Introduction
Recent studies have uncovered the considerable prevalence of discrimination experienced by older Australians, particularly in the workforce (Australian Human Rights Commission, 2015; O’Loughlin, Kendig, Hussain, & Cannon, Reference O’Loughlin, Kendig, Hussain and Cannon2017). Apart from acting as a barrier to older people’s full involvement in their families, communities, and workplaces, experiences of age discrimination have been shown to be associated with poor health outcomes in the later life course (Han & Richardson, Reference Han and Richardson2015; Lyons et al., Reference Lyons, Alba, Heywood, Fileborn, Minichello and Barret2018). Australian studies of age discrimination have focused predominately on the non-Indigenous population. Although this is qualitatively different, surprisingly little is known about the experiences of racial discrimination faced by older Aboriginal and Torres Strait Islander people and the resultant health impacts. This is despite racial discrimination being a considerable social problem in Australia, with one estimate valuing the cost to the Australian economy at approximately 38 billion dollars annually, or three per cent of the gross domestic product, attributable to deleterious health outcomes (Elias & Paradies, Reference Elias and Paradies2016).
Racism can be conceptualized as unfair and avoidable disparities in power, resources, capacities, or opportunities centered on ethnic, racial, religious, or cultural differences (Berman & Paradies, Reference Berman and Paradies2010). It can result in negative health impacts through several key pathways: (1) cognitive, emotional, and physical strain, stress, or damage impacting on mental, physical, spiritual, or social well-being; (2) reduced engagement in adaptive behaviours (e.g., physical activity); (3) maladaptive behaviours (e.g., alcohol and drug use); (4) compromised access to key health-promoting settings (e.g., employment, education, health care); (5) attenuated benefit from everyday routine activities (e.g., sleep); and (6) heightened contact with health-damaging exposures (e.g., toxic substances) (Paradies et al., Reference Paradies, Priest, Ben, Truong, Gupta and Pieterse2013). There is now considerable international evidence that racism has a detrimental impact on a range of mental and physical health outcomes (Paradies et al., Reference Paradies, Ben, Denson, Elias, Priest and Pieterse2015), behaviours, and life outcomes (Paradies, Reference Paradies, Quah and Cockerham2017).
Among Aboriginal and Torres Strait Islander adults, racism has been associated with poor self-assessed health status (Paradies & Cunningham, Reference Paradies and Cunningham2012b), mental ill-health (Ziersch, Gallaher, Baum, & Bentley, Reference Ziersch, Gallaher, Baum and Bentley2011), psychological distress (Kelaher, Ferdinand, & Paradies, Reference Kelaher, Ferdinand and Paradies2014), depression (Paradies & Cunningham, Reference Paradies and Cunningham2012a), reduced general physical and mental health (Larson, Gilles, Howard, & Coffin, Reference Larson, Gilles, Howard and Coffin2007), and poor oral health outcomes among Indigenous adults (Ben et al., Reference Ben, Jamieson, Priest, Parker, Roberts-Thomson and Lawrence2014a, Reference Ben, Paradies, Priest, Parker, Roberts-Thomson and Lawrence2014b). Kelaher et al. (Reference Kelaher, Ferdinand and Paradies2014) found that those experiencing racism in health care settings were almost twice as likely to have high or very high levels of psychological distress as Indigenous people who experienced racism in other settings.
