569965 other2015
RSH0010.1177/1757913915569965Current Topics & OpinionsCurrent Topics & Opinions
Current Topic & Opinion
The indigenous health gap: raising awareness and changing attitudes Many indigenous groups share a worrying commonality: a significantly shorter life expectancy when compared to the non-indigenous population. Lee Stoner, Rachel Page and Anna Matheson from Massey University, New Zealand, Michael Tarrant, Krystina Stoner and Donald Rubin from University of Georgia, USA and Lane Perry from Western Carolina University, USA take a look at the current situation and suggest ways to raise public awareness. A news article in the Newcastle (Australia) Herald in January 2012 starkly captures current norms for the health of indigenous peoples.1 The health of the Hunter’s Aboriginal population is at one of its worst levels in a decade, despite millions of taxpayer dollars going towards special programmes and numerous public services devoted to indigenous health. The gap between the region’s Aboriginal and non-Aboriginal communities has grown wider in areas including chronic disease, infant morbidity, smoking and alcohol-related hospital admissions. This situation is not unique to Newcastle, nor is it unique to Australia. More than 370 million indigenous people inhabit 70 countries worldwide, and there is significant variation between and within these indigenous populations in terms of worldview, culture, political forces, education, socioeconomic status, living conditions and familial factors. However, many indigenous groups do share a striking commonality: a significantly shorter life expectancy when compared to non-indigenous compatriots.2,3 This disparity holds even within high-income countries such as Australia, Canada, New Zealand and the United States. Poor advances in indigenous health status arguably result from a combination of socioeconomic circumstance as well as more specific historical factors such as colonisation, globalisation, migration, loss of language and culture, and disconnection from the land. Cardiovascular disease (CVD) is the primary factor explaining the life expectancy discrepancy between
the role these connections play in lifestyle choices. For instance, exercise prescriptions may be more effective if issued at the community level, since exercising as an individual may prevent a person from spending time with family and from contributing to the community. Researchers and healthcare providers indigenous and non-indigenous groups must also be aware that the concept of in many countries.4 As with the general ‘health’ may differ between indigenous population, CVD among indigenous and non-indigenous groups. Quite at groups has been linked to lifestyle risk odds to the western model, which factors, including physical inactivity, poor perceives health as ‘the absence of nutrition, tobacco consumption and sickness’, Ma¯ori traditionally view health alcohol abuse.5,6 as an all-embracing concept, Tackling these including spiritual, family, modifiable risk mental and physical wellbeing. Tackling these factors may work to For Ma¯ori, issues of Te modifiable risk narrow the health Whenua (land), Te Reo factors may gap between (language) and work to narrow indigenous and Whanaungatanga (extended the health gap non-indigenous family) are central to culture between populations. and to health:7 similar notions indigenous and However, this of health are shared among non-indigenous behaviour change other indigenous groups. populations will likely be Therefore, lifestyle modification achieved only by strategies are likely to be first raising limited, unless they are awareness and changing attitudes underpinned by a holistic perspective on among healthcare providers and health. researchers, among indigenous Additionally, recognition must be given populations themselves and those who to the sociocultural differences among implement their health programmes, and indigenous groups within the same among the general population and the nation. For example, in the United States, decision-makers they elect and influence. there are 569 federally recognised tribes,8 with different histories, unique languages, varied cultural traditions and Awareness and Attitudes various degrees of societal assimilation. among Healthcare Each indigenous group may also face a Providers and Researchers unique set of healthcare barriers, Healthcare groups and research teams including but not limited to the following: working alongside indigenous access to healthcare facilities, public populations to modify CVD risk factors transportation infrastructure, access to must be sensitive to sociocultural norms. recreation facilities, access to fresh For example, Aboriginal Australians have foods, language, communication and deep connections to the land, family, socioeconomic status.9 Therefore, even ancestors and to the wider community. within a given nation, campaigns to To affect this population, researchers and promote lifestyle change must be specific healthcare providers must understand to particular indigenous groups, not to
