Volume 34 Number 1

Author positionality statement

The authors would like to acknowledge the Traditional custodians of all the many Aboriginal and Torres Strait Islander Nations that make up the great continent of Australia. This work was undertaken on Kombumerri and Kaurna country, which we would like to acknowledge. As a Kaurna man, the 2nd author would like to acknowledge his Kaurna community, Elders, representatives, and ancestors. My people are the Traditional custodians of our ancestral lands, the Adelaide Plains area of South Australia. We maintain our deep feelings of attachment and relationship to our country, and we respect and value our past, present and ongoing connection to our land, waterways, airways and cultural beliefs. As an Aboriginal health professional and researcher, I bring to this review a First Nations’ standpoint rooted in our lived experience, cultural knowledge systems, and accountability to community.

Introduction

We honour and pay tribute to the deep and enduring connection of Aboriginal and Torres Strait Island peoples to this land, and to their profound contributions to our nation’s cultural landscape. We acknowledge the tireless efforts of generations of leaders and communities who have stood against racism and advanced the values of reciprocity, freedom, self-determination, human rights, custodianship, voice and equality. We pay respect to Elders past and present, and we recognise the resilience and strength of future generations of Aboriginal and Torres Strait Island peoples in continuing living cultures and traditions despite the ongoing impacts of colonisation and dispossession. The balanced and culturally respectful views presented by the authors in this manuscript acknowledge the survival, resistance and on-going cultural strength of Aboriginal and Torres Strait Island peoples.

According to the United Nations Permanent Forum on Indigenous Issues, approximately 370 million Indigenous peoples in 70 countries worldwide practice unique traditions that employ distinct social, cultural, economic, and political concepts from the dominant societies in which they live.¹ The Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS) determine that Australia’s Indigenous peoples are two distinct cultural groups composed of Aboriginal (referred to original inhabitants of mainland Australia, Tasmania and smaller islands of Australia) and Torres Strait Islander (referred to original inhabitants of the Torres Strait Islands at northern Queensland) peoples, with diverse identities exemplified by more than 250 languages across Australia, and many more that have been lost.²

Indigenous peoples have been environment knowledge-keepers for thousands of years, with a holistic perception of humanity that is intrinsically connected to the ecosystem through cultural law, including practising sustainable management of natural resources with ancestral lands, waters, and territories of fundamental importance for their physical and cultural survival.³ Even though Indigenous peoples across the world are culturally diverse and unique, they record a history of dispossession, physical and cultural genocide, and profound trauma generated from colonisation by outsiders who propagated alienation from their ways of life.⁴ This alienation had a negative physical, social, emotional and mental health impact including the legalised introduction of microorganisms to which Indigenous peoples had not been exposed before, substances such as tobacco and alcohol that represent long-term severe health risks, blocked access to or damaged traditional farming, food-gathering, hunting/fishing practices, and disruption to the thousands of years of traditional laws, languages, religions, and therapies.⁴ Profound negative impact was also accompanied by structured marginalisation and prejudice that consequently resulted in poverty, undereducation, unemployment, inadequate housing, high incarceration rates and oppressive healthcare systems that fail to prevent diseases, disabilities and premature death and to maintain/enhance the quality of life. This reflects the unequal health outcomes that Indigenous people experience globally, with a disproportionate burden of chronic conditions and mortality rates.⁵

In the present review, we highlight Aboriginal and Torres Strait Islander people’s disparities in health with a focus on risk of chronic wounds development, reviewing recently reported epidemiological data and the healthcare system’s inefficiency in attending to Aboriginal and Torres Strait Islander people’s needs while pointing to initiatives representing a movement towards health equity.

Methods

This comprehensive review was guided by the five-stage framework described by Arksey and O’Malley,⁶ with a research question outlining “Why is there a disparity in the development of chronic wounds afflicting Aboriginal and Torres Strait Islander people?” and data were reported following the PRISMA-ScR guidelines.⁷

The search for relevant information was limited to peer-reviewed published articles and grey literature, written in English, to adequately address the research question. Electronic databases used included NCBI PubMed, Scopus, Health and Society, Australian government electronic databases, and the websites of the United Nations and the National Aboriginal Community Controlled Health Organisation. Key search terms and phrases included “Aboriginal and Torres Strait Islander people” or “Indigenous” and “diabetes”, “chronic wounds”, “non-healing wounds”, “impaired wound healing”, “diabetic foot ulcers”, or “diabetic foot”, and title and abstract review were undertaken by authors. All databases were searched from inception to ensure comprehensive coverage of the literature. Only studies reporting on chronic wounds or related complications in Aboriginal and Torres Strait Islander populations were included in this review. Both qualitative and quantitative studies were considered, with no restrictions on publication type, to capture a broad range of evidence.