Among Aboriginal and Torres Strait Islander youth, racism has also been associated with emotional/behavioral difficulties and suicidal thoughts (Zubrick et al., Reference Zubrick, Silburn, Lawrence, Mitrou, Dalby and Blair2005), anxiety, depression, suicide risk, mental ill-health, physical illness (Priest, Paradies, Gunthorpe, Cairney, & Sayers, Reference Priest, Paradies, Gunthorpe, Cairney and Sayers2011; Priest, Paradies, Stevens, & Bailie, Reference Priest, Paradies, Stevens and Bailie2012; Priest, Paradies, Stewart, & Luke, Reference Priest, Paradies, Stewart and Luke2011), and poor oral health (Jamieson, Paradies, Gunthorpe, Cairney, & Sayers, Reference Jamieson, Paradies, Gunthorpe, Cairney and Sayers2011; Jamieson, Steffens, & Paradies, Reference Jamieson, Steffens and Paradies2013), as well as increased alcohol, tobacco, and marijuana use (Zubrick et al., Reference Zubrick, Silburn, Lawrence, Mitrou, Dalby and Blair2005). In a recent Australian national longitudinal study, racism was associated with child mental ill-health, asthma, obesity, and poor sleep outcomes (Shepherd, et al. Reference Shepherd, Li, Cooper, Hopkins and Farrant2017), while data from the same survey indicate that racism was associated with poor general health and increased anger, worry, and depression for adult primary carers (Bodkin-Andrews et al., Reference Bodkin-Andrews, Lovelock, Paradies, Denson, Franklin, Priest, Walter, Martin and Bodkin-Andrews2017).
Given the diversity and breadth of these findings, it is surprising that no empirical Australian study has examined the experiences of racial discrimination in the later life course and their potential implications for mental health. In this article, we seek to address this research omission. With the availability of nationally representative data from the Australian Bureau of Statistics (ABS), we answer two questions: (1) How prevalent is the reporting of racism (as measured by unfair treatment) and avoidance by older Aboriginal and Torres Strait Islanders, and (2) is there an association between instances of racism and poor mental health outcomes?
Methods
Data
To answer these questions, we draw upon unit record data from the National Aboriginal and Torres Strait Islander Social Survey (NATSISS) conducted by the ABS. Data were collected from personal interviews between September 2014 and June 2015, using a computer-assisted interviewing questionnaire. The NATSISS is of multi-stage design, and includes data from Aboriginal and Torres Strait Islanders living in private dwellings in remote and non-remote areas, including discrete communities, across all Australian States and Territories. Discrete communities include “regions uninhabited or intended to be inhabited predominately by Aboriginal and Torres Strait Islander people, with housing or infrastructure that is either owned or managed on a community basis” (Australian Bureau of Statistics, 2016). Persons living in non-private dwellings such as hospitals or nursing homes were not included in this survey.
The ABS sought input for NATSISS from Aboriginal and Torres Strait Islander peak bodies, government departments with Aboriginal and Torres Strait Islander responsibilities and from the ABS Advisory group for Aboriginal and Torres Strait Islander Statistics. ABS interviewers received extensive training in cultural awareness, and the collection methods used by interviewers varied across geographies. For example, some items on the questionnaire were reworded or their concepts were changed to take account of language and cultural differences. In community areas, Aboriginal and Torres Strait Islander facilitators accompanied ABS interviewers to assist with the data collection.
Following screening for the presence of an Aboriginal or Torres Strait Islander person living in the household, a response rate of 83.8 per cent was achieved in remote Australia and a response rate of 78.1 per cent was achieved in non-remote Australia. The confidentialised survey data file contains records on 11,178 persons who self-identify as being an Aboriginal and/or Torres Strait Islander.
Herein, we restrict the sample to 2,730 persons ≥ 45 years of age, which is common in studies of aging among Aboriginal and Torres Strait Islander people for several reasons (Cotter, Anderson, & Smith, Reference Cotter, Anderson, Smith, Borowski, Encel and Ozanne2007; Gubhaju et al., Reference Gubhaju, McNamara, Banks, Joshy, Raphael and Williamson2013; Waugh & Mackenzie, Reference Waugh and Mackenzie2011). First, there is a considerable gap in life expectancy of approximately one decade between Indigenous and non-Indigenous Australians, reducing the proportion of the population living into advanced old age ( Australian Institute of Health and Welfare, 2017). Second, many conditions and co-morbidities as well as frailties commonly associated with aging are of early onset in this population, as is the case with Canadian First Nations seniors (Australian Institute of Health and Welfare, 2016; Gubhaju et al., Reference Gubhaju, McNamara, Banks, Joshy, Raphael and Williamson2013; Hyde et al., Reference Hyde, Flicker, Smith, Atkinson, Fenner and Skeaf2016; First Nations Information Governance Centre & Walker, 2017). Third, in recognition of the previous two points, government programs such as those governing access to specific aged care services are available to Aboriginal and Torres Strait Islanders from earlier ages than for non-Indigenous Australians.
