Social Determinants of Health Module 3 Lecture PDF

Social Determinants of Health Dr Audra de Witt NSB 102: Professional practice and cultural safety. Lecture: Module 3. Semester 1  Acknowledgement of Traditional Owners In keeping with the spirit of Reconciliation, we acknowledge the Traditional Owners – the Jagera and the Turrbal peopl...

Social Determinants of Health Dr Audra de Witt NSB 102: Professional practice and cultural safety. Lecture: Module 3. Semester 1  Acknowledgement of Traditional Owners In keeping with the spirit of Reconciliation, we acknowledge the Traditional Owners – the Jagera and the Turrbal peoples of the land where QUT now stands and recognise these places have always been places of teaching and learning. We pay our respects to their Elders past and present, and acknowledge the important role Aboriginal and Torres Strait Islander peoples continue to play within the QUT community www.reconciliation.qut.edu.au  Social determinants of health 1 The socio-political context of 2 nursing Racism and the role of cultural 3 safety practices  What are social determinants of health? These are factors outside the control of individuals and people that impact on health They are factors that sit outside the domain of health – it is so powerful it affects health outcomes Such as where a person lives and works, education levels and social supports These factors often are underlying contributors to health inequities which must be addressed to achieve ‘Heath for All’ (as learned in module 1 lectures – health is a fundamental human right) Source: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 World Health Organisation - Definition of Social Determinants of Health (SDH) “The social determinants of health (SDH) are the non- medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems”. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1  Examples of social determinants of health Can Influence health equity  Income and social protection  Education  Unemployment and job insecurity  Working life conditions  Food insecurity  Housing, basic amenities and the environment  Early childhood development  Social inclusion and non-discrimination  Structural conflict  Access to affordable health services of decent quality Source: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1  SDH can influence health equity in positive and negative ways … Addressing Income & social Unemployment Access to affordable & quality SDH are said to influence services protection health more than lifestyle choices & health care Housing, basic amenities & Working Food environment conditions insecurity Studies suggest Social SDH accounts for between inclusion & Conflict Education 30-55% of health outcomes non- discrimination Source: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1  What does social determinants of health have to do with culturally safety? 1 Need to understand broader factors that impact on health and well-being to be able to provide high quality, culturally safe and holistic health care Having this knowledge and understanding of the connection between these factors will allow us to appreciate the complexity of health and well-being We begin to appreciate some things are outside the control of individuals and avoid blaming individuals for poor health We start to see the importance/role of health systems, other sectors, govts, need for intersectoral collaboration. Eg health policies & policies outside health domain, environments (home and work), housing, education What does social determinants of health have to do with culturally safety? 2 SDH significantly influences health inequities - can be seen at local, national and international levels International example- health status of populations in different countries. ↑ income countries, ↑ population health status. ↓ income countries, ↓ population health status World Health Organisation (WHO) states that people born in high human development (HD) countries have a higher life expectancy by 19 years compared to those born in low HD countries Source: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 What does SDH have to do with culturally safety? Top 10 Top 10 countries with the Highest Human Development Index – 2022 1. Switzerland (.962) 2. Norway (.961) 3. Iceland (.959) 4. Hong Kong [China] (.952 5. Australia (.951) 6. Denmark (.948) 7. Sweden (.947) 8. Ireland (.945) 9. Germany (.942) 10. Netherlands (.941) Most developed countries 0.8 or ↑, least developed countries ↓ 0.55 Source: https://worldpopulationreview.com/country-rankings/hdi-by-country Image source: https://www.publicdomainpictures.net/pictures/360000/velka/switzerland-alps.jpg Sociological