Results

A total of 396 articles were identified through database searching, and 18 additional records were identified through other sources. After removal of duplicates and screening of titles and abstracts, 123 full-text articles were assessed for eligibility. Of these, 41 studies met the inclusion criteria and were included in this review. The process is summarised in the PRISMA flow diagram below (Figure 1).

 

Figure 1. PRISMA flow diagram of search and selection of articles and documents.

 

Overviewing the Australian census

The Australian government estimated in 2022 that nearly 420,000 Australians suffer from chronic wounds each year, with a 25% prevalence among people with DM and 85% of the cases of amputations related to DM.^8,9 Examining Aboriginal and Torres Strait Islander peoples, the risk of developing chronic wounds is five to six times higher, with a greater risk among people living in rural and remote communities.¹⁰ Additionally, studies also reported an independent association between Aboriginality and chronic wounds besides increased risk of progression to amputation.^11,12 Despite these estimates, information on the rates of chronic wound development in Aboriginal and Torres Strait Islander people remains limited and revisiting Australia’s population structure is fundamental to understanding downstream causes.

The most recent Australian Bureau of Statistics Census, with the reference period of 2021 and released in 2023, estimated that Aboriginal and Torres Strait Islander people represent 3.8% of the total Australian population, with one-third (33.1%) being under 15 years of age, a median age of 24 years and people aged 65 and over comprising only 5.4% of their population. This age structure significantly differs from their non-Indigenous counterparts, with 17.9% of people being under 15 years of age, and 17.2% aged 65 and over.¹³ The data collection identified that Aboriginal and Torres Strait Islander people’s life expectancy at birth averaged 8.5 years less than for their non-Indigenous counterparts, with a significant proportion of these lost years attributed to chronic disease-related complications and death. The correlation between decreased life expectancy to chronic disease is based on estimations by the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) and the National Health Survey (NHS), which determined that Aboriginal and Torres Strait Islander people are twice (15% versus 8.4%) and three times (7.9% versus 2.7%) as likely to report cardiovascular diseases (CVD) and DM than their non-Indigenous counterparts, respectively.^14,15 Non-communicable diseases such as DM and CVD are important downstream causes of chronic wound development and contribute to multiple negative health outcomes, including amputations and death.

Chronic wounds – downstream causes, negative outcomes

Among DM complications, chronic wounds are usually related to amputations — a major negative outcome — and death, carrying multifactorial underlying causes. The combination of DM and impaired perfusion due to CVD increases the risk of developing chronic wounds and amputations by 5–10 times compared to patients with DM alone.¹⁶ A study in Western Australia estimated that Aboriginal and Torres Strait Islander people are nearly 32.5 times more likely to undergo minor and major leg amputations than non-Indigenous Australians with DM, while 98% of amputations are DM-related, indicating a higher prevalence of negative outcomes among Aboriginal and Torres Strait Islander communities.^17,18 Importantly, Aboriginal and Torres Strait Islander communities have long drawn on cultural knowledge of healing, including traditional knowledge of would care and medicines provided for thousands of years. Also, our strong community networks have worked together to provide wound care for our people to support recovery and wellbeing, offering important strengths that are often overlooked by western knowledge systems, so here we present the available information captured in the western research model.

Factors that are known to be significantly associated with DM and CVD among Aboriginal and Torres Strait Islander people, and consequently contribute to chronic wound development, are obesity, dyslipidaemia and cigarette smoking.¹⁹ In 2019, the NATSIHS and the NHS reports revealed that 71% of Aboriginal and Torres Strait Islander people aged 15 and over and 37% aged 2–14 were overweight or obese, representing approximately 5.9% and 48% higher incidence than their non-Indigenous counterparts, respectively.^14,15 A significant disparity was also reported in cigarette smoking, with Aboriginal and Torres Strait Islander people being three times more likely to be daily smokers (43% of adult population) than non-Indigenous people (14% of adult population).^14,15 According to the Aboriginal and Torres Strait Islander Health Performance Framework (ATSIF), the smoking rates for Aboriginal and Torres Strait Islander people ranged from 29% in major cities to 58% in remote areas, with a proportion of 41% smokers (being 37% reported being a daily smoker), for people aged 15 and over, and 13% for adolescents aged 15-17.²⁰ Notwithstanding, nearly 56% of Aboriginal and Torres Strait Islander adults reported having a CVD-related chronic condition, which includes dyslipidaemia, compared to 22% of their counterparts, in 2023.²⁰

