What is the most important social determinant of health to consider when caring for Aboriginal and Torres Strait Islander people?

Environmental health focuses on the physical, chemical, biological and social factors which affect people within their surroundings. Healthy environments need to be established and maintained by individuals, communities and government and non-government agencies. This involves the provision of adequate infrastructure (housing, water supply and sewage systems) and minimising environmental health risk factors. Environmental health should also be viewed within a social and cultural context.

The environments in which Aboriginal and Torres Strait Islander people live have a significant impact on their health. It is important to recognise healthy practices and identify and fix the risks present in Aboriginal and Torres Strait Islander communities.

The key factors in the physical environment which impact on the health and wellbeing of Aboriginal and Torres Strait Islander communities include:

water treatment and supply
access to affordable and healthy food and food safety
adequate housing and maintenance and minimisation of overcrowding
rubbish collection and disposal
sewage disposal
animal control (including insects)
dust control
pollution control
personal hygiene.

Examples of the types of health problems associated with the environment include; respiratory, cardiovascular and renal diseases, cancers and skin infections. Diseases can be spread as a result of overcrowding, pollution, poor animal management and gastrointestinal illnesses can be due to poor water quality, contaminated food or poor hygiene.

Preventing health problems by ensuring healthy environment standards reduces suffering and treatment costs.

What strategies are in place for the environmental health of Aboriginal and Torres Strait Islander communities?

The enHealth Council was responsible for the implementation of

. The enHealth Council provides national leadership on environmental health issues, for example, by setting environmental health priorities and coordinating national policies and programs. The council is made up of representatives from government and public health agencies, the environmental health profession and the community, including the Aboriginal and Torres Strait Islander community. Aboriginal and Torres Strait Islander environmental health is seen as a priority for the council and the National Environmental Health Strategy acknowledges the need to improve the health status of Aboriginal and Torres Strait Islander communities in rural, remote and urban areas, ‘through the development of appropriate environmental health standards commensurate (matching) with the wider Australian population’.

Who is responsible for healthy environments?

The responsibility for environmental health lies primarily with individuals and communities. However, communities often need to work with a range of government and non-government organisations to put into operation plans for improving environmental health standards in a community, evaluation of strategies and risk management.

Individuals and organisations who work in environmental health may differ between states and territories and between Aboriginal and Torres Strait Islander communities and include the following:

Environmental Health Officers and Workers
the Community Government Council, and its employees, for example, Essential Services Officers
electricity and water authorities
government housing departments
Aboriginal and Torres Strait Islander housing authorities
government departments responsible for land, planning and the environment
private consultants and contractors, for example, electricians, plumbers, builders
other non-government service providers, for example, land care agencies.

Many Aboriginal and Torres Strait Islander communities have an Environmental Health Worker based in their community who plays a vital role in reducing the day to day environmental risks which can affect the health and wellbeing of the communities’ residents. The Environmental Health Workers job is varied and often challenging as they are required to undertake a number of tasks including:

attending to day to day repairs and maintenance of infrastructure (e.g., housing and rubbish tips)
attending to urgent environmental health problems (e.g., sewage overflow)
planning and implementing programs
gaining the support of the community members and managers for community based programs

References and further reading

Pholi K, Black D, Richards C. Is ‘Close the Gap’ a useful approach to improving the health and wellbeing of Indigenous Australians? Aust Rev Public Affairs. 2009;9:2.
Google Scholar
Walter M. Data politics and Indigenous representation in Australia statistics. In: Kakutai T, Taylor J, editors. Indigenous Data Sovereignty: Toward an agenda. Canbera: ANU Press, The Australian National University; 2016. pp. 79–87.