68 Perspectives in Public Health l March 2015 Vol 135 No 2
Copyright © Royal Society for Public Health 2015 SAGE Publications Downloaded from rsh.sagepub.com by guest on November 14,ISSN 2015 1757-9139 DOI: 10.1177/1757913915569965
Current Topic & Opinion the indigenous population as a whole. For example, the particular history of colonisation among villages within even a single First Nations group can result in differences in community health status.10 Cultural tailoring may be achieved by undertaking a collaborative approach with indigenous groups at the community level. By engaging in techniques such as didactic teaching, mentorship and supervised experience in specific community settings,11 healthcare providers and researchers may place themselves in a position to better understand the worldview and perspectives of the different groups. However, it is worth noting that much of the evidence on community change and health education programmes shows they are unlikely to be successful if they are implemented in isolation of other interventions – such as those aimed at income and access to healthy food and health services. In other words, health education campaigns must work handin-hand with efforts to ameliorate the social determinants that lead to poor health status.12
Self-Awareness and Attitudes among Indigenous Populations Indigenous populations, like all others, are unlikely to take control of their physical health without first obtaining necessary health information. For example, much higher rates of cigarette smoking, which increase the incidence of CVD in a dose-dependent manner, have been reported for the indigenous populations of Australia,13 New Zealand14 and the United States15 compared to the general population. Among American Indians, who have long used tobacco for religious and therapeutic reasons, studies have found that smoking is often not perceived as a risk factor for CVD.16,17 A comprehensive culturally tailored education campaign might be effective in mitigating myths associated with cultural-specific tobacco use and in providing alternates to facilitate the preservation of traditional and celebratory practices.18 But how tobacco control programmes are delivered and evaluated, and whether implementing organisations
healthcare. These oppressive factors caused severe inequalities in indigenous health status relative to the mainstream culture and poor prospects for future generations.25 The insidious and persistent health threats faced by indigenous populations today are fuelled by the psychosocial and economic aftermath of dispossession. The consequences of detaching indigenous groups from their land cannot be over-stated. Indeed, it has been suggested that the term ‘indigenous’ is specifically reserved for those cultures that place special significance between people and the natural world, whereby people are integral to the world and have a seamless relationship with nature.24 For example, First Nations peoples contend that the relationship they have with the land shapes all aspects of their lives: cultural, spiritual, emotional, physical and social.26 Similar land–people relationships exist for Aboriginal Australians, American Indians and Native Alaskans, and Ma¯ori. Not surprisingly, evidence shows that the most effective intervention strategies recognise the long-term impact of removing people from their land.27 Key to raising indigenous selfAwareness and Attitudes determination and empowerment is the among the General recognition that the psychosocial and Population and Decisioneconomic ramifications of colonisation Makers persist, and this is why many indigenous The historical underpinnings of the groups continue the legal battle for health gap for many indigenous groups reclamation of traditional lands. This begin with colonisation, particularly by challenge, however, of raising indigenous Europeans.24 Following colonisation, a self-determination requires that common theme among the indigenous mainstream racism towards indigenous populations of Australia, Canada, New populations be addressed. Both Zealand and the United States is the individually directed racism and what is dispossession of indigenous lands and sometimes called ‘institutional racism’ – resources, leading to wherein governments and marginalisation and other power systems dependency on the Unless systematically exclude or dominant White mainstream marginalise groups – have a society.24 attitudes discernible impact on Marginalisation not towards indigenous health.28 only led to loss of indigenous Unless mainstream attitudes traditional lifestyle, populations towards indigenous but to poor access improve, populations improve, to employment, indigenous indigenous rights will be education, social rights will be further impinged as services and further impinged industrialised societies adequate continue to globalise.
