Addressing Inequities in Indigenous Mental Health and Wellbeing through Transformative and Decolonising Research and Practice

Aim: This paper discusses the current mental health and social and emotional wellbeing in Indigenous Australian mental health and wellbeing, the gaps in research, the need for transformative and decolonising research and practice, and the opportunities and recommendations to address existing mental health inequities. Method: This paper reviews key mental health and social and wellbeing policy documents and frameworks, and examines relevant literature documenting current decolonising www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 3, 2020 49 Published by SCHOLINK INC. strategies to improve programs, services and practice. It also draws on the key findings of the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention (CBPATSISP) and Transforming Indigenous Mental Health and Wellbeing research projects. In addition this work builds on the substantial work of the national Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (ATSISPEP) which outlines a range of solutions to reduce the causes, prevalence, and impact of Indigenous suicide by identifying, translating, and promoting the adoption of evidenced based best practice in Indigenous specific suicide prevention activities. Discussion and Conclusion: This paper details the challenges as well as the promise and potential of engaging in transformative and decolonising research and practice to address the existing health service inequities. Acknowledging and addressing these health inequities is an urgent and critical task given the current COVID-19 pandemic and potential for further increasing the adverse mental health and wellbeing gap for Indigenous Australians.


Introduction
Aboriginal and Torres Strait Islander (hereon respectfully referred to as Indigenous) peoples experience a disproportionate burden of health and mental health issues and suicide. Indigenous rates of death by suicide were double the rate of the non-Indigenous population in 2018 (Australian Bureau of Statistics (ABS), 2019a). In the same year, the ABSs' National Aboriginal and Torres Strait Islander Health Survey (NATSIHS), 2018-19 reported that:


One in four Indigenous people have a mental or behavioural condition.
 Indigenous people experience high and very high rates of psychological distress, about three times the rate of the non-Indigenous population.
 Anxiety was the most common mental or behavioural condition experienced by Indigenous people, reported by just under one in five (17%) respondents (ABS, 2019b).
In addition, the Australian Health Ministers' Advisory Council (AHMAC) reported that:  Depression (including feelings of depression) was the second most common condition experienced by Indigenous people, reported by about one in eight (13%) respondents.
 Indigenous population rates of hospitalisation for mental health and related conditions are 2.1 times higher for Indigenous men and 1.5 times higher for Indigenous women when compared to their non-Indigenous counterparts.
 Indigenous people are seen in the Emergency Room for mental health reasons at higher rates than non-Indigenous people (AHMAC, 2017).
Indigenous people in Victoria found "an over-representation of calls by Indigenous young people (59%) to Kids Helpline, for suicide and self-harm reasons" (p. 353). Also of relevance, are the findings of a youth mental health study examining the prevalence and patterns of psychological distress experienced by young people in Australia over seven years (Hall et al., 2019). The report found that a greater proportion of Indigenous young people (31%) experienced psychological distress compared to non-Indigenous young people but did not seek professional help; were three times as likely to report feeling they have no control over their lives and almost twice as likely to have low self-esteem (Hall et al., 2019). Only 67.8% Indigenous young people felt they had someone to turn to, compared to 80% of their peers, and were twice as likely to use the internet to access an online course or program. A greater proportion were more likely to chat with someone who had a similar experience or engage with a support group or forum. Indigenous young people commonly cited seeking help from friend/s (63.6%), internet (44.3%) and parents/s or guardian/s (43.5%), and a higher number turned to "a community agency, social media or a telephone hotline for help" (Hall et al.,p. 33).
A smaller proportion of Indigenous young people with psychological distress (approximately one quarter) reported stigma and embarrassment, lack of support, and fear as barriers to seeking help than their non-Indigenous peers); although a greater proportion of Indigenous young people reported that discrimination/punishment was a barrier (Hall et al., 2019). With a greater proportion indicating concerns over "gambling, domestic/family violence, drugs, discrimination, alcohol, LGBTIQ issues and suicide" (Hall et al., 2019, p. 54) compared with their non-Indigenous counterparts. It is important to consider these compounding concerns, given the leading causes of hospitalisation for mental and behavioural disorders experienced by Indigenous young people aged 10-24 years were due substance abuse, schizophrenia, and reactions to severe stress (Australian Institute of Health and Welfare (AIHW), 2018a; cited in Hall et al., 2019, p. 54). Of concern, the AIHW Report (2018a) also found that most Indigenous young people aged 15-24 (67%) "experienced low to moderate levels of psychological distress in the previous month, while 33% experienced high to very high levels" (AIHW, 2018a, p. xi).
Further, other studies have found that higher rates of trauma, including intergenerational and cumulative trauma, are the result of, and influence, a range of complex interrelated factors including incarceration (Heffernan et al., 2015), homelessness (AIHW, 2019b), mental health issues and youth suicide (Coroner's Court of Western Australian, 2019). Mental health challenges are compounded further by poverty and associated factors. For example, psychological distress increases as income and housing stability decreases (AHMAC, 2017). Overall, Indigenous people do not experience equal social and economic status compared with the wider population (Biddle & Markham, 2017).
Within these glaring inequities, the evidence suggests that the primary mental health care needed for early detection and treatment of Indigenous mental health issues is currently insufficient (Harfield et al., 2018;Kilian & Williamson, 2018). The early diagnosis of mental health disorders by General Practitioners (GPs) and lack of appropriate referral pathways that take account of cultural and geographic differences have been identified as a primary barrier to receiving appropriate treatment and care for Indigenous people (Hinton et al., 2015).