perspectives and health inequality One can have different perspectives on health, well-being, illness, disease, health systems etc We look at health from a unique perspective and consider how to improve systems we created (based on dominant society values – socially constructed) to address health inequalities that exist in society We recognise that culture and background significantly impact health and health outcomes Understanding the social determinants [the causes outside the control of individuals e.g. poverty, socioeconomic disadvantage] of a person’s, family's or community's health helps us to provide culturally safe and person-centred care Social determinants – impacts on health & access to care (global perspective) Covid-19 pandemic - groups that experienced increased rates of morbidity and mortality & the associated SDs for these inequities  Poorer people  Poverty & deprivation  Marginalised ethnic minorities,  Imposed mobility of low-paid including Indigenous Peoples workers in precarious employment  Low paid essential workers  Lack of social protection  Migrants  Crowded housing  Populations affected by  Low occupational health standards emergencies, inc conflicts & poor protection at work  Incarcerated populations  Stigmatization  Homeless people  Unequal access to affordable treatment, prevention & vaccination Source: https://www.instituteofhealthequity.org/resources-reports/covid-19-the-social-determinants-of-health-and-health-equity---who-evidence-brief/equity- covid-19-and-the-social-determinants-of-health-sdh.pdf Covid-19 pandemic - Toilet Paper panic across Australia Source: https://www.forbes.com/sites/brucelee/2020/03/06/how-covid-19-coronavirus-is-leading-to-toilet-paper-shortages/?sh=3f3d18ba7a8d  Professor Sir Michael Marmot International leader in social determinants of health and addressing inequities In the 2016 Boyer Lecture series Fair Australia: Social Justice and the health gap, of Australia Prof Sir Marmot said: “Australia’s claim to be an egalitarian country has always relied on ignoring the plight of its Indigenous population. Such willful ignorance is totally unacceptable. Among the non-Indigenous population, though, the egalitarian claim has had some evidence in fact. That egalitarian claim is now under threat in Australia as it is in other rich countries. We are discovering old concerns …. When an Australian Prime Minister mused that he could justify restrictions in spending on Indigenous communities because living in a remote rural community was a ‘life-style choice’, I asked my Australian medical colleagues if they found that helpful..”. Source: the 2016 Boyer Lectures  Professor Sir Michael Marmot – in his words … International leader in social determinants of health and addressing inequities “We have the knowledge and “This inequality ….. means to improve people’s lives threatens the very nature and reduce inequality” of our society” “The question is what do we have in “Poverty is NOT a our hearts? Do we have the will to destiny” close the gap in a generation?” (in context of the First Nation Australians life expectancy gap – 10 years lower than the general population Source: The 2016 Boyer Lectures: https://www.abc.net.au/radionational/programs/breakfast/boyer-lectures-michael-marmot-social- determinants-ill-health/7636982  Health inequity - continued ”The biggest enemy of health in the developing world is poverty” Kofi Annan, former Secretary- General of the United Nations Prof Sir Michael Marmot 2016: ”Income inequality in Australia is higher than the average of the rich countries that belong to the exclusive club, the OECD. In common with most of the members of the club in equality has been rising. Australian politican, Andrew Leigh, points out that since the mid 1970s, real earnings for the top tenth have risen by 59 per cent, while for the bottom tenth they have risen by just 15 per cent … Source: The 2016 Boyer Lectures: https://www.abc.net.au/radionational/programs/breakfast/boyer-lectures-michael-marmot-social-determinants-ill- health/7636982  Why does increasing inequality of income and wealth matter? 1. People feel, and the evidence shows that they are correct, that big inequalities limit opportunities in the next generation. Rich parents have children who become rich; poor parents have children who become poor. 2. There is widespread public concern at growth of inequality. It questions the legitimacy of society. Extremes of inequality are seen to work in the interest of the few and are inconsistent with a functioning democracy. It just ain’tt fair. Their kids have a chance and mine don’t. 3. Highly unequal societies are associated with social evils such as ill-health and crime – the theme of these lectures. But, poverty is not a destiny”  SDHs and impact on access to health & health care - summary  Children – depend on others  Older / Ageing person – how does society respond/ view an Ageing person?  