are responsive to lessons learned from the community, is key to effectiveness. Indigenous groups are more likely to pay greater respect to their physical health if they are fully aware of the interactions between poor physical health and emotional, mental and spiritual elements. For example, mental health disorders are known to amplify the effects of physical disorders on functionality.19 By the same token, augmented physical health has been demonstrated to enhance the capacity to cope with mental health disorders.20 Particular emphasis must be placed on regular physical activity, which not only reduces CVD risk in its own right, but also improves modifiable CVD risk factors such as obesity, hypertension, dyslipidaemia and type 2 diabetes.21,22 Culturally appropriate, community-based physical activity programmes can provide a cost-effective opportunity to encourage participation. For example, Ma¯ori are attracted to sport not only because of their love of competition (whakataetae) and achievement (whakatutukitanga), but because it provides a forum to experience feelings of whanau (extended family).23
March 2015 Vol 135 No 2 l Perspectives in Public Health 69 Downloaded from rsh.sagepub.com by guest on November 14, 2015
Current Topic & Opinion The World Health Organization (WHO) Commission on the Social Determinants of Health, in reviewing and popularising the global evidence of health inequalities, argued that it is through the mechanisms of government policy and political processes that equity needs to be championed and effective long-term action taken.29 Thus, efforts to reduce health disparities must include strong and deliberate components of political advocacy to sway mainstream policy makers. The reality is that advocates most often must emerge from indigenous communities themselves, as indigenous health services rarely constitute a high priority for the mainstream society.30
Conclusion CVD is the driving force behind the gap in life expectancy between indigenous and non-indigenous groups in many countries. Multiple studies have revealed that modifiable risk factors are responsible for a large number of premature deaths attributable to CVD. It is suggested that if, first, a unified emphasis can be invested in raising the awareness and understanding of modifiable risk factors within an indigenous population by adhering to the nuance that exists within cultures, then a change in attitudes of stakeholders can be subsequently addressed. Specifically, healthcare
providers and researchers must recognise that the indigenous concept of ‘health’ may include physical, as well as mental, family, and spiritual aspects, and is not simply perceived as ‘the absence of sickness’. At the same time, indigenous peoples must be aware of the important interactions that physical health has with the mental, family and spiritual facets of their lives. Finally, raising public awareness of issues such as institutional racism and the consequences of detaching indigenous groups from their land is required to improve self-determination and selfempowerment among indigenous populations.
References 1.
Jones J. Hunter Indigenous Health Hits Worst Levels in Decade. Newcastle Herald, 27th January 2012. Available online at: http://www. theherald.com.au/story/442564/hunterindigenous-health-hits-worst-levels-in-decade/ (Last accessed 22nd January 2015). 2. Australian Institute of Health and Welfare (AIHW). Life Expectancy, 2011. Available online at: http://www.aihw.gov.au/life-expectancy/ (Last accessed 15th April 2013). 3. Statistics New Zealand (SNZ). New Zealand Life Tables: 2005-07, 2008. Available online at: http://www.stats.govt.nz/browse_for_stats/ health/life_expectancy/nzlifetables_hotp05-07. aspx (Last accessed 15th April 2013). 4. Huffman MD, Galloway JM. Cardiovascular health in indigenous communities: Successful programs. Heart, Lung and Circulation 2010; 19(5–6): 351–60. 5. Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ et al. The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Medicine 2009; 6(4): e1000058. 6. Stoner L, Stoner KR, Young JM, Fryer S. Preventing a cardiovascular disease epidemic among indigenous populations through lifestyle changes. International Journal of Preventive Medicine 2012; 3(4): 230–40. 