Aboriginal and Torres Strait Islander populations suffer six times the rate of blindness and three times the rate of visual impairment compared to the rest of the Australian population. This gap is significant and there are some indications of improvement but the changes are limited, gradual and slow. In the remote areas of Australia, significant service limitations and gaps in the provision of eye care exist and improving the quantum and supply of Indigenous-specific eye services remains the main strategy to address these problems. However, in urban and regional areas there are generally ample existing mainstream services and it is the access and use of these services that requires improvement. The gap in vision and eye health cannot be closed until Aboriginal and Torres Strait Islander people have the access they need to high-quality eye-care services in both remote and urban settings.
Most Aboriginal and Torres Strait Islander people (75 per cent) live in the major cities and inner and outer regional areas of Australia. Around 43 per cent of the Indigenous population live in 28 urban centres with total populations greater than 2,000 people and this includes all of the state and territory capital cities. The proportion of the Indigenous population in 11 of these urban centres is less than the Australian average of 2.5 per cent and so while the Indigenous population is significant, the visibility of this population is often very low. Conversely, one-quarter of Aboriginal and Torres Strait Islander people live in remote and very remote areas of Australia but this proportion is projected to decline over the next decade to be only 20 per cent of the total Indigenous population.
The overall prevalence of eye disease is similar in urban and rural areas of Australia for the total population and this is also true for Aboriginal Australians. The persistent eye-care problems of Aboriginal people and Torres Strait Islanders were confirmed in the 2008 National Indigenous Eye Health Survey. Refractive error, cataract and diabetic retinopathy are the significant, treatable and preventable causes of blindness and visual impairment for Indigenous Australians in urban and regional areas. More broadly, 60 per cent of the health gap between Aboriginal and Torres Strait Islander people and the total Australian population is attributable to the poor health of Aboriginal and Torres Strait Islanders living in non-remote areas of Australia and so improvement must be made in urban and regional areas if we are to close the health gap.
There is considerable geographic variability in the use of eye-care services between urban and rural people and there remains significant inequities in access.[5, 7] Differences in utilisation can be explained by the shortage of optometric and ophthalmologic services in remote and very remote areas but the availability of eye-care services is also less in areas with higher proportions of Indigenous people.
There are currently 223 primary health-care services funded by the Australian Government providing primary health-care services to Aboriginal and Torres Strait Islander people and approximately three-quarters of these are community-controlled with a governing committee or board comprising Aboriginal and Torres Strait Islander people. There are also a smaller number of the Aboriginal and Torres Strait Islander primary health-care services which are largely state funded. Overall, 59 per cent of these services are in urban and regional areas and 75 per cent of all services report the availability of allied health services that include optometry. Interestingly, 66 per cent of the services also provide some ophthalmological services. It is not clear from the available information whether the Aboriginal Health Services without optometry are predominantly in urban and regional areas. While some services may include optometry, there is still need for a significant increase in optometric services to more remote areas where there are no other local service providers.
Overall Aboriginal and Torres Strait Islander people visit mainstream private medical practices and local community health services as well as health services designed for Aboriginal and Torres Strait Islander people at a similar rate to other Australians. Mainstream practices provide 80 per cent of primary medical services in major cities and this proportion reduces to 67 per cent in outer regional areas. The current rate of access of optometric services for Indigenous people is unknown as we do not know the number of Aboriginal people attending private optometric practices.
The barriers to accessing optometric services for Aboriginal and Torres Strait Islander patients are not unique to optometry or eye-care services. The availability of services is limited by geographic distance and access to transport. In non-remote areas, Aboriginal and Torres Strait Islander people report that appointments were not available when needed and the waiting times were too long. The affordability of services is a major limiting factor in access to health-care services, as there is a high sensitivity to costs. Over one-third of Indigenous people living in non-remote locations report problems accessing health services because of cost (compared to 16.5 per cent in remote locations). The exclusion of appropriate cultural values, through the attitudes of individuals and the appearance and design of health services, can also be a significant disincentive to access. The reasons given by patients for not seeking eye care were explored nationally in 2008 and included not enough time (41 per cent), condition not severe enough (22 per cent), too expensive (17 per cent), eye care not available in area (14 per cent), decided not to seek care (14 per cent), transport or distance issues (10 per cent) and waiting time too long (10 per cent).
