摘要：The pattern of association between socioeconomic factors and health outcomes has primarily depicted better health for those who are higher in the social hierarchy. Although this is a ubiquitous finding in the health literature, little is known about the interplay between these factors among indigenous populations. We begin to bridge this knowledge gap by assessing evidence on social gradients in indigenous health in Australia. We reveal a less universal and less consistent socioeconomic status patterning in health among Indigenous Australians, and discuss the plausibility of unique historical circumstances and social and cultural characteristics in explaining these patterns. A more robust evidence base in this field is fundamental to processes that aim to reduce the pervasive disparities between indigenous and nonindigenous population health. It is an almost universal truth that indigenous peoples of the world have poorer health than their nonindigenous counterparts. 1,2 Although a lack of high-quality data limits an accurate assessment of the health disparities between indigenous and nonindigenous populations in many countries, 3 the disparities in Australia, for example, are well documented and striking. 4,5 Life expectancy for Australian Aboriginal peoples is between 11 and 14 years lower than that for non-Aboriginal people, 6 a signal that indigenous health problems in Australia are pervasive and potentially worse than those of indigenous populations in other developed countries. 7–10 A recent study highlights that socioeconomic variables (such as weekly cash income, source of cash income, and completed years of schooling) explain between one third and one half of the gap in self-assessed health status between Australian Aboriginal and non-Aboriginal people. 11 Although socioeconomic factors assume some significance in explaining these health disparities, they do not necessarily account for health differences within indigenous population groups. The relationship between social factors and health has been discussed and acknowledged for centuries. 12 There is now a robust international literature that supports the notion that health inequities are the result of factors and processes that fall outside of the conventional domains of health. They are heavily influenced by the structures of society and the social conditions in which people grow, live, work, and age—or what are now popularly known as the social determinants of health. 13 The pattern of association between social class (or status) and health is typically characterized by poorer health for those at lower levels of the social hierarchy 14,15 —that is, health outcomes follow a social gradient. Importantly, social gradients reflect more than differences between the high and low ends of the distribution—at any point along this continuum, people will tend to have poorer health than those above them. This observation is not limited to a subset of measures, but extends to most measurable socioeconomic constructs (such as poverty, employment, occupational status, education, housing, and income) 13 and across a range of health outcomes (including most aspects of physical and mental health). 14,16 Despite the ubiquity of these observations, providing an explanation for the social gradient has proven to be a challenge. 17 Researchers continue to shed light on the pathways to disease and poor health and how these can differ between population groups. In particular, there is growing understanding of how psychosocial factors and the social environment (in addition to poor material conditions and health-related behaviors) can affect physical and mental health and resultant longevity. 13,18 Krieger outlines 3 causal frameworks that underpin the relationship between social inequalities and health outcomes each with a different emphasis on social and biological factors. 19 Psychosocial theories focus primarily on factors in the social environment that influence susceptibility to disease and illness; they point to stress as the link between lower perceived social standing and behaviors and choices that pose risks to health. 20 Theories of the social production of disease place greater emphasis on economic and political determinants in which the most important influences on health tend to be more distal factors that shape material well-being and principally have an indirect effect on health outcomes. Ecosocial theories and frameworks attempt to integrate theories of the social production of disease with biological explanations of disease by considering the dynamic interrelationship among social, biological, and ecological attributes and their joint and cumulative impact on health. 19 Although social gradients are clearly implicated in these theories and frameworks, no single theory accounts for the graded relationship between socioeconomic status (SES) and health. 21