Google Scholar
Yap M, Yu E. Data sovereignty for the Yawuru in Western Australia. In: Kakutai T, Taylor J, editors. Indigenous Data Sovereignty: Toward an agenda. Canberra: ANU Press, The Australian National University; 2016. pp. 233–47.
Google Scholar
Lovett R. Aboriginal and Torres Strait Islander community wellbeing: identified needs for statistical capacity. In: Kukutai T, Taylor J, editors. Indigenous Data Sovereignty: Toward an agenda. Canberra: ANU Press, The Australian National University; 2016. pp. 213–35.
Google Scholar
National Aboriginal Health Strategy Working Party. A national Aboriginal health strategy. Canberra: Commonwealth Government of Australia; 1989.
Google Scholar
Abercrombie B, Hill S, Turner B. The Penguin Dictionary of Sociology. 4th ed. United Kingdom: Penguin; 2000.
Bond C, Brough M. The Meaning of Culture within Public Health Practice - Implications for the Study of Aboriginal and Torres Strait Islander Health. In: Baum F, Bentle M, Anderson I, editors. Beyond Bandaids: Exploring the Underlying Social Determinants of Aboriginal Health. Cooperative Research Centre for Aboriginal Health, Darwin. 2007. pp. 229–38.
Kunitz S. Disease and Social Diversity: the European impact on the health of non-Europeans. New York: Oxford University Press; 1994.
Google Scholar
Chandler M, Lalonde CE. Cultural Continuity as a Hedge against Suicide in Canada’s First Nations. Transcult Psychiat. 1998. https://doi.org/10.1177/136346159803500202.
Article Google Scholar
Auger MD. Cultural continuity as a determinant of indigenous peoples’ health: a metasynthesis of qualitative research in Canada and the United States. Int Indigenous Policy J. 2016. https://doi.org/10.18584/iipj.2016.7.4.3.
Article Google Scholar
Bourke S, Wright A, Guthrie J, Russell L, Dunbar T, Lovett R. Evidence review of indigenous culture for health and wellbeing. Int J Health Wellness Soc. 2018. https://doi.org/10.18848/2156-8960/CGP/v08i04/11-27.
Article Google Scholar
Commonwealth of Australia. National Strategic Framework for Aboriginal and Torres Strait Islander peoples’ Mental Health and Social and Emotional Wellbeing 2017-23. Canberra: Department of Prime Minister and Cabinet; 2017.
Google Scholar
Australian Bureau of Statistics: National Aboriginal and Torres Strait Islander Social Survey. User Guide, 2014-15. 2016. https://www.abs.gov.au/ausstats/abs%40.nsf/mf/4720.0. Accessed 12 Feb 2021.
Victorian Aboriginal Health Service. The strengths of young Kooris: study of young people’s health and well-being. Melbourne: Victorian Aboriginal Health Service Co-operative; 2000.
Google Scholar
Howard K, Anderson K, Cunningham J, Cass A, Ratcliffe J, Whop L, et al. What Matters 2 Adults: a study protocol to develop a new preference-based wellbeing measure with Aboriginal and Torres Strait Islander adults (WM2Adults). BMC Public Health. 2020. https://doi.org/10.1186/s12889-020-09821z.
Article PubMed PubMed Central Google Scholar
Smith K, Gilchrist L, Taylor K, Clinch C, Logiudice D, Edgill P, et al. Good spirit, good life: a quality of life tool and framework for older aboriginal peoples. Gerontologist. 2020. https://doi.org/10.1093/geront/gnz185.
Article PubMed Google Scholar
Yap M, Yu E. Operationalising the capability approach: developing culturally relevant indicators of Indigenous wellbeing - an Australian example. Oxf Dev Stud. 2016. https://doi.org/10.1080/13600818.2016.1178223.
Article Google Scholar
Gee G. Resilience and Recovery from Trauma among Aboriginal Help Seeking Clients in an Urban Aborignal Community Controlled Organisation. Unpublished Doctor of Philosophy thesis. University of Melbourne, Melbourne School of Psychological Sciences. 2016.
Jones R, Thurber KA, Chapman J, D’Este C, Dunbar T, Wenitong M, et al. Study protocol: Our Cultures Count, the Mayi Kuwayu Study, a national longitudinal study of Aboriginal and Torres Strait Islander wellbeing. BMJ Open. 2018. https://doi.org/10.1136/bmjopen-2018-023861.
Article PubMed PubMed Central Google Scholar