Those living outside cities. The more remote, the more difficult (eg limited services, many not be appropriate  Cost of accessing services (eg transport)  Cost of living – all adds up.  Culturally safe services?  Education – there’s a strong relationship between education & health and also poverty, education and health  Income – higher income households are in position to make better choices,  Gender – stereotypes: Men = “masculine” - stoic attitudes especially in rural/remote areas. NOTE: men have lower life expectancy than women. Women – ”passive”, “emotional”. LGBTIQ – may feel discriminated against &/or stigmatization Discrimination of any kind or type is NOT acceptable  Socio-political context of nursing Global and Local Dr Audra de Witt NSB 102: Professional practice and cultural safety. Module 3. Semester 1, 2024 Nursing: Socio-political context (global) Source: https://www.refugeecouncil.org.au/how-many-refugees/  Who are asylum seekers and refugees? According to the Australian Human Rights Commission: “An asylum seeker is a person who has fled their own country and applied for protection as a refugee According to the United Nations Convention relating to the Status of Refugees, as amended by its 1967 Protocol (the Refugee Convention), a refugee is a person who is outside their own country and is unable or unwilling to return due to a well-founded fear of being persecuted because of their: o Race o Religion o Nationality o Membership of a particular social group or o Political opinion” Source: https://humanrights.gov.au/our-work/rights-and-freedoms/publications/asylum-seekers-and-refugees#who Why do people need to leave / be displaced from their homes (global context)  Desertification of land – once useful productive lands becomes drylands  Limited educational opportunities and tensions between communities (social)  Corruption and poor urban planning (political)  Poverty and lack of access to markets (economic)  Persecution of vulnerable groups- can be cause or result of conflict. Women and girls often at increased risk of gender-based violence during conflict  Disasters & the Environment – eg. natural disasters such as cyclones. Environment – such as climate changes as sea levels rise  Most common = Political reasons. People often feel forced to leave when they don’t enjoy (or have) political, social and civil rights  Think of what has been happening in Ukraine and Russia.  In Syria due to drought more than 1.5 million Syrians were forced to move from rural areas to urban areas (2015- 2010) – this contributed to conflict Source: https://www.refugeecouncil.org.au/why-people-leave/2/  Some examples of impacts of forced displacements relating to health and well-being Hardships such as lost of home and sometimes loss of living in country of origin Loss of assets Loss of livelihoods Loss of loved ones Not able to /difficulty planning for a future Having to start all over again Many suffer from trauma (eg from gender-based violence) Source: https://www.worldbank.org/en/topic/forced displacement#:~:text=The%20hardships%20they%20endure%20through,risk%20of%20gender%2Dbased%20violence.  Closer to home: Aboriginal and Torres Strait Islander Peoples  Aboriginal and Torres Strait Islander Australians are the oldest continuous civilization in the world.  Since colonization, thousands of First Nation Australian children were forcibly removed from their families and communities across Australia as a result of numerous government laws, policies & practices (1800s-1900s)  They were forcibly removed by governments, churches & welfare bodies – fostered out & put out for adoption by non-Indigenous Australians, nationally & internationally = they are known as the stolen generations Source:https://aiatsis.gov.au/explore/stolen-generations  Closer to home: Aboriginal and Torres Strait Islander Peoples (cont)  As heard, policy of forced removals was abolished – not that long ago  Imagine what it would be like to be removed from everyone and everything you have ever known? Families and communities torn apart … no idea where they are,  This ”assimilation” policy was to force First Nations Australians to change their ways – their everyday practices, culture, traditions and customs – basically the way they lived their lives and to adopt the European way – to “assimilate” /merge and integrate them into white society.^ Policy aimed to eradicate the race & was only abolished in 1973.  