Introduction

The disparities between the health of Indigenous and non-Indigenous populations continue to be prevalent within Australia [1–3]. Indigenous Australians have a shorter life expectancy (10.6 years less for males and 9.5 years less for females) and worse health outcomes than their non-Indigenous counterparts [1,2]. According to Vos et al. [4], 70% of the health gap between Indigenous and non-Indigenous Australians can be explained by non-communicable chronic diseases, with cardiovascular disease being the largest contributor (23%), followed by diabetes (12%), mental disorders (10%), and chronic respiratory disease (9%). It is recognised that health risk behaviour has a substantial impact on many non-communicable diseases [4–6], and Indigenous Australians more frequently engage in detrimental health risk behaviours, such as smoking tobacco and misuse of alcohol and drugs [4]. For example, in a recent national survey, 43.8% of Indigenous Australians were reported to be current daily smokers, compared with 15.7% of non-Indigenous Australians [7]. In light of the association between health risk behaviour and health outcomes, reducing health risk behaviour among Indigenous Australians may improve their health outcomes. Indeed, any efforts to curb health risk behaviours need to be considered within the broad social, economic, and political context in which individuals live and the way these social determinants of health impact daily living conditions and subsequent health risk behaviours [8–10]. From an equity perspective, it is necessary to critique the culture of the Australian public health system and note the ineffectiveness of many mainstream health interventions to effectively target Indigenous populations [11].

The factors that influence Indigenous Australians’ health behaviour are poorly understood [12]. Commonly, behaviour is believed to be driven by factors within the immediate control of the individual, such as perceived behavioural control and attitudes towards the behaviour [13]. However, research indicates that factors beyond the choice/control of the individual may influence Indigenous Australians’ health behaviour [14,15]. For instance, in some circumstances, the social disruption associated with historical events appears to promote health risk behaviours [16–19]. In particular, alcohol abuse and tobacco smoking have been linked with social disruptions [16], and the stress associated with daily life may exacerbate the practice of health risk behaviours such as tobacco smoking [14,19]. It has also been identified that social networks may promote health risk behaviours such as smoking [19]. Conversely, cultural identity and distinctiveness may be psychologically protective and therefore promote positive health behaviour [20–22].

During the colonisation of Australia, racism was pervasive [23]. Indigenous people were forced to live in missions and on reserves where freedom to hunt, socialise with relatives, practice traditional ceremonies, and marry were restricted [24]. Segregation and assimilation policies were introduced, along with institutionalisation and geographical restrictions [25]. In some instances, Indigenous people were prevented from speaking their traditional language, practicing their culture, and teaching their children their history and traditions [26]. The restrictions and conflict associated with colonisation led to loss of liberties and life and irrevocably altered Indigenous Australians’ cultural and social behaviour [27].

Past atrocities and continued discrimination have created long-term physical and psychological effects on Indigenous people that are often trans-generational [28]. This is reflected in numerous statistics and psychosocial circumstances that indicate that discrimination and racism towards Indigenous people still affects their lives [28–31]. For example, unemployment rates reveal a disparity, with 17% unemployment for Indigenous people compared with 5% for non-Indigenous [31]. Daily stressors related to such economic disparity also contribute to health disparities [32].

While this may indicate that the health behaviour of Indigenous Australians is affected by psychosocial circumstances beyond their control, there appears to be limited research exploring this aspect [12,33].

The association between health behaviour and factors that are beyond the control/choice of the individual suggests a broader psychosocial approach, employing a macro perspective, may be beneficial. This perspective enables the examination of factors that are associated with personal choice/control, in conjunction with factors that are beyond the choice/control of the individual [34,35]. Thus, factors that are traditionally considered instrumental in behaviour development could be considered simultaneously with factors that may be more influential within an Indigenous context [32,36,37]. Enquiry including sociological and psychological perspectives can be facilitated by the use of conceptual frameworks/models to assist the process of analysing the data [34,35]. One psychosocial model that has found traction within health research, including Indigenous health research [15,38–40], is the social ecological model [34,35]. Lynch’s [35] iteration of this model categorizes factors into a series of social levels that impact upon the issue under investigation. These levels include broader societal influences (i.e., culture, politics, and discrimination), neighbourhood or community social interactions (social interactions and connections through groups and organisations), close social connections (i.e., friends and family), and individual characteristics (i.e., behavioural and psychological). This model may assist when analysing data associated with understanding a diverse range of factors that affect a topic under investigation.