National Health and Medical Research Council. How to review the evidence: systematic identification and review of the scientific literature: handbook series on preparing clinincal practice guidelines. Canberra: National Health and Medical Research Council; 2000.
Google Scholar
Berry HL, Butler JR, Burgess CP, King UG, Tsey K, Cadet-James YL, et al. Mind, body, spirit: co-benefits for mental health from climate change adaptation and caring for country in remote Aboriginal Australian communities. NSW Public Health Bull. 2010. https://doi.org/10.1071/NB10030.
Article Google Scholar
Burgess CP, Johnston FH, Bowman DM, Whitehead PJ. Healthy country: healthy people? Exploring the health benefits of indigenous natural resource management. Aust N Z J Public Health. 2005. https://doi.org/10.1111/j.1467-842x.2005.tb00060.x.
Article PubMed Google Scholar
Salmon M, Doery K, Dance P, Chapman J, Gilbert R, Williams R, et al. Defining the Indefinable: Descriptors of Aboriginal and Torres Strait Islander Peoples’ Cultures and their Links to Health and Wellbeing. Aboriginal and Torres Strait Islander Health Team, Research School of Population Health, The Australian National University, Canberra. 2018. https://www.lowitja.org.au/content/Image/Defining_Indefinable_report_FINAL_WEB.pdf. Accessed 15 Mar 2019.
VicHealth. Life is health is life: Taking action to close the gap, Victorian Aboriginal evidence-based health promotion resource. Victorian Health Promotion Foundation, Melbourne. 2011. https://www.vichealth.vic.gov.au/-/media/ResourceCentre/PublicationsandResources/Health-Inequalities/Life-is-health/Life-is-health-is-life_web.pdf?la=en&hash=6F72B258F632599BFEFA93F28E3ED8343BD503C4. Accessed 15 Mar 2019.
Weir J, Stacy C, Youngtob K. The Benefits Associated with Caring for Country: Literature Review. Australian Institute of Aboriginal and Torres Strait Islander Studies, Canberra. 2011. https://aiatsis.gov.au/sites/default/files/research_pub/benefits-cfc_0_3.pdf. Accessed 15 Mar 2019.
Dahlberg EE, Hamilton SJ, Hamid F, Thompson SC. Indigenous Australians Perceptions’ of Physical Activity: A Qualitative Systematic Review. Int J Environ Res Public Health. 2018. https://doi.org/10.3390/ijerph15071492.
Article PubMed PubMed Central Google Scholar
MacLean S, Ritte R, Thorpe A, Ewen S, Arabena K. Health and wellbeing outcomes of programs for Indigenous Australians that include strategies to enable the expression of cultural identities: a systematic review. Aust J Prim Health. 2017. https://doi.org/10.1071/py16061.
Article PubMed Google Scholar
Behrendt L, Jorgensen M, Vivivan A. Self-determination: Background concepts - Scoping paper 1 for the Victorian Department of Health and Human Services. Jumbunna Indigenous House of Learning, University of Technology Sydney, Sydney. 2017. https://www2.health.vic.gov.au/about/publications/researchandreports/self-determination-background-concepts. Accessed 15 Mar 2019.
Ypinazar VA, Margolis SA, Haswell-Elkins M, Tsey K. Indigenous Australians’ understandings regarding mental health and disorders. Aust N Z J Psychiatry. 2007. https://doi.org/10.1080/00048670701332953.
Article PubMed Google Scholar
Crone D. Physical activity and mental health. A Life in the Day. 2003. https://doi.org/10.1108/13666282200300017.
Herrman H. The need for mental health promotion. Aust N Z J Psychiatry. 2001. https://doi.org/10.1046/j.1440-1614.2001.00947.x.
Article PubMed Google Scholar
Tsey K, Every A. Evaluating Aboriginal empowerment programs: The case of Family WellBeing. Aust N Z J Public Health. 2000. https://doi.org/10.1111/j.1467-842X.2000.tb00501.x.
Article PubMed Google Scholar
Phillips G. Addictions and Healing in Aboriginal Country. Canberra: Aboriginal Studies Press for the Australian Institute of Aboriginal and Torres Strait Islander Studies; 2003.
Google Scholar
Rose D. Dingo Makes us Human: Life and Land in an Australian Aboriginal Culture. 2nd ed. Cambridge: Cambridge University Press; 1992.
Google Scholar
Naughton JM, O’Dea K, Sinclair AJ. Animal foods in traditional Australian aboriginal diets: polyunsaturated and low in fat. Lipids. 1986. https://doi.org/10.1007/BF02537241.
Article PubMed Google Scholar