7 . Harris RB. Hauora: Màori Standards of Health IV. A Study of the Years 2000–2005. Wellington, New Zealand: Te Ròpù Rangahau Hauora a Eru Pòmare, 2007. 8. Government Printing Office (GPO). We the People: American Indians and Alaskan Natives in the United States. Washington, DC: GPO, 2006. 9. Marrone S. Understanding barriers to health care: A review of disparities in health care services among indigenous populations. International Journal of Circumpolar Health 2007; 66(3): 188–98. 10. Jacklin K. Diversity within: Deconstructing aboriginal community health in Wikwemikong
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Unceded Indian Reserve. Social Science & Medicine 2009; 68(5): 980–9. Holmes W, Stewart P, Garrow A, Anderson I, Thorpe L. Researching aboriginal health: Experience from a study of urban young people’s health and well-being. Social Science & Medicine 2002; 54(8): 1267–79. Baum F. Cracking the nut of health equity: Top down and bottom up pressure for action on the social determinants of health. Promotion & Education 2007; 14(2): 90–5. Australian Bureau of Statistics (ABS). National Aboriginal and Torres Strait Islander Health Survey, 2004-05. Canberra, Australia: ABS, 2006. Wellington Ministry of Health (MOH). A Portrait of Health: Key Results of the 2006-07 New Zealand Health Survey. Wellington, New Zealand: MOH, 2008. Pleis JR, Lucas JW, Ward BW. Summary health statistics for U.S. adults: National Health Interview Survey, 2008. Vital and Health Statistics 2009; 10(242): 1–157. Oser CS, Blades LL, Strasheim C, Helgerson SD, Gohdes D, Harwell TS. Awareness of cardiovascular disease risk in American Indians. Ethnicity & Disease 2006; 16(2): 345–50. Schweigman K, Eichner J, Welty TK, Zhang Y. Cardiovascular disease risk factor awareness in American Indian communities: The strong heart study. Ethnicity & Disease 2006; 16(3): 647–52. BlueEye L, Rohweder C. Sacred tobacco use in native American and Alaska native spirituality: Implications for tobacco control. In: AN Miller. DL Rubin (eds) Health Communication and Faith Communities. New York: Hampton Press, 2011; 97–114. Kessler RC, Ormel J, Demler O, Stang PE. Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: Results from the National Comorbidity Survey. Journal of Occupational and Environmental Medicine 2003; 45(12): 1257–66. Mason OJ, Holt R. Mental health and physical activity interventions: A review of the qualitative
70 Perspectives in Public Health l March 2015 Vol 135 No 2 Downloaded from rsh.sagepub.com by guest on November 14, 2015
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
literature. Journal of Mental Health 2012; 21(3): 274–84. Sattelmair J, Pertman J, Ding EL, Kohl HW 3rd, Haskell W, Lee IM. Dose response between physical activity and risk of coronary heart disease: A meta-analysis. Circulation 2011; 124(7): 789–95. Church T. Exercise in obesity, metabolic syndrome, and diabetes. Progress in Cardiovascular Disease 2011; 53(6): 412–8. Te Rito P. Leadership in Ma¯ori, European cultures and in the world of sport. MAI Review 2006; 1(8): 1–19. Cunningham C, Stanley F. Indigenous by definition, experience, or world view. British Medical Journal 2003; 327(7412): 403–4. Horton R. Indigenous peoples: Time to act now for equity and health. The Lancet 2006; 367(9524): 1705–7. Wilson K. Therapeutic landscapes and First Nations peoples: An exploration of culture, health and place. Health & Place 2003; 9(2): 83–93. Human Rights and Equal Opportunity Commission (HREOC). Bringing them home: Report of the National Enquiry into the Separation of Aboriginal and Torres Strait Islander children from their families. Sydney, Australia: HREOC, 1997. Paradies Y, Harris R, Anderson I. The impact of racism on indigenous health in Australia and Aotearoa: Towards a research agenda. Discussion Paper No. 4. Darwin, Australia: Cooperative Research Centre for Aboriginal Health, 2008. CSDH. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization (WHO), 2008. Bartlett B, Boff J. The impact of Aboriginal community controlled health service advocacy on Aboriginal health policy. Australian Journal of Primary Health 2005; 11(2): 53–61.