Insights from observers who are closely associated with a particular group or individual provide data from an opportune perspective that may enable new revelations regarding the factors that influence health behaviour, especially when analysed using a social ecological approach. In particular, people who provide support for groups or individuals are in a unique position to observe the people they support and the broader influences on the circumstances surrounding those people. Therefore, their perspective may encompass information regarding societal and community level factors, in conjunction with information regarding the effect of closer social connections. Prior research indicates that observers’/informants’ perspectives have provided valuable insight into the behavioural motivations of those they have personal or professional relationships with [14,41–44]. For example, Wood et al. [14] examined the factors that influenced Indigenous pregnant women’s smoking behaviour by seeking the opinions of health workers. Similarly, when Barnes et al.[41,45] sought to understand the factors that influenced Indigenous health behaviour, allied health professionals in support roles (i.e., nurses and health workers) were interviewed. Although the opinions of people in support roles have been included in some Indigenous health related studies, the type of roles often appear to be limited to health professionals. In order to gain a wider perspective, it is considered advantageous to include an interdisciplinary approach [46,47]. Consequently, the opportunity to include other support people such as educationalists or community development officers may provide a wider perspective on the factors that influence health behaviour. An integral aspect to such recruitment is the inclusion of Indigenous participants who, as well as providing insights relating to the people they support, are able to draw on their own experiences as Indigenous community members [14,44].

Attempting to further the understanding of Indigenous health behaviour by consulting a broad range of people who support Indigenous groups, but that also include Indigenous people, may have merit. Support workers are often exposed to the socio-political aspects of Indigenous health, as well as Indigenous people accessing community (i.e., health, education, or housing) services and as such are in an opportune position to provide a unique perspective on the situation under investigation [48]. They may also observe Indigenous community members attempting to moderate their health behaviours [14]. Wood et al. (2008) interviewed health workers during their investigation exploring the reasons why Aboriginal women continue to smoke during pregnancy. They included health workers because these support people were able to observe Aboriginal women during their pregnancy; at stage of when many people quit smoking. As a group, support workers can provide a useful perspective of Indigenous health across each of the main socio- ecological levels [38]. In light of prior research, the current qualitative study was designed to better understand the factors influencing health behaviour within Indigenous groups in Western Australia by mapping the emergent themes from discussions with people who support Indigenous groups into the social ecological model.

Method

Results

The focus of the discussions was not limited to one type of health behaviour; the participants mentioned a range of health behaviours throughout the discussions. These included smoking, alcohol consumption, physical activity, and dietary habits. The themes identified in this study were analysed and categorised within a social ecological framework. Fig 1 provides a concept map of the findings presented in this format. Broader social factors relating to culture, history, racism, and socio-economic circumstances were thought to influence health behaviour. Social connections with a variety of Indigenous people including family, other Indigenous community members, and non-Indigenous people (including health professionals) were also thought to influence health behaviour. In addition, personal circumstances and psychological factors were considered influential. Many of the factors were understood to act in a complex manner with respect to their effect on health behaviour. No differences between Indigenous and non-Indigenous interviewees were identified, indicating alignment between the two culturally different perspectives with respect to the topic under investigation.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Factors influencing the health behaviour of Indigenous Australians from the perspective of people who support Indigenous groups.

https://doi.org/10.1371/journal.pone.0142323.g001

Study participants felt there were multiple factors that influenced the health behaviour of Indigenous people within the Western Australian communities they supported. The factors that emerged from conversations regarding remote, regional, and metropolitan Indigenous community members were the same. The similarity in factors identified at a variety of geographical locations may indicate these factors transcend other geographical concerns because of the magnitude of their effect upon the circumstances. The findings are presented under emergent themes that were identified during the data collection episodes.

Discussion

This study explored Indigenous health behaviour in Western Australia from the perspective of support workers; around half of whom were Indigenous. The results reveal the complex relationship between social relationships and the broader Indigenous and non-Indigenous cultures and their impact on individual health behaviours. The results show that the participants in this study considered that the health behaviours of the Indigenous people they supported were extensively influenced by factors beyond the control of the individual. Culture, social networks, history, racism, socioeconomic disadvantage, and the psychological distress associated with some of these factors were thought to affect the health behaviour of the Indigenous community members supported by the participants involved in this study. In addition, the views expressed by all participants, regardless of their status as Indigenous or non-Indigenous were in alignment, with no differences observed.