From this group of 2,730 persons aged ≥ 45 years of age, 124 respondents could not adequately respond to questions on unfair treatment, leaving a final sample of 2,606 records. For analysis of the association between racism and mental health, the ABS could not adequately determine a Kessler score (the measure of psychological distress that we employ) for a small number of cases (n = 26), which were therefore omitted from this analysis.
Measures
The NATSISS survey instrument covers a range of subjects encompassing language and culture, health, employment, and access to services. Importantly, the 2015 cross-section of NATSISS included measures of discrimination as well as of psychological distress.
The discrimination module available in NATSISS consists of six questions to gauge experiences of discrimination and avoidance. First, respondents were asked “In the last 12 months, have you had any of the following experiences because you are Aboriginal and/or Torres Strait Islander?” A prompt card was displayed to the respondent with the following selections (multiple selections were possible):
• Called names, teased or sworn at
• Heard racial comments or jokes
• Ignored or served last while accessing services or buying something
• Not trusted
• Told you are less intelligent
• Left out, refused entry or told you don’t belong
• Spat at or had something thrown at you
• Any other experience that was unfair
For all respondents who indicated at least one from the previous list, that person was further requested to answer questions related to the frequency (over the previous 12 months) and the type of experience (from the list) in the most recent incident. Following, respondents reporting racial discrimination were asked “In which situation were you treated unfairly (because you are an Aboriginal and/or Torres Strait Islander), the most recent time?” A prompt card was displayed with the following options:
• Applying for work, or at work
• At home, by neighbors or at somebody else’s house
• At school, university, training course, or other educational setting
• While doing any sporting, recreational, or leisure activities
• By the police, security people, or lawyers, or in a court of law
• By doctors, nurses, or other staff at hospitals or doctor’s surgeries
• When accessing government services
• When seeking any other services
• On the Internet or telephone
• By members of the public
• Any other situation
Finally, respondents were asked whether they avoided “situations because you feel you have been treated unfairly in the past because you are Aboriginal and/or Torres Strait Islander?” For those indicating avoidance, a prompt card was shown similar to that outlined.
In addition to recording instances of discrimination, NATSISS collected information on mental health and psychological distress. The specific measure of psychological distress used was Kessler’s K5. The K5, although not a diagnostic tool, is a widely used screening instrument for psychological distress based on the respondent’s emotional state in the four weeks prior to the interview (Anderson et al., Reference Anderson, Sunderland, Andrews, Titov, Dear and Sachdev2013; Australian Bureau of Statistics, 2016). Consistent with earlier Australian research on the Aboriginal population, the reliability of this scale was high in NATSISS (α = 0.863) (Kelaher et al., Reference Kelaher, Ferdinand and Paradies2014). Following other examples in the literature, we indicate a “high” or “very high” score on Kessler’s measure as indicating psychological distress (Australian Bureau of Statistics, 2014; Kelaher et al., Reference Kelaher, Ferdinand and Paradies2014; Temple & Kelaher, Reference Temple and Kelaher2018).
Statistical Model and Estimation of Variance
To examine the association between experiences of discrimination and psychological distress, we fitted logistic regression models. Using the raw logit coefficients, we calculated odds ratios (OR), which measure the change in the odds of experiencing psychological distress given an experience of racism, once all other factors in the model are controlled for.