RSH0010.1177/1757913915569965Current Topics & OpinionsCurrent Topics & Opinions
Current Topic & Opinion
The indigenous health gap: raising awareness and changing attitudes Many indigenous groups share a worrying commonality: a significantly shorter life expectancy when compared to the non-indigenous population. Lee Stoner, Rachel Page and Anna Matheson from Massey University, New Zealand, Michael Tarrant, Krystina Stoner and Donald Rubin from University of Georgia, USA and Lane Perry from Western Carolina University, USA take a look at the current situation and suggest ways to raise public awareness. A news article in the Newcastle (Australia) Herald in January 2012 starkly captures current norms for the health of indigenous peoples.1 The health of the Hunter’s Aboriginal population is at one of its worst levels in a decade, despite millions of taxpayer dollars going towards special programmes and numerous public services devoted to indigenous health. The gap between the region’s Aboriginal and non-Aboriginal communities has grown wider in areas including chronic disease, infant morbidity, smoking and alcohol-related hospital admissions. This situation is not unique to Newcastle, nor is it unique to Australia. More than 370 million indigenous people inhabit 70 countries worldwide, and there is significant variation between and within these indigenous populations in terms of worldview, culture, political forces, education, socioeconomic status, living conditions and familial factors. However, many indigenous groups do share a striking commonality: a significantly shorter life expectancy when compared to non-indigenous compatriots.2,3 This disparity holds even within high-income countries such as Australia, Canada, New Zealand and the United States. Poor advances in indigenous health status arguably result from a combination of socioeconomic circumstance as well as more specific historical factors such as colonisation, globalisation, migration, loss of language and culture, and disconnection from the land. Cardiovascular disease (CVD) is the primary factor explaining the life expectancy discrepancy between
the role these connections play in lifestyle choices. For instance, exercise prescriptions may be more effective if issued at the community level, since exercising as an individual may prevent a person from spending time with family and from contributing to the community. Researchers and healthcare providers indigenous and non-indigenous groups must also be aware that the concept of in many countries.4 As with the general ‘health’ may differ between indigenous population, CVD among indigenous and non-indigenous groups. Quite at groups has been linked to lifestyle risk odds to the western model, which factors, including physical inactivity, poor perceives health as ‘the absence of nutrition, tobacco consumption and sickness’, Ma¯ori traditionally view health alcohol abuse.5,6 as an all-embracing concept, Tackling these including spiritual, family, modifiable risk mental and physical wellbeing. Tackling these factors may work to For Ma¯ori, issues of Te modifiable risk narrow the health Whenua (land), Te Reo factors may gap between (language) and work to narrow indigenous and Whanaungatanga (extended the health gap non-indigenous family) are central to culture between populations. and to health:7 similar notions indigenous and However, this of health are shared among non-indigenous behaviour change other indigenous groups. populations will likely be Therefore, lifestyle modification achieved only by strategies are likely to be first raising limited, unless they are awareness and changing attitudes underpinned by a holistic perspective on among healthcare providers and health. researchers, among indigenous Additionally, recognition must be given populations themselves and those who to the sociocultural differences among implement their health programmes, and indigenous groups within the same among the general population and the nation. For example, in the United States, decision-makers they elect and influence. there are 569 federally recognised tribes,8 with different histories, unique languages, varied cultural traditions and Awareness and Attitudes various degrees of societal assimilation. among Healthcare Each indigenous group may also face a Providers and Researchers unique set of healthcare barriers, Healthcare groups and research teams including but not limited to the following: working alongside indigenous access to healthcare facilities, public populations to modify CVD risk factors transportation infrastructure, access to must be sensitive to sociocultural norms. recreation facilities, access to fresh For example, Aboriginal Australians have foods, language, communication and deep connections to the land, family, socioeconomic status.9 Therefore, even ancestors and to the wider community. within a given nation, campaigns to To affect this population, researchers and promote lifestyle change must be specific healthcare providers must understand to particular indigenous groups, not to