First Nations peoples were not allowed to own any incl where they lived. Only changed in1994 - The Native Title Act 1993 enacted+  Significantly affected First Nations lives - resulting in financial, social, psychological, physiological stressors – all known to increase risk of chronic diseases.  This intergenerational trauma still exist today & conscious and unconscious racist attitudes all contribute to inequities that exist in health and in society.  14 October 2023 - Referendum to the nation to recognize Aboriginal and Torres Strait Islander peoples in the constitution, to have a representative voice in parliament * Source: ^https://humanrights.gov.au/our-work/bringing-them-home-chapter-2 *https://www.abc.net.au/news/2023-03-22/federal-parliament-voice-referendum-explainer/102129556. +https://www.ag.gov.au/nativetitle#:~:text=Following%20the%20decision%20in%20Mabo,can%20be%20recognised%20and%20protected +https://www.legislation.gov.au/Details/C2019C00054. https://www.pm.gov.au/media/next-step-towards-voice-referendum-constitutional-alteration-bill The next slide is a short video of the Stolen Generations (3 mins and 25 seconds) For Aboriginal and Torres Strait Islander peoples, please note – This video may contain historical images of Aboriginal and/or Torres Strait Islander peoples that have passed. You do not need to watch this video if you do not want to. You can skip the slide and/or this part of the lecture go to the next slide. Source: Eliminating An Entire Race | AUSTRALIA’S DARK HISTORY | The Stolen Generation (Youtube). https://www.youtube.com/watch?v=MHCDZrIpQYg.  Homelessness in Australia Another population that have either been forcibly removed &/or displaced ABS statistical definition : “ …. When a person does not have suitable accommodation alternatives they are considered homeless if their current living arrangement:  is in a dwelling that in inadequate  Has no tenure, of their initial tenure is short and not extendable; or  Does not allow them to have control of, and access to space for social relations (ABS 2012). Source: https://www.aihw.gov.au/reports/australias-welfare/homelessness-and-homelessness-services  Homelessness in Australia Result of social, economic and health related factors Some reasons include:  Low educational attainment  Employment circumstances  Family and domestic violence  Ill health (including mental health issues)  Disability  Trauma  Substance misuse can increase risk  Structural factors contribute to risk eg. – lack of adequate income, limited access to available housing Source: https://www.aihw.gov.au/reports/australias-welfare/homelessness-and-homelessness-services Source: ABC news. Homelessness up 22 percent in Queensland 23March2023 https://www.youtube.com/watch?v=oGgzmoumts0 Cultural safety, racism and health care Dr Audra de Witt NSB 102: Professional practice and cultural safety. Module 3. Racism and the health care system – definition 1 “Racism is a form of prejudice that assumes that the members of racial categories have distinctive characteristics and that these differences result in some racial groups being inferior to others. Racism generally includes negative emotional reactions to members of the group, acceptance of negative stereotypes, and racial discrimination against individuals; in some cases it leads to violence.” Source: American Psychological Association. https://www.apa.org/topics/racism-bias-discrimination Racism and the health care system – definition 2 Australian Human Rights Commission on racism “Racism is the process by which systems and policies, actions and attitudes create inequitable opportunities and outcomes for people based on race. Racism is more than just prejudice in thought or action. It occurs when this prejudice – whether individual or institutional – is accompanied by the power to discriminate against, oppress or limit the rights of others.” Source: https://humanrights.gov.au/our-work/race-discrimination/what-racism  Discrimination “Discrimination refers to the differential treatment of the members of different ethnic, religious, national, or other groups. Discrimination is usually the behavioral manifestation of prejudice and therefore involves negative, hostile, and injurious treatment of members of rejected groups”. Source: American Psychological Association. https://www.apa.org/topics/racism-bias-discrimination Racism in the health care system  Central to Australian society since European colonisation began in 1788  First Nations Australians suffered extensively – colonisaton processes & beliefs that underpin it continue to shape Australian society  Racism adapts and changes over time affecting different communities and people at different times and in different ways - can intensify at historical timepoints. Eg Covid-19 pandemic – spike in racism towards Asian people  Includes all laws, policies, ideologies and barriers that prevents people from experiencing justice dignity & equity due to racial identity.  