Drawing on previous Australian research, variables known to be associated with psychological distress among Aboriginal and Torres Strait Islanders were included in the regressions to control for potentially confounding effects (Kelaher et al., Reference Kelaher, Ferdinand and Paradies2014). These included age, gender, education, and region of residence. We test a further range of variables including age, gender, English speaking, employment status, education, remoteness, household composition, marital status, and household income. Variables were entered into the regression, and significance and improvement to model fit were assessed using the Bayesian Information Criteria following Raftery’s procedure (Raftery, Reference Raftery1995). With all models specified, we checked the conditioning of the matrix of independent variables to investigate any collinearity influence (Belsley, Kuh, & Welsch, Reference Belsley, Kuh and Welschm1980). The condition numbers and variance inflation factors were small, providing support for the model specification.
Because of the complex survey design, adjustments are necessary to generate correct variance estimates. The NATSISS includes 250 replicate weights on the data file to adjust for sample design and non-response. Utilizing an algorithm developed by Winter (Reference Winter2008), we employed the delete-one jackknife method to make the necessary replicate adjustments (Wolfer, Reference Wolfer1985). All analyses were conducted using Stata via the ABS Remote Access Data Laboratory.
Results
Prevalence of Experiences of Unfair Treatment and Avoidance
Results from the NATSISS show that experiences of racism were common among older Aboriginal and Torres Strait Islander people (Table 1). Approximately 31 per cent of respondents cited an instance of unfair treatment in the previous 12 months, and 15 per cent actively avoided situations because of previous experiences of unfair treatment. Of those who had experienced unfair treatment, more than 20 per cent cited it as occurring “always” or “often” and a further 40 per cent reported that it occurred “sometimes”.
Table 1: Prevalence, frequency, and types of unfair treatment, 2014–15
Note. 1, from a sample of 2,606 persons ≥ 45 years of age; 2, from a sample of 775 persons reporting unfair treatment.
The term “unfair treatment” covers a range of experiences that have the potential to adversely affect mental health. Approximately 45 per cent of those reporting unfair treatment cite being subject to racial jokes or comments in the most recent occurrence. Almost one in five also report being called names, teased, or sworn at (17.9%), or being ignored or served last while accessing services or buying something.
Context of Racism
There is considerable variation in the contexts or settings in which older persons experience these types of unfair treatment and avoidance behaviours (Table 2). The most prevalent sources or settings for experiencing unfair treatment include members of the public (30.4%) or applying for work or at work (19.4%). Less than 5 per cent of respondents cited a health care, legal, or educational setting as a source of unfair treatment in the most recent instance of discrimination. Legal and healthcare settings are, however, cited by over 1 in 5 respondents who have engaged in avoidance behaviours (20.8% for health care and 24.6% for a legal setting). Accessing government services (22.1%), applying for work or at work (26.6%) and members of the public (24%) are also cited as the key sources and situations avoided specifically because of past instances of unfair treatment.
Table 2: Setting of unfair treatment and avoidance, 2014–15
Note. 1, from a sample of 755 who cited an experience of unfair treatment; 2, from a sample of 344 who cited engaging in avoidance behaviours; n.a. = setting not applicable for avoidance.
Exclusion and Mental Health
From these descriptive statistics, it is clear that instances of unfair treatment (31.3%) and avoidance (14.5%) are reported by a significant minority of older Aboriginal and Torres Strait Islanders. For many, unfair treatment is a regular occurrence, with considerable heterogeneity in the types and sources of discriminatory behaviour. An important question, therefore, in this population of older Aboriginal and Torres Strait Islanders, is, do we observe an association between racism and mental health outcomes?
Results presented in Table 3 provide preliminary support for this hypothesis. Of those reporting an instance of unfair treatment, approximately 41 per cent were in psychological distress compared with 27 per cent of those who did not report unfair treatment. Over half of those who engaged in avoidance behaviours (52.6%) were in psychological distress compared with 28 per cent of those who did not avoid situations. Importantly, in these data we also observe that psychological distress is higher among those reporting both unfair treatment and avoidance. Whereas approximately one quarter of those who have not experienced unfair treatment or avoidance were in distress, those who had experienced unfair treatment only (34%), avoidance only (46%) or both avoidance and unfair treatment (54%) had a considerably higher risk of distress.