68 Perspectives in Public Health l March 2015 Vol 135 No 2
Copyright © Royal Society for Public Health 2015 SAGE Publications Downloaded from rsh.sagepub.com by guest on November 14,ISSN 2015 1757-9139 DOI: 10.1177/1757913915569965
Current Topic & Opinion the indigenous population as a whole. For example, the particular history of colonisation among villages within even a single First Nations group can result in differences in community health status.10 Cultural tailoring may be achieved by undertaking a collaborative approach with indigenous groups at the community level. By engaging in techniques such as didactic teaching, mentorship and supervised experience in specific community settings,11 healthcare providers and researchers may place themselves in a position to better understand the worldview and perspectives of the different groups. However, it is worth noting that much of the evidence on community change and health education programmes shows they are unlikely to be successful if they are implemented in isolation of other interventions – such as those aimed at income and access to healthy food and health services. In other words, health education campaigns must work handin-hand with efforts to ameliorate the social determinants that lead to poor health status.12
Self-Awareness and Attitudes among Indigenous Populations Indigenous populations, like all others, are unlikely to take control of their physical health without first obtaining necessary health information. For example, much higher rates of cigarette smoking, which increase the incidence of CVD in a dose-dependent manner, have been reported for the indigenous populations of Australia,13 New Zealand14 and the United States15 compared to the general population. Among American Indians, who have long used tobacco for religious and therapeutic reasons, studies have found that smoking is often not perceived as a risk factor for CVD.16,17 A comprehensive culturally tailored education campaign might be effective in mitigating myths associated with cultural-specific tobacco use and in providing alternates to facilitate the preservation of traditional and celebratory practices.18 But how tobacco control programmes are delivered and evaluated, and whether implementing organisations
healthcare. These oppressive factors caused severe inequalities in indigenous health status relative to the mainstream culture and poor prospects for future generations.25 The insidious and persistent health threats faced by indigenous populations today are fuelled by the psychosocial and economic aftermath of dispossession. The consequences of detaching indigenous groups from their land cannot be over-stated. Indeed, it has been suggested that the term ‘indigenous’ is specifically reserved for those cultures that place special significance between people and the natural world, whereby people are integral to the world and have a seamless relationship with nature.24 For example, First Nations peoples contend that the relationship they have with the land shapes all aspects of their lives: cultural, spiritual, emotional, physical and social.26 Similar land–people relationships exist for Aboriginal Australians, American Indians and Native Alaskans, and Ma¯ori. Not surprisingly, evidence shows that the most effective intervention strategies recognise the long-term impact of removing people from their land.27 Key to raising indigenous selfAwareness and Attitudes determination and empowerment is the among the General recognition that the psychosocial and Population and Decisioneconomic ramifications of colonisation Makers persist, and this is why many indigenous The historical underpinnings of the groups continue the legal battle for health gap for many indigenous groups reclamation of traditional lands. This begin with colonisation, particularly by challenge, however, of raising indigenous Europeans.24 Following colonisation, a self-determination requires that common theme among the indigenous mainstream racism towards indigenous populations of Australia, Canada, New populations be addressed. Both Zealand and the United States is the individually directed racism and what is dispossession of indigenous lands and sometimes called ‘institutional racism’ – resources, leading to wherein governments and marginalisation and other power systems dependency on the Unless systematically exclude or dominant White mainstream marginalise groups – have a society.24 attitudes discernible impact on Marginalisation not towards indigenous health.28 only led to loss of indigenous Unless mainstream attitudes traditional lifestyle, populations towards indigenous but to poor access improve, populations improve, to employment, indigenous indigenous rights will be education, social rights will be further impinged as services and further impinged industrialised societies adequate continue to globalise.
