Sixty-seven annual reports were analysed, representing 55% of the reports we sought to retrieve. Reports were retrieved through online searches (85%), phone calls (12%) and email correspondence (3%) over the 9-month period (May 2017 to January 2018). The sample included reports predominantly from 2015/2016 (60%), as per our search strategy, though also from other years where that financial year was the latest report available (2016/17 (21%), 2014/15 (13%), 2013/14 (5%)) (Table 1). ACCHOs described activities that were delivered to a range of population groups, namely: Mothers and Babies; Children and Young People; Women; Men; Older People; Families; People with Disability; People in the justice system; and LGBTQI people (Additional file 1) ACCHOs activities were extensive and included an abundance of programs for clients but also activities that targeted the ACCHO workforce and extended to local partnerships. The Client Activities and Workforce and Partnership Activities described by ACCHOs are presented in Table 2 in descending order of frequency, along with the WHO Framework determinants of health (intermediary, socioeconomic and socio-political contexts) they were thought to address.
Table 1
ACCHO Annual Reports, Retrieval Methods and Geographical Distribution
| ACT | NSW | NT | QLD | SA | TAS | VIC | TOTAL (%) |
Total ACCHOs(a) | 1 | 40 | 20 | 25 | 12 | 1 | 23 | 122 |
Annual Reports Retrieved (%) | 1 (100%) | 13 (33%) | 13 (65%) | 15(60%) | 10 (83%) | 1 (100%) | 14 (61%) | 67 (47%) |
Retrieval Method |
Online | 1 | 11 | 13 | 14 | 6 | 1 | 11 | 57 |
Email/Letter | 0 | 0 | 0 | 0 | 0 | 0 | 2 | 2 |
Phone Call | 0 | 2 | 0 | 1 | 4 | 0 | 1 | 8 |
Geographical Distribution(b) |
Major Cities | 1 | 2 | 0 | 5 | 3 | 0 | 4 | 15 (83%) |
Inner Regional | 0 | 7 | 0 | 3 | 1 | 1 | 4 | 16 (39%) |
Outer Regional | 0 | 2 | 1 | 5 | 2 | 0 | 6 | 16 (27%) |
Remote | 0 | 2 | 7 | 2 | 2 | 0 | 0 | 13 (48%) |
Very Remote | 0 | 0 | 5 | 0 | 2 | 0 | 0 | 7 (30%) |
Notes: Geographical classification according to the Australian Standard Geographical Classification (ASGC) [21] |
(a) as per NACCHO Member list as of 27/10/2017
(b) ACCHO reports retrieved as a proportion of total ACCHOs within the geographical area
[Table 1 Legend: A description of the participating ACCHOs classified by State, method of retrieval and geographical distribution]
Table 2
Determinants of health addressed by ACCHO activities reported
ACCHO Activities | TOTAL CODED ANNUAL REPORTS N(%) | STRUCTURAL DETERMINANTS: SOCIAL DETERMINANTS OF HEALTH INEQUITIES | INTERMEDIARY DETERMINANTS: SOCIAL DETERMINANTS OF HEALTH |
SOCIO- POLITICAL CONTEXT | SOCIOECONOMIC POSITION |
Client activities(a) |
Total ANNUAL REPORTS CODED n(%) | 67 (100) | 36 (53.7) | 67 (100) | 67 (100) |
Clinical Care | 62 (92.5) | 0 | 0 | 62 |
Community and Cultural Engagement | 59 (88.1) | 1 | 27 | 55 |
Health Promotion | 59 (88.1) | 1 | 20 | 58 |
Drug, Alcohol and Addiction | 53 (79.1) | 2 | 8 | 50 |
Mental Health | 52 (77.6) | 2 | 8 | 50 |
Family Support | 48 (71.6) | 1 | 10 | 41 |
Schools, Education and Training | 47 (70.1) | 1 | 37 | 23 |
Case Management | 45 (67.2) | 1 | 4 | 40 |
Advocacy | 42 (62.7) | 33 | 15 | 29 |
Transport | 37 (55.2) | 0 | 6 | 32 |
Personal Empowerment | 37 (55.2) | 0 | 9 | 27 |
Capacity Building and Community Empowerment | 31 (46.3) | 5 | 16 | 24 |
Legal and Justice Services | 28 (41.8) | 5 | 2 | 27 |
Financial Services | 26 (38.8) | 0 | 6 | 24 |
AGING and disability CARE(b) | 22 (32.8) | 0 | 3 | 21 |
Housing and Homelessness | 22 (32.8) | 2 | 2 | 21 |
Employment | 15 (22.4) | 0 | 11 | 4 |
WORKFORCE AND Partnership Activities |
WORKFORCE | 67 (100) | 0 | 67 | 27 |
COLLABORATIONS & PARTNERSHIPS | 57 (85.1) | 13 | 31 | 48 |