Table 3: Characteristics of persons experiencing psychological distress, 2014–15
Note. Comparison category for test of proportion; ***p < 0.001, **p < 0.01, *p < 0.05; household income = gross household income in quintiles; table includes 2,580 observations. It excludes 26 cases for which the ABS was “unable to determine” a Kessler score.
Although these differences point to a potential association between discrimination and psychological distress, it is important to control for factors that are associated with distress. For example, we observe that distress is higher among certain demographic groups (Table 3). Groups reporting statistically significantly higher rates of psychological distress included younger persons (relative to older); women (relative to men); those living in households containing both indigenous and non-indigenous persons (relative to those living in Aboriginal and Torres Strait Islander households only); persons separated, divorced, or never married (versus those who were married); the unemployed and those not in the labour market (versus the employed); and those with lower levels of household income Table 3). Following the model selection techniques outlined previously, a reduced list of control variables was included in the final regression analyses. These variables included age, gender, employment status, marital status, and household income.
Even when extensive controls were included, unfair treatment and avoidance was strongly associated with psychological distress (Table 4). Aboriginal and Torres Strait Islanders who cited an instance of unfair treatment were approximately twice as likely to be in psychological distress, as those who had not experienced unfair treatment in the past year (Model 1 OR = 1.95 95% confidence interval [CI ]= 1.41, 2.69). Individuals who actively avoided situations because they were Aboriginal or Torres Strait Islanders were almost three times as likely to be in psychological distress as those who did not avoid situations (Model 2 OR = 2.81, 95% CI = 1.89, 4.17).
Table 4: Logistic regression models of the association of unfair treatment and avoidance with psychological distress, 2014–15
Note. OR = odds ratio with controls for age, sex, employment status, marital status, and household income; n.a. = not applicable for relevant model specification; table includes 2,580 observations. It excludes 26 cases for which the ABS was “unable to determine” a Kessler score.
To examine the relative role of unfair treatment and avoidance in psychological distress, we include a categorical variable combining both in Model 3 (Combined). Compared with those who had not experienced discrimination or avoidance, those who had experienced unfair treatment only were approximately 1. 5 times more likely to experience psychological distress (OR = 1.51, 95% CI = 1.02, 2.23). Those who had experienced avoidance only were approximately 2.5 times more likely to experience psychological distress (OR = 2.47, 95% CI = 1.10, 5.55) and respondents reporting avoidance and unfair treatment were approximately 3.3 times more likely to experience psychological distress (OR = 3.34, 95% CI = 2.17, 5.13) when compared with those reporting neither.
These results indicate an association between the severity of racism and psychological distress, such that when avoidance is combined with unfair treatment, the resulting psychological distress is exacerbated. A further proxy for the severity of racism is the reported frequency of unfair treatment, which we included in an additional regression model (Model 4). Those who cited unfair treatment as occurring “always” or “often” were more than three times as likely to be in psychological distress, when compared with those who did not report unfair treatment (OR = 3.34, 95% CI = 2.05, 5.46). Those who reported unfair treatment occurring “sometimes” were just less than three times as likely to report distress than those who had not reported it (OR = 2.86, 95% CI = 1.87, 4.39).
Sources of Unfair Treatment, Avoidance, and Mental Health
Separate regression models were also fitted to examine the association among sources of unfair treatment, types of situations avoided, and psychological distress (Table 5). We note that more than half of this group of older Aboriginal and Torres Strait Islander people reporting unfair treatment and/or avoidance in health facilities (52.1%), home (54.5%), education (55.6%), and service settings (50.2%) were in psychological distress. Settings with a minimum twofold increase in levels of distress included education (OR = 2.95, 95% CI = 1.05, 8.27), health care (OR = 2.21, 95% CI = 1.14, 5.31), services (OR = 2.21, 95% CI = 1.26, 3.85), and work (OR = 2.01, 95% CI = 1.18, 3.44). Each of these settings represents a crucial point of contact germane to the human capital of older Aboriginal and Torres Strait Islanders.