Can be in form of harassment, abuse or humiliation, violence or intimidating behaviour  Also exists in systems, institutions, polices that lead to injustice and inequity Source: https://humanrights.gov.au/our-work/race-discrimination/what-racism  Racism and its impacts on health  Negatively impacts physical and mental health and wellbeing  Can lead to premature & avoidable death  Acts as deterrent to health care access – fear & avoid repeated exposure to racism  Manifest in different ways – eg. individual - beliefs, attitudes & behaviours; in organisations through – policies, practices and in systems (eg health system  Austn National Data - evidence of discrimination in health care system against First Nations Australians and other Ethnic minorities  Eg. lower access to hospital procedures, higher rates of discharge against medical advice^  Experiences of racism and discrimination also reported by Health profs* Source: ^Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2020 summary report. Cat. no. IHPF 2. Canberra: AIHW; 2020. ^Australian Institute of Health and Welfare. Better cardiac care measures for Aboriginal and Torres Strait Islander people: Fourth national report 2018–19. Canberra: AIHW; 2019. ^Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2017 report. Canberra: AIHW; 2017. Available at: https://www.niaa.gov.au/sites/default/files/publications/ indigenous/hpf-2017/tier3/309.html. *Vukic A, Jesty C, Mathews SV, Etowa J. Understanding race and racism in nursing: Insights from Aboriginal nurses. ISRN Nurse 2012; 2012: 196437. *Huria T, Cuddy J, Lacey C, Pitama S. Working with racism: A qualitative study of the perspectives of Ma¯ori (Indigenous peoples of Aotearoa New Zealand) registered nurses on a global phenomenon. J Transcult Nurs 2014; 25: 364–72. doi:10.1177/1043659614523991  One example of negative outcomes due to racism in health care system Naomi Williams was a 27-year old Aboriginal woman who was 6 months pregnant with her first child. She died of septicaemia in 2016. She tried multiple times to seek treatment at her local hospital but failed. Her family waited over three years for the inquest investigation findings which found:  Naomi made 18 visits to local hospital in few months before she & her unborn child died  She was never referred to a specialist  Nurses assumed she was a drug-seeking & lying about her pain levels even though she presented with vomiting, dehydrated and abdominal pain  She was given 2 paracetamols and was sent home with no physical examination  She died 15 hours later with meningococcal septicaemia  She told her family and friends before she died that she didn’t want to go to hospital because “they treated me like a junkie” Inquest found her death was due to implicit bias and racism. Without reference to medical notes, the nurses missed clear signs Naomi had a high-risk pregnancy Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122304/pdf/ijerph-18-04399.pdf Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122304/pdf/ijerph-18-04399.pdf An equitable health system Dr Audra de Witt NSB 102: Professional practice and cultural safety Addressing racism through cultural safety practices 1 Nursing & Midwifery Board of Australia (NMBA): Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122304/pdf/ijerph-18- 04399.pdf  ‘Cultural safety is a philosophy of practice that is about how a health professional does something, not [just] what they do.  It is about how people are treated in society, not about their diversity as such, so its focus is on systemic and structural issues and on the social determinants of health.  Cultural safety represents a key philosophical shift from providing care regardless of difference, to care that takes account of peoples’ unique needs.  