It was apparent that these factors were often interrelated and, therefore, affect health behaviours in a complex manner that is not easily described. For example, inadequate housing leading to overcrowding may detract from an individual’s ability to enact positive health behaviours [20,21] However, the social and emotional wellbeing involved in interacting with other Indigenous people may negate or in some cases confound the effect of the overcrowding and have positive effects on health behaviour [20,21]. The intimate social connections that occur in such situations may have positive effects on psychological factors such as self-esteem, which can have a positive on influence health behaviour [20,21]. Further, it was apparent that the Indigenous culture was a strongly empowering and capacity building force within Indigenous communities. However, the unrelenting discrimination within the broader Australian community appeared to act as a moderating force that potentially undermined the empowering effects of the culture. The synergetic effect of such interactions impacted upon health behaviour.

Support workers’ accounts of the challenges of changing health behaviour focused on the importance of socio-cultural factors. This was primarily facilitated by the emphasis that was placed on social connections /networks by the culture. It was believed that some cultural aspects may have reinforced social connections in a manner that promoted group conformity and group expectations. This led to a complex interaction between socio-cultural factors and health behaviour. Consequently, it appeared Indigenous people were more likely to listen to advice which was provided by their relatives or other Indigenous people. Such reliance on advice from familiar sources is common in situations where cultures live together but have different socio-cultural traditions [57,58]. Moreover, the importance of relationships with family and kin, and the associated obligation to these relationships, significantly influenced health behaviour. In light of economic circumstances, one aspect that appeared to be particularly important was the cultural obligation to share resources with family members. Interviewees felt that this issue resulted in diminished resources available for maintaining personal health behaviour. Johnston and Thomas [59] noted that such cultural obligations add another layer of complexity to social dynamics that is not experienced by non-Indigenous groups. Passey et al. [19] also noted the importance of cultural identity (Aboriginal identity) in social network formation, and the role social networks play in perpetuating smoking behaviour. Similar to this, the current study highlights that in some instances, the desire (or perhaps obligation) to share that arises from, and reinforces, cultural identity may reduce the opportunity and inclination to make health behaviour adjustments, which are necessary for specific health issues, such as diabetes. This cultural focus on family and kin altered the priority of personal needs and the motivational influence derived from identity, self-esteem, and empowerment.

According to support workers, the importance of maintaining cultural distinctiveness impacted on the health behaviour of Indigenous people. Moreover, the continual experience of racism and discrimination may polarise Indigenous people towards their own culture, in a manner similar to that theorised in social identity theories such as in-group (us)/out-group (them) theory [60]. This theory states that people may develop strong links with a group they identify with and, conversely, can develop prejudice against opposing groups [60,61]. This may indicate that racism and discrimination have a confounding effect on cultural identity. In light of this, the necessity to maintain cultural distinctiveness may outweigh caution regarding the negative consequences of health risk behaviour. In their review of social theories, Dixon and Banwell [62] supports the notion that health risk behaviour is sometimes perpetuated in disadvantaged groups by the need to maintain distinctiveness from other groups. In a similar manner, a study involving Indigenous Australians from four rural communities within New South Wales indicated the necessity for cultural distinction may influence smoking behaviour [19]. Brough et al. [20] also suggested that cultural identity and cultural distinctiveness have important psychological protective qualities in the face of marginalisation and racism.

The importance of cultural distinction may promote resistance to embracing health behaviours that are perceived as being aligned to another culture which in turn could promote engagement with health risk behaviours or healthful behaviours depending on the situation. A social resistance framework has been devised in an attempt to explain such resistance within non-dominant minority groups [63,64]. In this context, engaging in health risk behaviours could be explained as everyday acts of resistance against the ideations and concepts of the dominant group [63]. This framework also explains minority group members’ criticism towards embracing attitudes and beliefs of the dominant group [63,65,66]. Factor et al. [64,65] used this framework to provide insight into health risk behaviour within the African American minority group in the United States. Given the sentiment expressed in the current study’s discussion, if positive health behaviours were perceived to be part of the non-Indigenous culture this may create a barrier to those behaviours.

The separation between Indigenous and non-Indigenous social connection/networks that appears to be fostered by marginalisation and racism may influence the effect of social networks. Support workers’ comments indicated that social connections with non-Indigenous people may be hindered by the maintenance of cultural distinctiveness, an oppressive history, and racism. This supports suggestions that marginalisation and racism impact upon social networks to diminish the availability of non-Indigenous connections [19,20,67]. Acceptance of health behaviour information that is derived from non-Indigenous sources or depicted from a non-Indigenous perspective may be diminished by the influence of marginalisation, racism, and desire for cultural distinctiveness.