Table 5: Source of discrimination and situations avoided and their association with psychological distress, 2014–15
Note. % report = weighted percentage of all persons ≥ 45 years of age reporting each specific source/situation; % in distress = weighted percentage of persons in each unfair treatment/avoidance category reporting high or very high on the Kessler K5 Scale; OR = odds ratio with controls for age, gender, income, employment, and marital status; 95% CI = 95% confidence interval for the odds ratio; No. = base case for the test of proportions by distress category; ***p < 0.001, **p < 0.01 for tests of proportions; table includes 2,580 observations. It excludes 26 cases for which the ABS was “unable to determine” a Kessler score.
Discussion and Conclusions
Large national level surveys show that Aboriginal and Torres Strait Islander people are a population with a considerably high risk of psychological distress (Australian Bureau of Statistics, 2014; Gubhaju et al., Reference Gubhaju, McNamara, Banks, Joshy, Raphael and Williamson2013). Whereas approximately 9 per cent of non-Indigenous Australians ≥ 55 years of age experienced distress in 2012–13, approximately one quarter of Aboriginal and Torres Strait Islanders were in this situation (Australian Bureau of Statistics, 2014). This figure is relatively consistent with levels of psychological distress that we observe in the NATSISS from 2014 to 2015. Motivated by recent studies of younger (child and adult) Aboriginal and Torres Strait Islander populations, we sought to measure the association of experiencing racial discrimination with poor mental health in the later life course.
Using nationally representative data, we show that experiences of racism (as measured by unfair treatment) and avoidance are encountered by a significant minority of older Aboriginal and Torres Strait Islanders, with 31 per cent reporting unfair treatment and 17 per cent reporting engaging in avoidance behaviours. This rate of unfair treatment is lower than that experienced earlier in the life course, with approximately 40 per cent of those 30–44 years of age reporting racism in a recent study (Temple, Kelaher, & Paradies, Reference Temple, Kelaher and Paradies2019). Yet, there is considerable heterogeneity in the sources and contexts in which older people experience discriminatory behaviour. Among the most prevalent situations or settings for experiencing unfair treatment include by members of the public (30.4%), when applying for work, or at work (19.4%). Although some settings such as health care or educational settings were cited in only 5 per cent of cases as sources of unfair treatment, levels of avoidance were considerably higher (more than 20%).
Of concern to policy makers, unfair treatment (19%) or avoidance (26%) in the workplace or during a job search were noted by a sizeable proportion of those experiencing discrimination. The poorer levels of labour force participation among older Aboriginal and Torres Strait Islander people has been noted elsewhere, and contributes significantly to lower levels of superannuation, with obvious implications for their financial well-being and health in later life (Bianchi, Drew, Walk, & Wiafe, Reference Bianchi, Drew, Walk and Wiafe2016). Although qualitatively different, the high prevalence of racial discrimination faced in this context also mirrors the considerable prevalence of age-based discrimination experienced by older non-Indigenous Australians in the workforce (Australian Human Rights Commission, 2015; O’Loughlin et al., Reference O’Loughlin, Kendig, Hussain and Cannon2017). With population aging placing increasing demands on the Australian labour market, eliminating discriminatory practices that impact on the mature age labour force participation of Aboriginal and non-Indigenous Australians is critical (Australian Human Rights Commission, 2015; Temple & McDonald, Reference Temple and McDonald2017).
Apart from uncovering the types and sources of racial discrimination experienced by older Aboriginal and Torres Strait Islander people, we expected and found a strong association between experiencing racism and psychological distress. Previous Australian studies have found that exposure to racism in health care (OR = 4.49, p < 0.05) and other settings (OR = 2.66, p < 0.05) significantly increased the odds of psychological distress (Kelaher et al., Reference Kelaher, Ferdinand and Paradies2014). Supporting and extending these findings, discrimination (OR = 1.95, p < 0.05), particularly when occurring frequently (OR = 3.34, p < 0.05) or in tandem with avoidance (OR = 3.34, p < 0.05) was strongly associated with psychological distress.