Multiple sociodemographic factors contribute to inequalities observed in the incidence of DM and CVD, chronic wounds and, ultimately, amputations. Among related demographic factors, or social determinants of health, nutrition and stress are important causes of health disparities. Estimates indicate that 15% of the health gap between Aboriginal and Torres Strait Islander people and their non-Indigenous counterparts is attributed to dietary factors.²¹ In this sense, a systematic review including 21 studies with data from Aboriginal and Torres Strait Islander people’s concerns and priorities related to food and nutrition exposed that lower-quality food, including fat and simple sugar-rich fast food, is more accessible and affordable than higher quality fresh food. The National Indigenous Australians Agency also reported that only 39% of Aboriginal and Torres Strait Islander people aged 15 and over ate the recommended daily amount of fruits, and 4.2% ate the recommended daily amount of vegetables.²² Notwithstanding, about one in five Aboriginal and Torres Strait Islander people self-reported having run out of food in the previous 12 months.²² This is sustained by multiple factors, including affordability, inadequate or insecure housing to safely prepare and store food, logistics and mobility issues.²³ In this sense, inadequate macro/micronutrients intake and imbalanced energy intake directly contribute to higher prevalence of obesity, DM, CVD, and its complications, including chronic wounds.^24,25

Importantly, stress is another factor impacting overall health and development of chronic conditions.²⁶ Colonisation employed profoundly detrimental practices that included war, ethnic and cultural genocide, environmental destruction, diseases, assimilation, persecution and extermination of social, cultural and spiritual practices that resulted in intergenerational trauma.^27-29 Studies indicate that intergenerational trauma and profound stress manifest through other risk factors including violence, incarceration, alcohol and cigarette misuse, depression, anxiety and self-harm, directly affecting overall health and risk of developing chronic conditions.^29-30 Nevertheless, such health inequities are perpetuated through significant barriers to accessing the healthcare system, which result in delayed diagnoses, fragmented care and poorer outcomes. These barriers are exacerbated by intergenerational trauma and marginalisation, discussed below. However, it is important to acknowledge that resilience and strength remain central in Aboriginal and Torres Strait Islander communities who actively engage in cultural renewal, community-led healing programs, language revitalisation and intergenerational knowledge-sharing that serve as protective factors for holistic health and wellbeing, countering the impacts of trauma and colonisation.

A summary of the main downstream factors affecting the development of chronic wounds in Aboriginal and Torres Strait Islander people compared to non-Indigenous Australians is presented in Figure 2.

 

Figure 2. Chronic wounds downstream factors: inefficient healthcare systems combined with trauma, genocide, dispossession and colonisation influencing the incidence of overweight/obesity, dyslipidaemia and cigarette smoking that consequently contribute to the development of diabetes mellitus (DM) and cardiovascular disease (CVD). Negative outcomes of chronic wounds include amputations and impact on life expectancy. Data shows the average of males and females combined. The grey colour displays non-Indigenous Australian data, and the green colour displays Aboriginal and Torres Strait Islander people data.

 

The healthcare system, inefficiency and initiatives to promote health equity

The healthcare system is based on a Western biomedical model worldwide, and that is not different in Australia. Studies indicate that the Western biomedical model holds unconscious bias that fails to consider and meet Aboriginal and Torres Strait Islander people’s holistic health and well-being paradigms. These paradigms, grounded in Country, spirituality, cultural identity and connection to the land, offer strengths-based approaches to health that remain under-recognised in mainstream practice. At the same time, distrust — generated by collective intergenerational trauma — is built towards the medical system, which significantly contributes to the disparities discussed here.³¹ Table 1 summarises the key studies outlining the health disparity in chronic wounds among Aboriginal and Torres Strait Islander people, identified in this review and summarised by topic.

 

Table 1. Key studies supporting health disparity in chronic wounds including Aboriginal and Torres Strait Islander people.

 

In 2019, nearly 30% of Aboriginal and Torres Strait Islander people reported needing but not accessing the healthcare system at least once due to varied reasons, including logistical issues, unavailable services, high costs and personal decisions, with such challenges being more pronounced in remote areas.²⁰ Significant barriers to aftercare are also faced, with causes including miscommunication, lack of cultural safety, treatments disconnected from Aboriginal and Torres Strait Island worldviews of holistic health and healing, healing practices that disregard community and Elder-led, co-designed models of care, besides racism.³³

Interestingly, despite significant barriers to accessing the healthcare system, a study showed that DM-related hospitalisation rates are 5.6 times higher for Aboriginal and Torres Strait Islander people nationwide than for their non-Indigenous counterparts.³⁴ In addition, over 50% of hospitalised patients of Aboriginal and Torres Strait Islander origin for treatment or management of chronic wounds are re-admitted within one year, reflecting ineffective discharge planning, regular wound care, and control of co-morbidities, including DM and hypercholesterolemia.³⁹ These observations may suggest limitations in accurately estimating the incidence and prevalence of chronic wounds and their related complications in this population, which might project even higher occurrences than recent estimations. In addition, this also reveals the inadequacy of biomedical-only models in addressing complex health needs that embed Aboriginal and Torres Strait Island people’s knowledges and self-determined health strategies that provide a viable pathway toward improving these outcomes.