It requires nurses and midwives to undertake an ongoing process of self- reflection and cultural self-awareness, and an acknowledgement of how a nurse’s/midwife’s personal culture impacts on care’ (2018, p. 15)  Addressing racism through cultural safety practices 2 Remember Module 1 lectures? We learned about the key professional attributes – this is important when working with all people and especially so when working with migrants, refugees, First Nations peoples, those experiencing homelessness and those traditionally less represented populations. These incl:  Respect  Non-judgemental attitudes  Trust  Reciprocity  Empathy  Working with the person together as a team When delivering health care as Student / future nurse  Avoid blame for ill health and  Think critically re privileged, white, disadvantage medical and western ways of thinking …social constructionism  Social determinants: historical and current social and political impact  Address conscious/unconscious racism and others forms of  Self-reflection…..examine own disrespect, bias and prejudice in realities and attitudes nursing education and care  Open minded and flexible towards  Challenge systemic/institutionalised those we see as ‘different’ racism  Well educated, self aware  Improve the experience of workforce …culturally safe to care/education practice as defined by the people we serve  Culturally safe services/ organisations increases likelihood of  Nurses must deliver cultural safety positive experiences which in turn care – mandated by Australian increases accessibility, Code of Conduct for Nurses & acceptability of health/education required of the B Nursing curricula services by the Australian Nursing and Midwifery Accreditation Council (Ramsden 2002, p. 94) What does this mean for you - a student and future nurse? 1  Be aware that some people you care for may have been through a lot of trauma and hardship. Eg. People who have been forcibly displaced  Asylum seekers can spend many years awaiting final determination of their case, fear of being returned to country of origin, isolation and destitution – can be overwhelming & challenging  Be kind, offer good support & link-in to organisations, resources & supports  Refer to mental healthcare support team as required (especially if any statements relating to suicide)  Just because someone can’t speak English it does not mean they are not intelligent. Source: https://refugeehealthguide.org.au/asylum-seekers/ What does this mean for you - a student and future nurse? 2  Encourage good diet (may eat poorly & frugally) and check access to supplies  Encourage use of heating in winter (if needed) – (tend to economise on this)  Be aware of support services available (eg food banks, local charities for clothing & essential items, refugee support organisations  My not understand health ‘norms’ such as vaccinations, screening programs, check ups etc. and/or health may be poor due to barriers to accessing care not because they don’t care or don’t want it  Interpreter services – organize as needed  Be aware there may be many cultural differences & focus on provided person-centred culturally safe care  Space for family to visit Source: https://refugeehealthguide.org.au/asylum-seekers/  What does this mean for you - a student and future nurse? 3  First Nations Australians may have previously negative experiences in health care – this may mean they may be reluctant to communicate and disclose information  Like with other population groups, work on building trust and be respectful providing person-centred care  Help reduce barriers to care – eg. engage and liaise with PHC service, hospital liaison officer, include family in discussions etc  Applies when caring for all people but especially less represented populations - be aware of being in a position of power – “share” this power  Allow space and time for cultural practices (applies to all people) What does this mean for you - a student and future nurse? 4  May not have had access to facilities to present well (may be unkept, may not have showered, old and unlaundered clothing) – provide person- centred care  They may be other ‘hidden’ challenges that are not disclosed eg. mental illness, assaults, feelings of embarrassment /shame  Provide person-centred care  Link in with appropriate services (referral to social worker)  Screen and do thorough helath check ups and appropriate health education  Ask about best way to communicate after hospital discharge (difficult if no email, phone or street address) Source: Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople/objectives -and-data/social-determinants-health Source: Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople/objectives- and-data/social-determinants-health Cultural safety ongoing process: CULTURAL SELF AND (adapted by Leonie Cox from SYSTEM AWARENESS There Ramsden, 2002, p.117) is difference. The focus is NOT only on one’s own culture as organisations have culture too. CS about self-awareness & the emotional, social, economic & political context of life. YOU COLLEAGUES THE HEALTH CULTURAL CARE SYSTEM SENSITIVITY CULTURAL SAFETY SOCIETY differences are legitimate - outcome of education, encourages reflection on reflective practice, own experience, position power sharing, and