Although we do not contend that racial discrimination alone accounts for the heightened level of psychological distress among older Aboriginal and Torres Strait Islanders, it is certainly an important contributing factor. Indeed, the effects of racial discrimination in causing psychological distress are now well established in Australia and internationally (Lewis, Cogburn, & Williams, Reference Lewis, Cogburn and Williams2015; Paradies et al., Reference Paradies, Ben, Denson, Elias, Priest and Pieterse2015). As exposure to discrimination and associated psychological distress is more common among younger people (Greer & Spalding, Reference Greer and Spalding2017), research and interventions have tended to focus on younger people particularly in Australia. Herein, we highlight the negative impacts of discrimination on the mental health of older Aboriginal and Torres Strait Islander people.
Moreover, we demonstrate that avoidance behaviours, particularly when experienced in tandem with racial discrimination, may be associated with deleterious mental health outcomes. Avoidance has been shown to exacerbate the effects of racism on psychological well-being in a number of populations (Kaholokula et al., Reference Kaholokula, Antonio, Ing, Hermosura, Hall and Knight2017; Villegas-Gold & Yoo, Reference Villegas-Gold and Yoo2014; Vines et al., Reference Vines, Baird, McNeilly, Hertz-Picciotto, Light and Stevens2006). There are several explanations for this effect. Avoidance may prevent people from receiving help and services that they need, which in turn leads to greater psychological distress. In the case of older people this may also lead to more serious health problems, or in the case of employment, it may contribute to poorer financial outcomes. An alternate explanation is that avoidance is disempowering and in itself contributes to greater psychological distress (Fernando, Reference Fernando1984; Kaholokula et al., Reference Kaholokula, Antonio, Ing, Hermosura, Hall and Knight2017; Thomas & Gonzales-Prendes, Reference Thomas and Gonzales-Prendes2009). These explanations are not mutually exclusive, and either may explain why avoidance had more pernicious effects than discrimination. Moreover, it may be that older Aboriginal and Torres Strait Islander people begin avoidance behaviours because they were specifically strongly affected by previous experiences of unfair treatment, indicating that future instances of unfair treatment may also have particularly deleterious outcomes. The additive effects of discrimination and avoidance on psychological distress are not surprising, as they suggest both adverse exposures and an inability to control these exposures. Relatedly, we also show that persons with more regular experiences of unfair treatment (as a measure of the severity of racism) are at a threefold risk of distress relative to those who have not reported it.
We further demonstrate that when discrimination (through unfair treatment or avoidance) occurs in settings crucial to the human capital development of Aboriginal and Torres Strait Islander people, the association with psychological distress remains strong or is strengthened. Specifically, we observe this association in settings such as health care, education, the workplace, or accessing government services. The finding builds on previous research in showing that discrimination leads to avoidance of health care services (Kelaher et al., Reference Kelaher, Ferdinand and Paradies2014). Concerns about the negative impacts of racism in health have led to the development of policy, interventions, and training to improve cultural safety (Kelaher et al., Reference Kelaher, Ferdinand and Paradies2014). A focus on developing approaches to reduce the discrimination experienced by older Aboriginal and Torres Strait Islander people in the community and aged care sector is less developed. Developing approaches to ensure that older Aboriginal and Torres Strait Islander people are not exposed to discrimination or exposed to events that trigger avoidance is crucial to supporting their independence and delivering the promise of aged care reforms underway in Australia.
Recent aged care reforms have focused on services becoming more client centred, to enable older people to remain at home and independent (Australian National Audit Office , 2017). Clearly, a situation in which people are exposed to racism in the context of receiving services or are avoiding going to services is antithetical to this aim. A recent audit of the delivery of aged care services to Aboriginal and Torres Strait Islander people suggested that, in contrast to the rest of the Australian population, the growth of the uptake of home care packages among Aboriginal and Torres Strait Islander people was at the higher needs level rather than at the basic/minimum needs level (Australian National Audit Office, 2017). This suggests that until the need for services is unavoidable, Aboriginal and Torres Strait Islander people may not be being offered and/or seeking home care packages. Failure to receive home care may lead to a higher level of dependence in the future or a preventable earlier loss of dependence.