O’Dea K. Marked improvement in carbohydrate and lipid metabolism in diabetic Australian Aboriginees after temporary reversion to traditional lifestyle. Diabetes. 1984. https://doi.org/10.2337/diab.33.6.596.
Article PubMed Google Scholar
Anderson P. Priorities in Aboriginal Health. In: Robinson G, editor. Aboriginal Health: Social and Cultural Transitions. Darwin: University Press; 1995.
Google Scholar
Commonwealth of Australia. Return to Country, The Aboriginal Homelands Movement in Australia. Australian Government of Publishing Service, Canberra. 1987. http://www.culturalsurvival.org.au/ref_docs/Back_to_Country_House%20Reps_1987_PP125A.pdf. Accessed 15 Mar 2019.
Coombs HC. Aboriginal autonomy: issues and strategies. Cambridge: Cambridge University Press; 1994.
Book Google Scholar
Holmes T. Contemporary experiences of ‘non-medical healing’ among Aboriginal women in a rural Victorian community: Insisting on improving wellbeing, cultural involvement and community-building. Internet J Language Cult Soc. 2016;41:29-44.
Altman JC. People on country, healthy landscapes and sustainable Indigenous economic futures: the Arnhem Land case. Aust Rev Public Affairs. 2003;4:2.
Google Scholar
Altman JC, Whitehead P. Caring for Country and Sustainable Indigenous Development: Opportunities, Contraints and Innovation. Centre for Aboriginal Economic Policy Research, Australian National University, Canberra. 2003. https://caepr.cass.anu.edu.au/sites/default/files/docs/CAEPRWP20_0.pdf. Accessed 15 Mar 2019.
Garnett S, Sithole B. Sustainable Northern Landscapes and the Nexus with Indigenous Health: Healthy Country, Healthy People. Canberra: Land & Water Australia, Australian Government; 2007. https://library.dbca.wa.gov.au/static/FullTextFiles/069385.pdf. Accessed 21 Mar 2019.
Preuss K, Dixon M. ‘Looking after country two-ways’: Insights into Indigenous community-based conservation from the Southern Tanami. Ecol Manag Restor. 2012. https://doi.org/10.1111/j.1442-8903.2011.00631.x.
Green D, Minchin L. Living on climate-changed country: indigenous health, well-being and climate change in remote Australian communities. Ecohealth. 2014. https://doi.org/10.1007/s10393-013-0892-9.
Article PubMed Google Scholar
VicHealth. Building Indigenous Leadership: Promoting the Emotional and Spiritual Wellbeing of Koori Communities through the Koori Communities Leadership Program. Melbourne: Victorian Health Promotion Foundation; 2005.https://www.vichealth.vic.gov.au/-/media/ResourceCentre/PublicationsandResources/Health-Inequalities/IndigenousLeadership/BI_Leadership.pdf?la=en&hash=9E7E86A60D9F2A82BBBC91963C9A1B1424B341D9. Accessed 1 Apr 2019.
Baum F. Social Capital. In: Carson B, Dunbar T, Chenhall R, Bailie R, editors. Social Determinants of Indigenous Health. Crows Nest NSW: Allen & Unwin; 2007. pp. 109–34.
Burgess P, Morrison J. Country. In: Carson B, Dunbar T, Chenhall R, Bailie R, editors. Social Determinants of Indigenous Health. Crows Nest NSW: Allen & Unwin; 2007. pp. 177–202.
Kingsley J, Townsend M, Phillips R, Aldous D. “If the land is healthy… it makes the people healthy”: the relationship between caring for Country and health for the Yorta Yorta Nation, Boonwurrung and Bangerang Tribes. Health Place. 2009. doi:https://doi.org/10.1016/j.healthplace.2008.05.009.
Article Google Scholar
Devitt J, Hall G, Tsey K. Underlying causes. In: Condon J, Warman G, Arnold L, editors. The Health and Welfare of Territorians. Northern Territory: Department of Health and Community Services; 2001. pp. 9–17.
Google Scholar
Nelson A. Sport, physical activity and urban Indigenous young people. Aust Aboriginal Stud. 2009;2:2.
Google Scholar
Nelson A, Macdonald D, Abbott R. A risky business? Health and physical activity from the perspectives of urban Australian Indigenous young people. Health Risk Soc. 2012. https://doi.org/10.1080/13698575.2012.680949.
Article Google Scholar
Nel P, Pashen D. Shared antenatal care for indigenous patients in a rural and remote community. Aust Fam Physician. 2003;32:3.
Google Scholar
Preuss K, Brown JN. Stopping petrol sniffing in remote Aboriginal Australia: key elements of the Mt Theo Program. Drug Alcohol Rev. 2006. doi:https://doi.org/10.1080/09595230600644640.

