Rationale and plan for a focus on First Nations urban health research in Australia

Urbanisation is a global phenomenon. The World Health Organization reported in 2015 that 55% of the global population lived in cities and is predicting this to increase to 68% by 2050.1 First Nations peoples globally are disproportionately affected by urbanisation, with major drivers being climate change, deforestation and increased pressures created by globalisation. Despite this, there is limited research to address urbanisation and its impact on human health and wellbeing. Similarly, there is an urgent need for a focus on improving health and wellbeing outcomes for urban First Nations peoples in Australia given the rapid urbanisation of First Nations people.

Between 2011 and 2021, First Nations populations residing in Australia's capital cities increased overall by 67% and, at the same time, the number of non‐Indigenous Australians residing in cities increased by 21%.2 During this same period, Brisbane and Melbourne experienced the greatest increase in First Nations populations (80% each) and Darwin the least (a 31% increase).2 However, there is a limited policy and research focus on urban First Nations populations in Australia. The prevailing discourse of equal access to health care, employment, educational opportunities, and all the available services necessary to close the persistent health gap may be true in theory for urban populations, but these fail to account for the social, structural, political and economic determinants that affect First Nations peoples in contemporary Australia.3 Urbanisation can contribute to significant health inequities and can diminish opportunities for facilitating social and cultural cohesion, which are important for First Nations peoples in maintaining cultural identity, culture, and connection to kin. Moreover, people in cities can easily be isolated from communities and often in areas of greater social dysfunction.3

Urbanisation places additional pressures and burden on an already extended health care system, especially in the context of First Nations health care, affecting health system performance and access to, and utilisation of, health care services by First Nations people. In 2021, 37% of First Nations Australians were reported as living in the major capital cities of Australia.2 Yet, in 2018, urban First Nations people accounted for 56% of the total disease burden, 61.4% of the non‐fatal burden and 50.4% of the fatal burden of all First Nations Australians.2 The life expectancy of a First Nations person born in a major city in 2021 is about eight years shorter than for a non‐Indigenous Australian.4 Almost a third of First Nations people in non‐remote areas, aged 18 years and over, self‐reported high or very high levels of psychological distress5; and only 48% of people living in major cities reported their health status as excellent or very good compared with 47% living in very remote areas.6

Health system performance for urban First Nations people in Australia remains suboptimal. The proportion of pregnant women in major cities who attend primary health care organisations for antenatal visits was highest in remote areas (48%) and lowest in major cities (32%),7 and the rate ratio of potentially preventable hospitalisations between urban First Nations and non‐Indigenous peoples living in capital cities is 2.1.8 Conversely, we know that when First Nations‐led health care is adequately resourced and implemented in cities, these clinics and programs can result in significant improvements in health care access, utilisation and outcomes.9,10

Further, two Australian First Nations urban health research reviews have highlighted major gaps in research effort and investment. In 2010, the first review found that just 11% of all articles in the previous five years focused on urban First Nations health, despite almost 55% of the total First Nations population living in urban areas (including inner regional areas).11 In 2021, a second review showed that up to three times as many research articles focused on remote First Nations health than urban First Nations health issues.12 In addition, health care research is increasingly dependent on digital health data and platforms. This capability is almost absent in First Nations research, creating a “digital divide”.13 This imbalance is a persistent problem that inhibits the holistic understanding of health issues and responses for large First Nations populations in urban settings. In order to ameliorate First Nations health disadvantage nationally, much more investment and effort must focus on urban populations and communities. This perspective article provides a rationale for why there should be a greater focus on urban First Nations people's health and wellbeing in Australia, as well as a framework for implementing research on this issue.

What does an Indigenous urban health research agenda look like?

The University of Queensland Poche Centre for Indigenous Health (UQ Poche Centre) is a First Nations‐led health research centre working closely with the Institute for Urban Indigenous Health (IUIH) and other urban Aboriginal community‐controlled health services (ACCHS) across Australia to transform urban First Nations peoples’ experiences of injustice and inequity in health and wellbeing. The WHO Urban Health Research Agenda launched in 2021 and included a set of global urban health research priorities for 2022–2032, which assisted us in the identification of knowledge and implementation gaps and in the development of our regionalised Indigenous Urban Health Research Agenda.1 To inform this Research Agenda, over the past few years, we have established partnerships with urban Aboriginal and Torres Strait Islander community‐controlled health services, recently forming an alliance known as the Research Alliance for Urban Community‐Controlled Health Services (RAUCCHS).14 Importantly, this Alliance will use the expertise and capacity of members to achieve transformational changes in systems, policy and care through research that enhances the capacity of ACCHS to achieve their respective and collective vision for their community's wellbeing. This newly developed Indigenous Urban Health Research Agenda will generate research that:

• is of priority to urban First Nations communities, is First Nations‐led, and strives towards equitable health outcomes for urban First Nations people;
• improves health care delivery for urban First Nations people;
• provides local‐level evidence on the relationships between social, cultural, policy and economic determinants of health and health outcomes for urban First Nations people; and
• provides local‐level evidence on under‐researched urban First Nations populations such as homeless or LGBTQI+ people.

Six specific areas of research were identified by RAUCCHS members and included:

• improving efficiency and effectiveness of Indigenous models of care especially within ACCHS;
• identifying and addressing gaps in systems of care for First Nations people;
• examining the impact of changing social and population demographic characteristics;
• examining the impact of intersecting determinants of health (who is affected and how in different contexts and settings);
• improving First Nations Australians’ access to culturally safe services in urban settings; and
• using evidence to support increased funding of urban ACCHS.

This research centres Indigenous ways of knowing, being and doing by privileging Indigenous voices and world views, underpinned by Indigenous methodologies that encompass the principles of ethical research with First Nations people in Australia.15

Conclusion

As we move forward in striving to close the gap in health and wellbeing outcomes for First Nations peoples in Australia, we have to move toward a greater focus on urban populations. At the same time, we are not advocating for decreasing efforts to improve health and wellbeing outcomes in regional and or remote areas, we stress that it cannot be one or the other. To improve First Nations health disadvantage nationally, considerably more effort and investment in research, policy and clinical services must focus on urban populations and communities, especially with a focus on Aboriginal community‐controlled health care.

Here, we have outlined the UQ Poche Centre Indigenous Urban Health Research Agenda, which enables research to be driven by communities and conducted by a First Nations‐led research centre. We also call to action governments and research funding bodies to reimagine understandings of First Nations health research in Australia and to provide greater policy focus and funding allocation to urban First Nations health research.