are responsive to lessons learned from the community, is key to effectiveness. Indigenous groups are more likely to pay greater respect to their physical health if they are fully aware of the interactions between poor physical health and emotional, mental and spiritual elements. For example, mental health disorders are known to amplify the effects of physical disorders on functionality.19 By the same token, augmented physical health has been demonstrated to enhance the capacity to cope with mental health disorders.20 Particular emphasis must be placed on regular physical activity, which not only reduces CVD risk in its own right, but also improves modifiable CVD risk factors such as obesity, hypertension, dyslipidaemia and type 2 diabetes.21,22 Culturally appropriate, community-based physical activity programmes can provide a cost-effective opportunity to encourage participation. For example, Ma¯ori are attracted to sport not only because of their love of competition (whakataetae) and achievement (whakatutukitanga), but because it provides a forum to experience feelings of whanau (extended family).23
March 2015 Vol 135 No 2 l Perspectives in Public Health 69 Downloaded from rsh.sagepub.com by guest on November 14, 2015
Current Topic & Opinion The World Health Organization (WHO) Commission on the Social Determinants of Health, in reviewing and popularising the global evidence of health inequalities, argued that it is through the mechanisms of government policy and political processes that equity needs to be championed and effective long-term action taken.29 Thus, efforts to reduce health disparities must include strong and deliberate components of political advocacy to sway mainstream policy makers. The reality is that advocates most often must emerge from indigenous communities themselves, as indigenous health services rarely constitute a high priority for the mainstream society.30
Conclusion CVD is the driving force behind the gap in life expectancy between indigenous and non-indigenous groups in many countries. Multiple studies have revealed that modifiable risk factors are responsible for a large number of premature deaths attributable to CVD. It is suggested that if, first, a unified emphasis can be invested in raising the awareness and understanding of modifiable risk factors within an indigenous population by adhering to the nuance that exists within cultures, then a change in attitudes of stakeholders can be subsequently addressed. Specifically, healthcare
providers and researchers must recognise that the indigenous concept of ‘health’ may include physical, as well as mental, family, and spiritual aspects, and is not simply perceived as ‘the absence of sickness’. At the same time, indigenous peoples must be aware of the important interactions that physical health has with the mental, family and spiritual facets of their lives. Finally, raising public awareness of issues such as institutional racism and the consequences of detaching indigenous groups from their land is required to improve self-determination and selfempowerment among indigenous populations.
References 1.
Jones J. Hunter Indigenous Health Hits Worst Levels in Decade. Newcastle Herald, 27th January 2012. Available online at: http://www. theherald.com.au/story/442564/hunterindigenous-health-hits-worst-levels-in-decade/ (Last accessed 22nd January 2015). 2. Australian Institute of Health and Welfare (AIHW). Life Expectancy, 2011. Available online at: http://www.aihw.gov.au/life-expectancy/ (Last accessed 15th April 2013). 3. Statistics New Zealand (SNZ). New Zealand Life Tables: 2005-07, 2008. Available online at: http://www.stats.govt.nz/browse_for_stats/ health/life_expectancy/nzlifetables_hotp05-07. aspx (Last accessed 15th April 2013). 4. Huffman MD, Galloway JM. Cardiovascular health in indigenous communities: Successful programs. Heart, Lung and Circulation 2010; 19(5–6): 351–60. 5. Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ et al. The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Medicine 2009; 6(4): e1000058. 6. Stoner L, Stoner KR, Young JM, Fryer S. Preventing a cardiovascular disease epidemic among indigenous populations through lifestyle changes. International Journal of Preventive Medicine 2012; 3(4): 230–40. 