Review of Relevant National Mental Health and Wellbeing Literature and Policies
This paper reviews key current mental health and social and wellbeing policy documents and frameworks and survey evidence of the extent to which their stated goals have been implemented and and promoting the adoption of evidenced based best practice in Indigenous specific suicide prevention activities. An analysis of relevant findings include a systematic review of effective strategies in mental health and wellbeing  and a meta-analysis of evaluated suicide prevention programs.

Gaps and Uncertainties
An analysis of the literature findings confirmed there are a number of gaps and uncertainties that clearly contribute to the current inequities in Indigenous mental health and wellbeing. These include: health services gaps, barriers to access; lack of understanding of the exact nature and extent of unmet need; the costs and benefits of adopting Indigenous-led and targeted and upstream prevention initiatives; as well as significant data limitations to address them. As Dudgeon et al. (2016c)  health stigma and shame along with fear of ostracism and government intervention" (p. 7).
As Canuto et al. (2019) point out there are "multiple, complex and interacting factors that enable (or inhibit) Aboriginal and Torres Strait Islander men from accessing and using available care" (p. 307).
These include "a lack of continuity of care, cultural factors pertaining to communication and understanding, counteracting social pressures, and both self-determination and control" (p. 307). Other studies (Isaacs et al., 2016;Mitchell & Gooda, 2015) have shown that a lack of culturally responsive and available services can inhibit help seeking, contributing to higher levels of intergenerational trauma, self-harm and suicide. Part of the problem resides in the fact that Indigenous people "are not sufficiently involved in planning, delivering and evaluating relevant healthcare services" (Hayman et al., 2006, p. 485, as cited in Canuto et al., 2019.