Communication between Indigenous people and non-Indigenous people may also be disrupted by the sense of wariness or distrust some Indigenous people feel towards non-Indigenous people. The participants in the current study noted that distressing historical encounters and present day racism lead to an inclination by Indigenous people to distrust non-Indigenous people. Moreover, Indigenous participants’ comments indicated that the emotional distress and sorrow associated with tragic historical events, such as family massacres, impacted greatly upon Indigenous people. The detrimental impact of racism and historical events has been noted in previous studies that indicate such encounters have been psychologically distressing for Indigenous Australians [68,69]. Bond et al. (2012) noted that cognitive disparity may arise in response to advice regarding healthy living when provided by state institutions that were instrumental in the oppressive colonisation of Indigenous people.

Communication has a relational component that can be disrupted by distrust [70]. Gilson (2003) suggested that trust is affected by past encounters, either between people or people and organisations. Within an Australian Indigenous context, cultural emphasis on relationships and connections indicates that the importance of this relational aspect of communication may be heightened. Therefore, the trustworthiness of the messenger is a very important part of validating the information they convey. When the messenger is a stranger, trust stems from the reputation of the organisation they represent, or the credibility of known associates [70]. In light of this, preconceived distrust may have the potential to diminish the effect of communication from non-Indigenous sources. The findings in this study suggest that distrust may create a communication barrier with regards to promoting health behaviour to Indigenous Australians.

It was posited that it may be difficult for individuals to change their health behaviour without the wider community implementing similar changes. Research into the factors influencing health promotion within Samoan communities emphasised the conundrum that is caused when health is considered from an individually oriented perspective and from a culturally oriented social wellbeing perspective [71]. They concluded that this resulted in changes in health behaviour being suspended until cultural change occurs; thereby inadvertently placing the responsibility for improving health back on the cultural leadership. The notion that the normative behaviour of a group (for instance, a cultural group) will influence the individuals within the group is commonly acknowledged [72]. Such influence can encourage and spread behavioural change through the group’s social networks [13,72]. However, in instances where there is discrimination or oppression, the expectation for cultural leadership to champion health change may inadvertently exacerbate inequities. For instance, Hardin [71] suggested that when culture is acknowledged as the most important factor to changing health behaviour, health practitioners inadvertently reproduce structural inequalities in their encounters with clients. A re-framing needs to occur whereby there is much more importance and validation of Indigenous culture expressed through mainstream channels to cultivate a deeper population-wide understanding of the rich culture of Indigenous Australians.

Limitations

Due to the qualitative nature of the study, the findings cannot be generalised beyond the study sample. However the credibility and validity of the themes was substantiated by the methodological and interpretive rigour employed throughout the study (as per [55,73]). The use of the social ecological model may have limited the scope of the findings. This model facilitated a broad inspection of the data, which may have detracted from examining minute differences in the data. However, in using this model the findings highlight factors that transcend the heterogeneity within Indigenous groups. In terms of methodological limitations, it is acknowledged that despite no differences being observed between the Indigenous and non-Indigenous informants, the recruitment of non-Indigenous people in support roles may be insufficient to explain Indigenous individual health behaviours. While Indigenous perspectives were obtained in the current study, future research should prioritise the perspectives of a larger and more geographically diverse sample comprised of only Indigenous people in explaining their own health behaviours to complement the findings of the present study. Further, in the current study, culture is portrayed as a homogenous entity, when in fact it is a nuanced and complex part of Indigenous populations’ lives that cannot be explicated fully from a small sample comprising both non-Indigenous and Indigenous informants.

Conclusion

The current study highlights the complexities and challenges created by the intersection of (in broad terms) two cultures (Indigenous and non-Indigenous cultures). This dynamic is confounded by the oppressive history combined with racism that persists into contemporary circumstances, and the associated marginalisation. In addition to marginalisation, the desire for cultural distinctiveness and the influences of cultural perspectives further confounds and exacerbates the dynamics caused by other enablers and barriers, such as social connections and social support. In particular, the data suggests that distrust created by historical and contemporary racism may impede any health and broader assistance that might be gained from non-Indigenous sources. Conversely, it also highlights the conundrum involved in promoting health behaviour without reinforcing oppression or inequalities. It also points to the necessity for Indigenous community coalition driven efforts to improve health behaviour as a way of reducing inequities and empowering communities [74].

Acknowledgments

The authors thank the participants who were part of the research project for their commitment to the study.