Article PubMed Google Scholar
Osborne K, Baum F, Brown L. What works? A review of actions addressing the social and economic determinants of Indigneous health. 2013. https://equityhealthj.biomedcentral.com/submission-guidelines/preparing-your-manuscript/review. Accessed 30 Apr 2019.
O’Brian A. Factors shaping Indigenous mental health: an ethnographic account of growing up Koori from a Gubba perspective. Aust J Holist Nurs. 2005;12:1.
Google Scholar
McLennan V, Khavarpour F. Culturally appropriate health promotion: its meaning and application in Aboriginal communities. Health Promot J Aust. 2004. https://doi.org/10.1071/HE04237.
Article Google Scholar
Dimer L, Dowling T, Jones J, Cheetham C, Thomas T, Smith J, et al. Build it and they will come: outcomes from a successful cardiac rehabilitation program at an Aboriginal Medical Service. Aust Health Rev. 2013. doi:https://doi.org/10.1071/ah11122.
Article PubMed Google Scholar
Priest N, Mackean T, Davis E, Briggs L, Waters E. Aboriginal Perspectives of Child Health and Wellbeing in an Urban Setting: Developing a conceptual framework. Health Sociol Rev. 2012. https://doi.org/10.5172/hesr.2012.21.2.180.
Article Google Scholar
Larkins S. Strengthening Culture, Strengthening Identity: Keys to healing for Aboriginal and Torres Strait Islander children and young people and securing their social and emotional wellbeing. Fam Relationsh Q. 2010;17:10-13.
Priest N, Paradies Y. The impact of racism on parenting and the outcomes of Victorian Aboriginal children and young people. Melbourne: Victorian Department of Early Childhood Development; 2009.
Google Scholar
Diabetes Western Australia. Strong Culture: A Road to Good Health: A Resource for Engaging Aboriginal School Students in Diabetes Prevention. Subiaco: Diabetes Western Australia; 2014. https://webarchive.nla.gov.au/awa/20160321150137/http://www.aboriginalhealthdiabeteswa.com.au/wp-content/uploads/2015/02/Strong-Culture_manual.pdf. Accessed 1 May 2019.
Phipps P, Slater L. Indigenous cultural festivals: Evaluating impact on community health and wellbeing. Globalism research Centre, RMIT University, Melbourne. 2010. https://ro.uow.edu.au/artspapers/1503/. Accessed 1 May 2019.
Ritchie SD, Wabano MJ, Russell K, Enosse L, Young NL. Promoting resilience and wellbeing through an outdoor intervention designed for Aboriginal adolescents. Rural Remote Health. 2014. https://doi.org/10.22605/RRH2523.
Article PubMed Google Scholar
Ware VA, Meredith V. Supporting healthy communities through sports and recreation programs. Australian Institute of Health and Welfare and Australian Institute of Family Studies, Canberra. 2013. https://www.aihw.gov.au/getmedia/61c83f53-3d74-40e4-8c99-554b5bce71cf/ctgc-rs26.pdf.aspx?inline=true. Accessed 7 May 2019.
Poroch N, Arabena K, Tongs J, Larkin S, Fisher J, Henderson G. Spirituality and Aboriginal People’s Social and Emotional Wellbeing: A Review. Cooperative Research Centre for Aboriginal Health, Casuarina. 2009. https://winnunga.org.au/wp-content/uploads/2018/10/Spirituality-Review-2009.pdf. Accessed 9 May 2019.
Vicary D, Bishop B. Western psychotherapeautic practice: Engaging Aboriginal people in culturally appropriate and respectful ways. Aust Psychologist. 2005. https://doi.org/10.1080/00050060512331317210.
Article Google Scholar
Victorian Aboriginal Community Controlled Health Organisation and Cooperative Research Centre for Aboriginal Health. Communities Working for Health and Wellbeing: Success stories from the Aboriginal community controlled health sector in Victoria. Cooperative Research Centre for Aboriginal Health, Casuarina. 2007. https://www.lowitja.org.au/content/Document/Lowitja-Publishing/VACCHO-Successes-Booklet-hi-res-screen.pdf. Accessed 10 June 2019.
Paradies Y. Unsettling truths: modernity, (de-)coloniality and Indigenous futures Postcolonial studies. 2020. https://doi.org/10.1080/13688790.2020.1809069.