WORKFORCE TRAINING | 51 (76.1) | 1 | 52 | 20 |
Building Cultural Competency | 33 (49.3) | 0 | 31 | 15 |
a activities were coded to all applicable social determinants categories and therefore could be found to address one or more areas of the WHO framework and can result in totals adding to more than 67. For example, an income or employment program may have also added addressed housing and would be coded to both Socio-economic Position and Intermediary Determinants. |
b in-community programs for older people and people with a disability to assist them to continue to live independently. |
[Table 2 Legend: The social determinants of health and health inequity addressed by ACCHOs through the range of services they provided.]
Many activities that ACCHOs engaged in could not be categorised into one area of the WHO Framework since they often addressed community need using a multifaceted approach. So, while they may address the more urgent intermediary determinants, ACCHOs also worked to improve the structural determinants that impacted their clients and communities. As a result, activities were coded to all relevant determinant of health categories.
Socio-economic and political context
The analysis revealed that ACCHOs addressed the socio-political context of the social determinants of health in many of the activities they provided (Table 2). Activities at this level revolved predominantly around Advocacy but also included activities related to Collaborations and Partnerships, Capacity Building and Community Empowerment, and Legal and Justice Services (Table 2). The following quote provides an example of a remote ACCHO responding to community need using a broad, multi-level approach. The ACCHO was working within the socio-political context through efforts to influence a Parliamentary Joint Committee as well as developing a responsive workforce and addressing the immediate health, social and cultural needs of their clients.
“In response to the prevalence of crystalline methamphetamine use (ICE) and community concern, [we] advocated to strengthen existing AOD treatment services to provide access to medical care, psychological treatment and social and cultural support including intensive care management for all drug addictions including alcohol and ICE.’ [ACCHO] advocated against a separate, stand-alone service system for ICE users. We continued to argue for investment in early childhood as key to the prevention of all forms of addiction. [ACCHO] also submitted a response to the Parliamentary Joint Committee on Law Enforcement inquiry into ICE use. We commissioned [local training organisation] to deliver “Working with clients that use Methamphetamine (ICE)” Workshops for clinicians and social support staff, with over 60 staff attending.” [Remote ACCHO]
ACCHO leaders and workforce also participate on committees that go beyond direct clinical or health-related conditions to broader public policy reflective of the broad social determinants of health. One example included an ACCHO improving communications through formal agreements between multiple agencies responsible for youth justice:
“The [justice] program has now established communications with DHHS, Corrections and the Department of Justice and is also looking at developing MOUs with these agencies. [ACCHO] has been an active member of [Local Aboriginal Justice Advisory Committee] and a variety of [Aboriginal] Youth Justice Support networks and has been present to represent community members during court hearings.” [Inner Regional ACCHO]
Within the reports, there is clear evidence of ACCHOs creating opportunities for Aboriginal societal and cultural values to be seen and expressed in the dominant western socio-political context in Australia.