Lack of Culturally Relevant Epidemiological Data
In order to close the mental health gap there is also the need for epidemiological studies to systematically-collect information about Indigenous people's use of mental health services, the nature of interventions they access, their alignment with best practice evidence, their unmet needs for care, and the barriers to care. Both subjective and objective indicators of the quality of care provided are also needed to identify the inequities in mental health service systems to address existing disparities in mental health. Information about barriers to access will assist health planning in the reallocation of resources. For example, a study by Ypinazar et al. (2007) found that spirituality is strongly related to Indigenous understanding and management of mental health and substance use issues.
Currently information about Indigenous Australians' mental health service use is collected through the Australian Aboriginal and Torres Strait Islander Health Survey (AATSIHS). This survey collects information on the health status, socio demographics, chronic health conditions, health risk factors, use of health services including GPs and other health practitioners, and other help-seeking behaviour.
Questions regarding respondents' unmet needs include whether they needed care but did not receive it, spirituality, Indigenous health professionals, traditional healers, traditional health and wellness practices, alcohol treatment, and substance use education programs, communication barriers, and cultural appropriateness (ABS, 2013). While the AATSIHS obtains relevant information with respect to Indigenous mental health service needs it does not include questions regarding the use of alternative therapies, psychotherapy or cognitive-behavioural therapy, and perceived need for care (McIntyre et al., 2017), there is still a need for further ongoing work in this area.
Given the increasing use of e-health options, the Indigenous health surveys of Indigenous people could include questions about online information retrieval and online support group participation, including the use of culturally specific resources. Currently the use of culturally-specific websites such as the "yarning places" message boards on Australian Indigenous HealthInfoNet, and their impact, has not been systematically assessed. While recent studies have suggested that the internet is an effective platform to increase Indigenous access to health information and suicide prevention resources, (Dudgeon et al., 2019) there is a need for greater understanding of the availability of culturally appropriate health information online (Levett, 2011).
With respect to epidemiological and population health research, a recent study by McIntyre and colleagues confirms there is an urgent need to improve Indigenous health survey questions in order to collect information about "Indigenous people's use of health services that takes into account their specific service preferences and service contexts" (2017, p. 14). This is necessary to identify and understand the existing inadequacies in mental health services; and inform health service planning to assist in closing the mental health gap for Indigenous Australians.

A framework for Addressing Indigenous Mental Health and Wellbeing
There is a broad consensus and evidence base to suggest that SEWB is the most effective and culturally appropriate approach to view and address Indigenous mental health issues. The concept of SEWB includes mental health as part of encompassing a holistic view of health and wellbeing. Broadly, SEWB is the foundation for physical and mental health for Indigenous Australians which "results from a network of relationships between individuals, family, kin and community connection to land, culture, spirituality and ancestry, and how these affect the individual" (Gee et al., 2014, p. 55  Islander identity grounded within a collectivist perspective" (DPMC, 2017, p. 6). Around this ecology are social, historical and political determinants that include education, employment, housing, access to health care and freedom from racism and discrimination. In response to these conditions, the SEWB ecology includes those protective factors that strengthen mental health (DPMC, 2017).

Responses to Address Identified Gaps
In order to effectively address Indigenous mental health and suicide prevention, there is a need for a range of responses to operate within the SEWB Framework (DPMC, 2017). This section outlines how these responses can address identified gaps including the need for: 1) culturally responsive services; 2) a culturally and clinically competent workforce; 3) transformative, decolonising research and practice; 4) strategies, programs and services to address the social determinants impacting mental health and wellbeing; and, 5) decolonising the curriculum.

The Need for Culturally Responsive Services
It is widely accepted that mainstream services' delivery of acute, tertiary, and primary care has been built on western paradigms and biomedical models of care, and continue to operate as colonial systems.  Support to recover in community, including continuity of care and patient transitions. This could include outreach/assertive outreach in response to suicide attempts (Dudgeon et al., 2016a).
While the establishment of ACCHS has been a crucial first step towards providing more culturally appropriate and culturally secure care for Aboriginal peoples, the lack of integration by mainstream healthcare services and hospitals' with ACCHS means there are still many gaps in service delivery and continuity of care for patients and their families. There is still a need for all health and mental health practitioners to shift from a sole focus on a disease or illness to an approach that encompasses the whole person as well as their family and community, and the social, cultural, historical and environmental determinants that impact their wellbeing. This holistic conception of health and wellbeing is widely recognised and enacted by Indigenous peoples in Australia and globally (Dudgeon et al., 2020a;Harfield et al., 2018).

The Need for a Culturally and Clinically Competent Workforce
Building an effective and culturally responsive workforce with the knowledge, skills, understandings and attributes to provide culturally secure care in diverse cultural settings is also necessary .

The Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing
Principles and Practice Book (Dudgeon et al., 2014a) is a foundational and crucial resource to inform mental health practitioners. Studies confirm that integrated and place-based responses are most effectively delivered by multidisciplinary SEWB teams and mental health teams who are skilled to provide "collaborative interdisciplinary, client centred practice" to address complex health needs (Schultz et al., 2014, p. 221 (Dudgeon et al., 2010, abstract).
The majority of health and mental health research is dominated by the biomedical paradigm, underpinned by foundational and largely uncontested assumptions operating within a Western scientific framework. This biomedical approach has historically influenced research and practice to focus on physical and mental illness, rather than SEWB and mental health more holistically.
One of the critical areas for future research involves investigating the impacts and limitations of dichotomising cultural and clinical perspectives. There is a propensity to set these two perspectives up as a binary, rather than acknowledging that culture is fundamental to effective clinical practice, and one does not need to exclude the other (Napier et al., 2014). Napier et al. (2014) (Dudgeon et al., 2012); the subsequent National Empowerment Project (NEP) , and the Cultural, Social and Emotional Wellbeing (CSEWB) Program (Mia et al., 2017). Their most recent work demonstrates that "extending conventional Participatory Action Research (PAR) principles, protocols and practice, APAR has been successfully applied to achieve Indigenous voice and epistemic self-determination, strengthen community SEWB and contribute to the development of a distinctive Indigenous psychology" (Dudgeon et al., 2020b).
Moreover, there is growing evidence that a tailored Knowledge Translation (KT) approach integrated with PAR can help improve clinician practice in Indigenous community contexts (Laird et al., 2020).
Culture-centred approaches that include community engagement are strongly associated with effective health literacy to improve research translation and sustainability. This suggests an integrated KT combined with PAR is an essential component to closing the gap in Aboriginal health. Co-design, co-production, and co-ownership of health literacy resources to empower communities with knowledge about particular health issues is essential (Laird et al., 2020 threats to culture and identity; imposition of and from Whiteness and colonial mentality; and the impact on access to basic determinants including education, employment, housing, and the effects of racism. The social determinants of health associated with colonisation that influence Indigenous wellbeing include poverty, social exclusion, racism, lack of education and employment, and population-level disempowerment (AIHW, 2018). These interrelated factors adversely impact Indigenous SEWB. A focus on transforming mental health and suicide prevention services, alongside addressing social determinants of health, is critical if Indigenous mental health is to improve and suicide rates are to reduce.
A social determinants approach considers the broad historical, social, political, economic, cultural, and environmental context in which people live and the impact these contexts have on health and wellbeing (Osborne et al., 2013). Whilst there is broad agreement regarding the importance of addressing social determinants including housing, education, employment, and socioeconomic circumstance, little to no culturally appropriate research has been undertaken to investigate the link between these factors and Aboriginal health in general, and mental health and SEWB specifically (Zubrick et al., 2014). Mental health and wellbeing are shaped by a range of factors, including: genetics, family and peer relationships, psychological and physiological functioning, lifestyle, occupation and education, physical environment, socioeconomic status, cultural factors, and the historical and political context (Furber et al., 2016).
While the interplay of both positive and negative factors can be complex, it is well established that the accumulation of risks and adversities throughout childhood and adolescence increases the risk of poor mental health and developing a mental illness (Felitti, 2009). Studies have shown that exposure to poverty, family violence, child abuse and neglect, and homelessness in early childhood can adversely impact the developing brain and psychological health with negative consequences for mental health and wellbeing across the lifespan and intergenerationally (Shonkoff et al., 2012).
A review of evidence by Osborne et al. (2013) relating to improving Indigenous outcomes and closing the gap across a range of key social and economic determinants of health and wellbeing found several gaps, which restricted the ability to specifically identify effective strategies in addressing the social determinants of Indigenous health and wellbeing. These gaps include a lack of:  high quality, publicly available evaluation data on programs and interventions, that can be deemed best practice;  clear causal links regarding the "upstream" or distal causes of health outcomes that are mediated through a variety of pathways (Osborne et al., 2013).
Given the complex and multi-directional nature of the impacts of social determinants, it is difficult to identify which specific determinants contribute directly to particular health outcomes. In an effort to address this gap, several researchers have attempted to map causal pathways across the life course and to argue for upstream strategies (Scrine et al., 2015;Osborne et al., 2013;Zubrick et al., 2014) to promote early intervention and optimise positive health and wellbeing outcomes. Osborne et al. (2013) also suggest that ascertaining what works in these instances would require extensive multivariate modelling of high quality longitudinal epidemiological data, which is generally not available. One exception is the Longitudinal Study of Indigenous Children (LSIC), discussed later in this paper.
Detailed analyses of risk exposure in early childhood and the cumulative impacts and prevalence of multiple risks in Indigenous children is essential for planning and implementing programs and services to address the complexities experienced in Indigenous families that can contribute to mental health issues. It is also necessary to build a picture of what the risk and protective factors are for individuals and families (i.e., young people, women in the perinatal period) at critical transition points across the lifecourse and for vulnerable groups (i.e., LGBTIQ, people with lived experience of suicide, people recently released from incarceration, people who are homeless, people who are experiencing mental health issues). Such information is essential to help guide policies to strengthen the mental health system to prevent the compounding risk cycles that lead to mental health issues and transgenerational trauma. Modelling, and indeed all research in the mental health and wellbeing context, needs to understand and address the inter-connections and potential pathways to poor health and mental health and wellbeing outcomes.
Based on their review findings, Osborne et al. (2013) outline key characteristics of successful programs and interventions when adopting a social determinants approach in research and practice.  (Osborne et al., 2013, p. 2).
In addition, Osborne et al. (2013) (Dudgeon et al., 2014b) and reinforced in the ATSISPEP Final Report (Dudgeon et al., 2016b). Some initiatives that have started to address this current gap are discussed under "Opportunities".