Page 2

From: Cultural determinants of health for Aboriginal and Torres Strait Islander people – a narrative overview of reviews

First Author [reference number] Year	Family/community	Country and place	Cultural identity	Self-determination
Berry [21] 2010	Unknown yet whether community-led caring-for-Country projects could produce both benefits for country and personal empowerment	Greater physical activity (associated with caring-for-country projects) is linked to better mental health directly and because it improves physical health, itself strongly linked to mental health [30, 31]	Caring for Country could support connectedness to identity and generate powerful co-benefits for social and emotional wellbeing	To reduce the current preventable burden of disease, we must address lack of control as one aspect of a broader experience of Aboriginal powerlessness [5, 32]
Burgess [22] 2005	Cohesion with kin, ancestors and geography are all important factors in the formation of collective esteem and efficacy [33, 34]	Engagement with Country provides opportunities for physical activity, improved diet as well as boosting individual autonomy and self-esteem [35, 36]	“Our identity as human beings remains tied to our land… Destroy this relationship and you damage – sometimes irrevocably – individual human beings and their health” [37]	Renewed ties to Country can form the basis of reinvigorated governance and can develop a sense of autonomy and mastery over life [38, 39]
Salmon [23] 2018	Social support, in the form of community affection, is a strong determinant of health for Aboriginal women [40]	Caring for country has benefits for the socio-political, cultural, economic, and physical and emotional wellbeing of Aboriginal peoples [22, 41,42,43,44,45]	Culture is critically important – it is the central core of Aboriginal child health and wellbeing	Leadership is critical to the long-term survival and growth of Koori [Aboriginal people from New South Wales and Victoria] communities [46]
VicHealth [24] 2011	Family and kinship networks and community connections can promote health and can be harmful to health [47]	Programs that involve Aboriginal Natural and Cultural Resource Management are associated with lower levels of risk factors for CVD and diabetes and improved self-esteem [48]	Caring for Country appears to be linked to improved identity and is recommended as a means to improving health [49]	A requirement for reversing colonisation is self-determination. Self-determination helps people restore control over their lives and destinies
Weir [25] 2011	Not reported	Caring for Country has benefits for individual health and wellbeing, and the health of communities	A relationship between identity, autonomy and wellbeing and caring for Country [48]	Control over life is an important determinant of wellbeing [50]
Dahlberg [26] 2018	Family determines a child’s level of activity and type of sport they practice [51, 52]	A big emphasis is placed on physical and social environment when it comes to physical activity	Evidence of the positive impact in the strong sense of collective identity and pride that is experienced when part of a team [51]	Not reported
MacLean [27] 2017	Welcoming extended family members to attend antenatal care and childbirth supports the expression of cultural identity and can decrease perinatal morbidity [53]	Activities on Country can be used to improve health [54]	Programs that include components to enable and support Aboriginal peoples to express cultural identity can have positive health and wellbeing effects	Not reported
Behrendt [28] 2017	Not reported	It is not possible to conceive of Aboriginal health determinants without appreciating the inseparable connection between wellbeing and Country	Valuing Aboriginal knowledge and cultural beliefs and practices is necessary for positive cultural identity and social and emotional wellbeing [55]	A link between self-determination and improved health and wellbeing; however, demonstrating this link can be challenging [55]
Ypinazar [29] 2007	Family is considered pivotal to emotional, physical and cultural health [56]	Not reported	A positive sense of identity is connected to individual and community wellbeing [56, 57]	Not reported