[ACCHO] has hosted Cultural Immersions for key external service partners and members of government, which has initiated culturally appropriate changes within their respective services and strengthened partnerships. This approach allows other organisations to hear from local women at a grass roots level, and initiate an interest and awareness of Aboriginal culture from a face to face experience, out on country. [Inner Regional ACCHO]
Socio-Economic Position
All 67 annual reports described ACCHO activities that aimed to reduce inequity related to socio-economic position. The socio-economic context was addressed by ACCHOs in every activity excluding clinical care (Table 2). This was demonstrated by ACCHOs providing support with and increasing access to social services (such as Centrelink, Housing, Human Services) through transport, advocacy, and case management. ACCHOs reported supporting families in the education of their children through a range of programs that promoted access to education, as demonstrated by the quotes below:
[ACCHO] Indigenous Education Services: this program’s primary responsibility is to ensure increased school readiness for our young children between the age of three (3) to five (5). The program is being delivered to increase Aboriginal and Torres Strait Islander families and children’s smooth transition and success rate from Early Childhood into Prep, including contributing to community well-being. The service has also offered tutoring support and playgroups over the past 12 months. [Major City ACCHO]
Through casual conversation and genuine interest, [ACCHO worker] was able to identify her interests and, with another Case Manager, took [teenage girl] on a tour of a flexible learning centre which offered a flexible approach to schooling. [Major City ACCHO]
Another example demonstrated how an ACCHO was able to provide career advice to support individuals’ employment prospects upon exiting a rehabilitation program:
We ensure that we provide clients with support once they exit the rehabilitation centre by providing transitional housing and programs such as career advice counselling, training and assistance in obtaining ongoing independent accommodation for clients. [Major City ACCHO]
Most ACCHOs reported a high proportion of Indigenous employment.
Our clinic boasts 50% Indigenous staff, 100% female staff with 80% full time staff. [Major City ACCHO].
Additionally, ACCHOs provided training opportunities for Indigenous staff to obtain qualifications through external channels and supported in-house training and development.
[ACCHO] is proud to support two (2) [Aboriginal Health Workers] to undertake a Social Work degree through [a University]….The [ACCHO] Research section continued to prioritise developing internal capacity through the ongoing employment of Aboriginal Research Officers (AROs) to develop select projects. [Remote ACCHO]
Through partnerships ACCHOs contributed to reducing institutional racism. Not only was there considerable evidence that ACCHOs worked to build and maintain partnerships but there was also evidence that these partnerships created understanding of Aboriginal and Torres Strait Islander culture in mainstream organisations as demonstrated in the following quote:
This project formed a working partnership with students and staff from [local private school] in the painting of a mural on the wall enclosing the garden that is demonstrative of community ownership and enhances the appearance bringing to mindfulness our connection to Country and ownership via participants’ hand prints and paintings on this wall. A second partnership with [NGO] resulted in the labour required and successful completion of Certificate II in Horticulture for 11 Participants who also received a certificate of appreciation for completing an eight week life skills program through [ACCHO]. [Outer Regional ACCHO]
Intermediary Determinants
The intermediary determinants were addressed in all reported ACCHO activities (Table 2). While most commonly addressing clinical care, ACCHOs also engaged in intermediary determinants through extensive work in Community and Cultural engagement, Health Promotion, Drug, Alcohol and Addiction Services, and Mental Health (Table 2). ACCHOs demonstrated supporting their clients to navigate their way through health and social sectors to increase their access to these services.