The Need for Decolonising the Curriculum
Importantly, transforming health care systems also requires making changes within academic institutions that teach health professionals across all disciplines. This is important to build the capacity and commitment among health professionals to provide holistic, culturally responsive, and secure care.
It is not enough to simply embed Indigenous content into the curriculum, rather the premises underpinning all curriculum content must be decolonised. There is a need to increase the number of psychology training programs to play their role in closing the gap. They have developed the AIPEP Curriculum Framework (Dudgeon et al., 2016b), the AIPEP Guidelines for Increasing the Recruitment, (Dudgeon et al., 2016c) and AIPEP Workforce Capabilities Framework to increase the capability of psychology graduates to work appropriately and effectively with Indigenous peoples (Dudgeon et al., 2016d).

Retention and Graduation of Aboriginal and Torres Strait Islander Psychology Students
Together these frameworks and guidelines outline the workforce standards and ethical obligations endorsed by the Australian Psychology Society, and which are required to help address the mental health crisis facing Indigenous Australians and to close the gap in health, education and economic status with the wider population.
However, given the significant gaps in mental health and wellbeing between Indigenous and other Australians outlined earlier, there remains an urgent need and opportunity to extend these gains more broadly as part of a major health care reform in Australia and across universities to achieve equity for all.

Challenges in Achieving Equitable Mental Health Outcomes
Culturally appropriate research about Indigenous SEWB and mental health has tended to be marginalised within larger mainstream research programs, and remains underfunded. Reasons for the gaps in current knowledge stem from historical and ongoing colonisation, and the domination and privileging of Western models informed by biomedical paradigms. Indigenous research is not prioritised or legitimised within the Western scientific framework and therefore is generally not supported by funding bodies. Systemic racism inhibits the ability of Indigenous researchers to conduct sufficiently funded research and impedes non-Indigenous researchers from conducting culturally appropriate research.
There is ample evidence to confirm that consideration of the historical, political, and social context of Indigenous wellbeing needs to be an essential part of any research for improvements to take place.
Limiting research to biomedical models will not lead to an understanding of the complex and layered nature of Indigenous SEWB and mental health-related challenges. These challenges also stem from a lack of willingness by funding bodies, policy decision-makers, and service providers, to acknowledge and address ongoing impacts of colonisation of the Indigenous population in the implementation of programs and services. wellbeing.