7 . Harris RB. Hauora: Màori Standards of Health IV. A Study of the Years 2000–2005. Wellington, New Zealand: Te Ròpù Rangahau Hauora a Eru Pòmare, 2007. 8. Government Printing Office (GPO). We the People: American Indians and Alaskan Natives in the United States. Washington, DC: GPO, 2006. 9. Marrone S. Understanding barriers to health care: A review of disparities in health care services among indigenous populations. International Journal of Circumpolar Health 2007; 66(3): 188–98. 10. Jacklin K. Diversity within: Deconstructing aboriginal community health in Wikwemikong
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Unceded Indian Reserve. Social Science & Medicine 2009; 68(5): 980–9. Holmes W, Stewart P, Garrow A, Anderson I, Thorpe L. Researching aboriginal health: Experience from a study of urban young people’s health and well-being. Social Science & Medicine 2002; 54(8): 1267–79. Baum F. Cracking the nut of health equity: Top down and bottom up pressure for action on the social determinants of health. Promotion & Education 2007; 14(2): 90–5. Australian Bureau of Statistics (ABS). National Aboriginal and Torres Strait Islander Health Survey, 2004-05. Canberra, Australia: ABS, 2006. Wellington Ministry of Health (MOH). A Portrait of Health: Key Results of the 2006-07 New Zealand Health Survey. Wellington, New Zealand: MOH, 2008. Pleis JR, Lucas JW, Ward BW. Summary health statistics for U.S. adults: National Health Interview Survey, 2008. Vital and Health Statistics 2009; 10(242): 1–157. Oser CS, Blades LL, Strasheim C, Helgerson SD, Gohdes D, Harwell TS. Awareness of cardiovascular disease risk in American Indians. Ethnicity & Disease 2006; 16(2): 345–50. Schweigman K, Eichner J, Welty TK, Zhang Y. Cardiovascular disease risk factor awareness in American Indian communities: The strong heart study. Ethnicity & Disease 2006; 16(3): 647–52. BlueEye L, Rohweder C. Sacred tobacco use in native American and Alaska native spirituality: Implications for tobacco control. In: AN Miller. DL Rubin (eds) Health Communication and Faith Communities. New York: Hampton Press, 2011; 97–114. Kessler RC, Ormel J, Demler O, Stang PE. Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: Results from the National Comorbidity Survey. Journal of Occupational and Environmental Medicine 2003; 45(12): 1257–66. Mason OJ, Holt R. Mental health and physical activity interventions: A review of the qualitative
70 Perspectives in Public Health l March 2015 Vol 135 No 2 Downloaded from rsh.sagepub.com by guest on November 14, 2015
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
literature. Journal of Mental Health 2012; 21(3): 274–84. Sattelmair J, Pertman J, Ding EL, Kohl HW 3rd, Haskell W, Lee IM. Dose response between physical activity and risk of coronary heart disease: A meta-analysis. Circulation 2011; 124(7): 789–95. Church T. Exercise in obesity, metabolic syndrome, and diabetes. Progress in Cardiovascular Disease 2011; 53(6): 412–8. Te Rito P. Leadership in Ma¯ori, European cultures and in the world of sport. MAI Review 2006; 1(8): 1–19. Cunningham C, Stanley F. Indigenous by definition, experience, or world view. British Medical Journal 2003; 327(7412): 403–4. Horton R. Indigenous peoples: Time to act now for equity and health. The Lancet 2006; 367(9524): 1705–7. Wilson K. Therapeutic landscapes and First Nations peoples: An exploration of culture, health and place. Health & Place 2003; 9(2): 83–93. Human Rights and Equal Opportunity Commission (HREOC). Bringing them home: Report of the National Enquiry into the Separation of Aboriginal and Torres Strait Islander children from their families. Sydney, Australia: HREOC, 1997. Paradies Y, Harris R, Anderson I. The impact of racism on indigenous health in Australia and Aotearoa: Towards a research agenda. Discussion Paper No. 4. Darwin, Australia: Cooperative Research Centre for Aboriginal Health, 2008. CSDH. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization (WHO), 2008. Bartlett B, Boff J. The impact of Aboriginal community controlled health service advocacy on Aboriginal health policy. Australian Journal of Primary Health 2005; 11(2): 53–61.
