accommodation. Similar result was also reported in a published systematic review, which showed that “provision of culturally appropriate delivery models with a central role for Indigenous health workers, and provision of support processes for communities” are common features of effective interventions/programs [5]. The importance of cultural competency among healthcare staff cannot be underestimated. The key research finding from a systematic review is that the cultural adaptation strategies used in health interventions are the key to success [6].

Although the social determinants of health were not presented in the Showcase Day, they do play a vital role in affecting a personal health. The social determinants refer to the social, economic, and environmental factors. The Indigenous Australians are known to experience health inequities due to historical and contemporary social factors.

The historical factor is colonization. It disrupted Indigenous people's social structures, land ownership, and cultural practices, which has resulted in a loss of cultural identity. This can lead to social exclusion, marginalization, and discrimination. It is a common sense that all of these consequences can negatively impact Indigenous people’s health outcomes.

Another critical social determinant is socioeconomic status. Indigenous people in Australia experience high levels of poverty, unemployment, and housing insecurity, which can lead to inadequate access to health services and resources [7]. For example, a lack of safe, affordable housing can result in overcrowding and poor living conditions, which can lead to increased risks of infectious diseases.

Additionally, education and literacy levels are essential social determinants of health, with lower levels of education linked to poorer health outcomes [8]. Indigenous Australians experience lower levels of education compared to non-Indigenous Australians, with factors such as a lack of access to quality education, cultural differences, and language barriers contributing to this disparity [9].

The impact of racism is another critical social determinant of health that Indigenous people in Australia face. Research findings demonstrated that racism can lead to discrimination in employment, education, and healthcare, and eventually lead to poorer health outcomes [10], including mental health or mental illness, such as increased levels of anxiety, depression, and stress [11], as well as physical health such as hypertension and cardiovascular disease [12].

There are a wide range of reasons or mechanisms behind the impact of racism on Indigenous health outcome in Australia, such as the institutional racism in the healthcare system which can directly lead to unequal treatment and access to services based on race or ethnicity. For example, research has shown that people of colour often receive lower-quality care than white patients, leading to worse health outcomes [13]. Another example is a lack of diversity in the healthcare workforce. There is a continuous urgent need to have more Indigenous health workers in the Australian health system [14].

To address these social determinant factors for Indigenous Australians, we need to develop and implement strategies in the health system levels, including increasing access to affordable healthcare services, increasing diversity in the healthcare workforce, addressing bias and discrimination in the healthcare system, and recognizing and addressing the impact of historical and ongoing racism on health outcomes.

It needs to be noted that there are some limitations among the presented success stories on the Showcase Day, such as the lack of scientifically appropriate evaluation. This is a common scenario in a published scoping review where half of the interventions were not evaluated [15].

To further improve the design and implementation of interventions to improve Indigenous access to and experience of healthcare systematically, the other possible means could be to use some high-level framework for guidance, such as the six essential Steps for Quality Intervention Development (6SQuID) [16] and structural interventions to address multilevel structural determinants that systemically lead to and perpetuate health inequities [17].

These insights would support future development and implementation of health system interventions to close the gap in equity and quality care for Indigenous people in the Australian healthcare system, which is potentially applicable in other countries.

The salaries of authors Hou and Sanjida are funded by Research Alliance for Urban Goori Health (RAUGH)

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