privilege & the impact partnership, trust - of our personal, enables safe service to professional & institutional be defined by service cultures on others. users Sensitive to systemic racisms, stigma, all discrimination  References Australian Human Rights Commission. Historical context—The stolen generations. [Internet]; Canberra: Australian Human Rights Commission: https://bth.humanrights.gov.au/significance/historical-context-the- stolen-generations. Australian homelessness monitor 2022. https://apo.org.au/sites/default/files/resource-files/2022-12/apo-nid321101.pdf American Psychological Association. https://www.apa.org/topics/racism-bias-discrimination Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2020 summary report. Cat. no. IHPF 2. Canberra: AIHW; 2020 Australian Institute of Health and Welfare. Better cardiac care measures for Aboriginal and Torres Strait Islander people: Fourth national report 2018–19. Canberra: AIHW; 2019 Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2017 report. Canberra: AIHW; 2017. Available at: https://www.niaa.gov.au/sites/default/files/publications/ indigenous/hpf-2017/tier3/309.html Attorney-General's Department (Australia). Native title. [Internet] Canberra: Attonery-General’s Department; https://www.ag.gov.au/nativetitle#:~:text=Following%20the%20decision%20in%20Mabo,can%20be%20recognised%20and%20protected. Australian Government. Native Title Act 1993 [Internet]. Canberra: Federal Registrar of Legislation. Australian Government; 1993; https://www.legislation.gov.au/Details/C2019C00054 Boyer lectures. 2016. The 2016 Boyer Lectures: https://www.abc.net.au/radionational/programs/breakfast/boyer-lectures-michael-marmot-social-determinants-ill-health/7636982 Brunner E. Stress and the biology of inequality. BMJ. 1997;314(7092):1472–6. Channel 9 news in forbes. 2020, march 6: https://www.forbes.com/sites/brucelee/2020/03/06/how-covid-19-coronavirus-is-leading-to-toilet-paper-shortages/?sh=3f3d18ba7a8d Cultural safety ongoing process: (adapted by Leonie Cox from Ramsden, 2002, p.117) Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople/objectives-and-data/social-determinants-health Human Rights and Equal Opportunity Commission. Bringing them home: report of the national inquiry into the separation of Aboriginal and Torres Strait Islander children from their families (Australia). Sydney: Human Rights and Equal Opportunity Commission; 1997. Huria T, Cuddy J, Lacey C, Pitama S. Working with racism: A qualitative study of the perspectives of Ma¯ori (Indigenous peoples of Aotearoa New Zealand) registered nurses on a global phenomenon. J Transcult Nurs 2014; 25: 364–72. doi:10.1177/1043659614523991 Nursing and Midwifery Board of Australia. (2018). Code Of Conduct For Nurses, NMBA PM media release. Next step towards voice referendum: Constitutional alteration bill. 23 March 2023. https://www.pm.gov.au/media/next-step-towards-voice-referendum-constitutional-alteration-bill  References Racism. It Stops With Me – Ask yourself the hard questions. 2022. Australian Human Rights Commission. Youtube: https://www.youtube.com/watch?v=6-5ezuQmVm0 Ramsden, IrihapetiM. (2002). Cultural Safety and Nursing Education in Aotearoa and TeWaipounamu. Unpublished PhD Thesis. Massey University. Renazaho AM, Houng B, Oldroyd J, Nicholson J, D'Esposito F, Oldenburg B. Stressful life events and the onset of chronic diseases among Australian adults: findings from a longitudinal survey. Eur. J. Public Health. 2014;24(1):57–62. Refugee Council of Australia. (2021) Why people leave? https://www.refugeecouncil.org.au/why-people-leave/2/ Steering Committee for the Review of Government Service Provision. Overcoming Indigenous disadvantage: key indicators 2016 report. Canberra: Productivity Commission; 2016. Stock photo of Switzerland (creative common licence) https://www.publicdomainpictures.net/pictures/360000/velka/switzerland-alps.jpg Vukic A, Jesty C, Mathews SV, Etowa J. Understanding race and racism in nursing: Insights from Aboriginal nurses. ISRN Nurse 2012; 2012: 196437 World health organization – health as a human right World Health Organisation. Social determinants of health https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 World Health Organisation. Top 10 Countries with the Highest Human Development Index (HDI) 2022. https://worldpopulationreview.com/country-rankings/hdi-by-country World Health Organisation. Covid-19 and the social determinants of health and health equity. (2021). https://www.instituteofhealthequity.org/resources-reports/covid-19-the-social- determinants-of-health-and-health-equity---who-evidence-brief/equity-covid-19-and-the-social-determinants-of-health-sdh.pdf