Based on the reporting, ACCHOs understood the importance of material circumstance on health and wellbeing and intervened where they could, highlighted by one ACCHO that delivered on the need for food and basic household products for families in crisis,
Family Services continued to manage the Food Bank here at [ACCHO], providing the community with fresh fruit, vegetables, pantry items and household products. Referrals for Emergency Relief to [Aboriginal Health Peak Body] for financial emergency assistance. Family Services have also been able to refer to other services as community has required it. With all the limitations on the program we are still able to have positive outcomes for families in crisis. [Major City ACCHO]
One ACCHO identified the need to be able to provide specialised clinical care to Aboriginal and Torres Strait Islander people for conditions that are rarely seen in the mainstream Australian population,
[Community health centre] Health Services has been proactive in addressing diseases and conditions which may be uncommon in a mainstream environment but are usually associated with extremes of poverty, such as rheumatic heart disease and trachoma, and which require specific expertise and services to address them. [Very Remote ACCHO]
ACCHOs reported addressing the psychosocial health and wellbeing of many groups within the community, including men and women separately,
We held a men’s painting group titled “Healing through Art” addressing cultural, spiritual and social wellbeing. Participants were encouraged to tell their story through art and express their ideas in a culturally safe environment and to discuss social, cultural and grief and loss issues with access to other supports relating to their wellbeing. [Major City ACCHO]
Women’s yarning groups; Have started in [local area], these groups are run at [community organisation] by the women with support from the counsellor. Discussions include but not limited to, grief and loss, trauma and, sexual abuse are discussed in relation to alcohol and other drug impacts. Also craft making and a nice lunch provided. [Remote ACCHO]
Emerging Themes
Culture
Aboriginal and Torres Strait Islander culture and partnerships emerged as strong themes throughout the coded data. It was evident that culture was a major driver of service delivery and often standard clinical services had a cultural element embedded in their delivery. The quote below was chosen as an example of how an ACCHO demonstrated the importance of connection to Country by providing critical clinical care for their clients on-Country. The annual report explained,
‘We are developing this service in response to strong community demand to be able to receive treatment on country and remain connected with family. It also allows for people to return home for short term respite stays to ensure they can fulfil important cultural and ceremony obligations. It is important to note that the community feel so strongly about this, that they have self-funded this program through royalty association money.’ [Very Remote ACCHO]
The analysis revealed that through providing culturally safe care clients were more comfortable using the service. One Mums and Bubs program reported that clients prefer their culturally appropriate service:
[ACCHO] Mums and Bubs provides a contemporary and modern approach to family medicine for Aboriginal and Torres Strait Islander families in the area. Traditional services such as ante-natal and post-natal care are provided in a personalised culturally appropriate service delivery environment. Our families feel safe and secure when visiting the service and prefer it when seeking support on lactation, immunisation, contraception advice and child health and development check ups. [Major City ACCHO]
Social Capital and Social Cohesion
In many of the services ACCHOs reported, there was evidence of efforts to strengthen or build social capital and social cohesion. The following example demonstrates the complexity of the work of ACCHOs in building partnerships with organisations improving their community’s social capital:
The program currently has two staff members employed and provides support and cultural services to kindergartens which are listed as having Aboriginal children enrolled. There are currently approx. 25 kindergartens having had services being delivered with another one recently requesting service delivery. [ACCHO] works in close collaboration with the kindergarten teachers and cluster management organisations including [local kindergarten association] and [local council] to ensure that the services provided by [the ACCHO] meet both the needs of the community, children and Kindergarten teachers and also fall in alignment with Early Years policy framework, the [State Aboriginal Education plan] and the [Jurisdiction] Early Years Learning and Development Framework. [Inner Regional ACCHO]
There was evidence of ACCHOs building strong partnerships with cross sector organisations so as to facilitate client access to services that could improve their living situation. The following quote demonstrates the work of an ACCHO to improve the social capital of their community through a partnership with a local housing organisation:
The strong collaboration and partnership between program staff and the Private Rental Liaison Officers situated within Housing [organisation], has seen a high number of clients obtain affordable housing in the private rental market.
[Major City ACCHO]
ACCHOs reported a range of community engagement activities that brought community together and promoted social cohesion, as described in the following examples.
Regular community meetings and events were introduced so that all members and the broader community can meet with Board and management representatives face-to-face. This will be an ongoing program. [Remote ACCHO]
Youth Consultation Day at [youth community centre]– Our youth said they would enjoy opportunities to spend time with local elders, learn more about land and native plants and native art and dance. Key words that described ‘Culture’ for them: Native plants/animals, Dreamtime stories, Proud of who you are, Tradition, Dance (No opportunity for girls), NITV, Music (Modern/traditional), Food, ‘Knowing your mob’ and learning from family. [Outer Regional ACCHO]