There is a myriad of challenges which could impair effective negotiation of the referral pathway as Indigenous patients move from primary medical care to specialist eye care, including optometry. Active and effective collaboration and integration are required between primary care and eye-care services. Geographic availability, service co-ordination and case management for patients at risk of vision loss are needed to ensure successful referral and care. Our understanding of the health needs and behaviour of Indigenous people living in urban areas is limited but the issues are clearly different from those in remote areas.
To achieve equitable outcomes, inequities in access to eye care need to be addressed. Services that are affordable and acceptable need to be available at the right place and the right time. Turner, Mulholland and Taylor have shown that the provision of eye-care services within Aboriginal Health Services results in better vision for the community. Communities where Aboriginal Health Services host optometric services have a reduced prevalence of visual impairment and provide a higher coverage for distance spectacle correction than communities where services are available through private or state hospital-based facilities. It has been established that access to services for Indigenous people is improved if their care is delivered within culturally appropriate facilities.
The recent Roadmap to Close the Gap for Vision report provides a comprehensive suite of recommendations to support improved Indigenous eye-care outcomes. Extensive consultation was conducted at 21 sites across Australia and involved over 530 people from the Aboriginal community, Aboriginal health sector, eye-care and health-care sectors, including professional organisations and the government and non-governments sectors. One of a suite of 42 interlocked recommendations is to increase the accessibility and use of existing optometric services in urban and regional areas by making them available within Aboriginal Health Services through the Indigenous Visiting Optometrists Scheme (VOS) funding. Existing VOS funding has been targeted for rural and remote areas and where significant practitioner travel is required but incentives are also required for regional and urban practitioners to leave their practices and offer eye care within their local Aboriginal Health Services. There appears to be some government resistance to this approach, but similar strategies have been adopted to support medical specialist services in urban areas in recent years through the federal government-funded Urban Specialist Outreach Assistance Program (USOAP).
Mainstream service providers are able to successfully engage with Indigenous communities and establish genuine and successful partnerships. Burton has outlined the principles underpinning these approaches to include:
- a commitment to developing long-term sustainable relationships based on trust
- respect for Aboriginal and Torres Strait Islander cultural knowledge, history and connection to community and country
- commitment to self-determination for Aboriginal and Torres Strait Islander peoples
- shared responsibility and accountability for shared objectives and activities with the community
- commitment to redressing structures, relationships and outcomes that are unequal and/or discriminatory and
- an openness to working differently with Aboriginal and Torres Strait Islander peoples, recognising that the mainstream approaches are frequently not the most appropriate or effective.
It is possible for mainstream optometric practices to provide services that Aboriginal and Torres Strait Islander peoples want to access and use but this may be more readily achieved through Aboriginal Health Services.
The current system for providing eye care in urban and regional areas relies on health-seeking behaviour that may not be followed by many Aboriginal and Torres Strait Islander peoples. Our field studies suggest that most Indigenous people do not walk into a private optometric practice and seek care, nor do they request referral from their general practitioner. Most eye examinations result from the general practitioner or Aboriginal Health Worker initiating the referral to either an optometrist or ophthalmologist. Compared to those in more remote areas, Aboriginal people living in urban areas are less well supported by local organisations that could help co-ordinate and facilitate eye care. Optometric clinics that provide predominantly mainstream services face practical difficulties in adopting culturally welcoming services for minority groups. They have business models that may not embrace free or low-cost services and that may be limited in their capacity to engage with the Indigenous community through promotion and community participation. There is merit in providing optometric services within Aboriginal Health Services that are controlled by Indigenous organisations and are seen to be culturally safe.[2, 8, 14] This allows the provision of services in a familiar and comfortable space and overcomes a number of barriers around the cultural appropriateness of the facility, including arranging appointments. Aboriginal Health Services are publicly funded operations and have links to government support for provision of aids and the purchase of equipment. They also have health promotion activities that can engage the local community. It remains incumbent on the practitioners providing the service to ensure their own cultural awareness and respect.
Optometric services must be available within Aboriginal Health Services and appropriately linked with primary health-care services, ophthalmology and hospital services to support equitable access and eye-health outcomes for Aboriginal and Torres Strait Islander people and to effectively close the gap for vision. This is particularly important in urban and regional areas of Australia where Indigenous access and use of services is not delivering the necessary eye-health outcomes.