Importantly, the clinical management of downstream causes encompassing DM, CVD, obesity and dyslipidaemia is insufficient, and therefore has been shown to significantly contribute to chronic wound development and potential negative outcomes. Besides control of downstream causes, results from an additional study also revealed that Aboriginal and Torres Strait Islander people also face significant barriers to obtaining timely and effective wound care, which significantly increases the risk of infection, prolonged healing times, and long-term complications such as hospitalisations, amputations and even death, outcomes related to poor management of chronic wounds.¹⁷

From the perspective of the Australian government, it is well recognised that considering cultural differences and needs is fundamental to implementing healthcare improvement strategies to ensure that Aboriginal and Torres Strait Islander people find a safe, accessible, culturally responsive healthcare system.³² Initiatives like the Aboriginal Community Controlled Health Organisations (ACCHO) encompass the work of 145 clinics at over 550 sites around the country under the operation of local Aboriginal and Torres Strait Islander leadership, essential to properly compose a health system that aims to provide accessible, holistic and culturally safe health services to Indigenous communities.^35-37 Studies reporting the impact and efficiency of these mobile clinics are still limited, but findings indicate that ACCHO is a promising model to address unique needs and help mitigate health disparities. One ACCHO alone provided 564 consultations and 75 new client registrations in the course of two years, supporting the need for ACCHO-led models to improve healthcare system accessibility.³⁸ The most recent National ACCHO report, published in 2023, showed a growth of more than 25% in the sector and 3.1 million episodes of care per year for about 410,000 people. These findings underscore the strength of community-led models in reducing inequities and advancing health equity.

Additionally, the International Working Group on Diabetic Foot (IWGDF) also provides global prevention recommendations on chronic wounds and was adapted to the Australian context to include unique geography, diversity, cultures, and healthcare settings in the country to attend Aboriginal and Torres Strait Islander people’s needs.^{40, 41} This is an important initiative that aims to deliver effective, equitable, culturally sensitive, and responsive healthcare, integrating Aboriginal and Torres Strait Island people’s knowledges, lived experiences, and community-led solutions . It represents a powerful step towards achieving health equity.

Limitations in the conception of this study include search limitations. Many articles/documents might not have been found in our search, and limited data availability may have reduced the number of scientific, large-scale studies included. The scarcity of studies may contribute to underreporting, misdiagnosis, and variability in reported outcomes. Additionally, cultural and contextual factors may not be fully captured in the existing literature, highlighting the need for research co-designed with communities and guided by cultural safety and data sovereignty principles.

In conclusion, there is still much to learn about chronic wound disparities between Aboriginal and Torres Strait Islander peoples and their non-Indigenous counterparts. Initiatives supporting both qualitative and quantitative research — focusing on wound care management, medical history, and short and long-term outcomes — are essential for developing effective therapeutic strategies tailored to unique communities. Expanding the ACCHO system to enhance healthcare system accessibility with local leadership offers a novel pathway to mitigating significant health disparities discussed. Additionally, the expansion of this model will further facilitate data collection and research. Co-designed methodologies, with Aboriginal and Torres Strait Islander data sovereignty principles and leadership, will provide a more solid cultural and scientific foundation for future strategies for better wound management of Aboriginal and Torres Strait Islander peoples. We believe that it is imperative that such strategies must foreground Aboriginal and Torres Strait Island peoples’ knowledge, cultural protective factors, self-determined solutions with community-led initiatives, recognising that living traditions are central to health and healing.

Conflict of interest

The authors declare no conflicts of interest.

Ethics statement

The authors confirm that the studies cited in the paper followed ethical guidelines, including informed consent for human participants.

Funding

The authors acknowledge contribution of Aboriginal and Torres Strait Islander communities to studies included in this review. ZK is supported by Mid-Career Fellowship from Channel 7 Children’s Research Foundation.

Author contributions

Conception JCS, ZK; drafting JCS, ZK; critical reviewing for intellectual content JCS, ZK, JC; final approval of the version to be published JCS, ZK, JC.

Author(s)

Jacqueline Cavalcante Silva*¹, James Charles², Zlatko Kopecki^1
1Future Industries Institute, University of South Australia, South Australia, Australia
²School of Health Science and Social Work, Faculty of Health, Griffith University

*Corresponding author email cavalcantejacque@gmail.com

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