Opportunities in Achieving Equitable Mental Health Outcomes
Several relevant policy initiatives present an important opportunity to address the current national  2) An emphasis on promotion (that builds resilience to protect against mental health conditions) and prevention in the mental health system as a whole.
3) More services to meet unmet mental health needs.

4)
More culturally appropriate services.
Major changes in Indigenous mental health and wellbeing also require significant research opportunities, particularly including evaluating the effectiveness of the uptake and implementation of the SEWB framework across sectors. To culturally secure, effective and sustained change Indigenous research initiatives need to take a three-tiered approach:  Local (communities and Aboriginal organisations);  State/Regional (PHNs, mental health commissions, universities);  National (peak bodies, commonwealth, universities).
A study by Dudgeon et al. (2014b) found that programs developed or implemented with regard to the 9 guiding principles underpinning the National Strategic Framework for Aboriginal and Torres Straits Islander Peoples' Mental Health and Social and Emotional Well Being 2004-2009(SHRG, 2004) (now revised to 2017-2023, are more likely to be effective and have positive outcomes than those that do not.  (Dudgeon et al., 2019a, p. 10).
Each of these research initiatives described above include important opportunities for transformative change to improve Indigenous mental health and wellbeing in the future.
It is also promising to see that the NHMRC Special Initiative in Mental Health has proposed a "multidisciplinary and nationally focussed team to establish a national centre for innovation in mental health care as a collaborative network across Australia (involving key institutions, existing national networks in mental health, and other relevant bodies)" (NHMRC, 2019, para. 7). In order to address the gaps and challenges identified above, a similar opportunity to establish an Indigenous-specific national research institute is imperative to build research capacity among Indigenous and non-Indigenous researchers -specifically for those conducting research to improve mental health and wellbeing and suicide prevention services, and practice and knowledge translation in remote, rural, and urban settings,

Conclusion
Substantial progress has occurred in the past decade within the Indigenous mental health and suicide prevention field. However, given the different experiential and cultural contexts around Indigenous SEWB and mental health, significantly more culturally appropriate and dedicated research is urgently needed and cannot be mainstreamed. Recent studies reveal an over-representation of Indigenous people experiencing psychological distress, depression and trauma, which mainstream mental health service models, and clinical paradigms have been unable to address adequately. Addressing these issues "requires a comprehensive well-coordinated whole of government response which include the full suite of service interventions (from early intervention to clinical treatments), a robust research agenda, and a strong evidence base around what works" (Mitchell & Gooda, 2015, p. 27). There is also an urgent need to understand the potential effectiveness of alternative therapeutic initiatives and healing practices and to demonstrate the efficacy and cost effectiveness of widely incorporating the Indigenous SEWB model and Indigenous Psychology along-side mainstream clinical practices.
There is evidence that increasingly, children and young people are accessing online services such as Kids Helpline, often for suicide and self-harm reasons. There is also great interest and focus on the appropriateness of E-mental health initiatives including crisis helplines, web based technologies, text services, mental health and suicide prevention apps, and tele psychiatry services, which have emerged as a cost effective extension of conventional mental health services (Dudgeon et al., 2019a). However, there is a need for research, training and partnerships with ACCHS to ensure that such services and programs are culturally secure and effective. In addition, addressing the social determinants of health requires more research to understand how primary health care, drug and alcohol and mental health services can work together with hospitals and first responders to provide culturally responsive integrated services to improve Indigenous mental health and SEWB. Furthermore, greater understanding of mental health service participation and outcomes, including suicide prevention services for vulnerable sub-population groups in culturally and geographically diverse settings is urgently needed. This in turn requires recognition of Indigenous data sovereignty and the need for timely and disaggregated data. Issues of data collection and the development and validation of culturally relevant screening and assessment tools and SEWB indicators and measures are also a high priority area.
A study by Dudgeon et al. (2014b)