The Australian government audit acknowledged that there are barriers specific to accessing aged care services that disproportionately impact older Aboriginal and Torres Strait Islander Australians, that current service models do not always have the time to build up trust, and that Aboriginal and Torres Strait Islander service providers are often not aware of the packages available (Australian National Audit Office, 2017). The report also suggested that the number of service providers addressing the needs of Aboriginal and Torres Strait Islander people has increased.
Although this is laudable, it is important that measures are put in place to ensure that the care provided is culturally safe, supported by ongoing research in the area. As argued by Davy et al in their detailed systematic review of care for older Aboriginal and Torres Strait Islanders, “having the support of culturally safe primary health-care and aged-care services that understand the importance of maintaining an Indigenous identity and promoting independence will be crucial for the well-being of older Indigenous peoples” (Davy et al., Reference Davy, Kite, Aitken, Dodd, Rigney and Hayes2016; p. 90). Indeed, one potential barrier to achieving these aims is the considerable under-representation of Aboriginal people in aged care, health, and allied services, including at the policy development and decision-making level (LoGiudice, Reference LoGiudice2016).
Limitations and Summary
In interpreting our findings, it is important to recognize the study’s limitations. The NATSISS data are cross-sectional, and we cannot draw causal inferences about the relationship among racism, avoidance, and psychological distress. Unfortunately, there is a dearth of nationally representative longitudinal data with measures of racism and psychological well-being in Australia, in which the relevant pathways between each could be explored. Relatedly, our measures of discrimination and avoidance are subject to recall bias, and again, longitudinal data would be required to negate this effect.
A further limitation of the use of cross-sectional data in examining racism and psychological distress in the later life is selectivity. As is well established in the economics of aging literature, selective mortality removes from the population a disproportionate number of older people with low levels of economic resources and poorer health (Borsch-Supan, Reference Borsch-Supan1992; Danziger, Van der Gaag, Smolensky, & Taussig, Reference Danziger, Van der Gaag, Smolensky and Taussig1983). This is of importance to this study, as Aboriginal and Torres Strait Islander life expectancy is one decade lower than that of non-indigenous Australians (Australian Institute of Health and Welfare, 2017). Moreover, this selectivity effect may also operate through migrating out of the survey population through entry to aged care facilities (Danziger et al., Reference Danziger, Van der Gaag, Smolensky and Taussig1983), a point that is particularly pertinent given that NATSISS do not include persons in non-private dwellings. For example, it may be that the risk of psychological distress reduces in the group that is ≥ 65 years of age because the poorest sections of the aged have a higher mortality risk, or are more likely to have entered a managed care facility. Therefore, the strength of the observed association between exposure to racism and psychological distress may be diluted in this study. Longitudinal data are required to measure these complex movements, and further data collections would be necessary to examine the generalizability of the findings presented here to individuals living in cared accommodation and other institutions (non-private dwellings).
Noting these limitations and potential extensions, although several Australian studies have examined the experiences and consequences of racial discrimination for younger and working age Aboriginal and Torres Strait Islander people, no study (to our knowledge) has examined the association of experiences of racism with mental health in later life. This represented a significant research gap. Our study shows that experiences of racism are encountered by a significant minority of older Aboriginal and Torres Strait Islanders and that it occurs in a variety of contexts and situations. We observe a clear association between experiences of racism and distress, with these results being robust to a range of confounding factors and complex survey design features, and the associations are amplified by the severity of racism and occur in contexts or situations crucial to the human capital development of older Aboriginal and Torres Strait Islander people.
These findings underscore the importance of delivering culturally safe health and social services/employment programs, particularly in the context of aged care reforms underway, and the significantly lower levels of mature age labour force participation influencing financial well-being. More generally, discrimination, including racism, irrespective of its consequences, is a violation of human rights and should be prevented in any reasonable society. The moral imperative to address racism is further underscored by the evidence presented here showing that exposure to racial discrimination is associated with a deleterious effect on mental health in later life.
