Public health and Indigenous eye health: more work to be done in optometry

Optometrists have not only a critical role to play but also a responsibility to contribute to public health and to the specific health needs of Indigenous peoples, as highlighted in the Australian Health Practitioner Regulation Agency shared ‘Code of Conduct’.¹ The term ‘Indigenous’ is respectfully used in this editorial to refer to Aboriginal, Torres Strait Islander and Māori peoples collectively. Aboriginal and Torres Strait Islander or Māori will be used when referring to the First Nations people of Australia or Aotearoa New Zealand, respectively.

This special issue, the first of its kind in Clinical and Experimental Optometry, was conceived to reflect contemporary evidence in public health and Indigenous eye health, particularly to explore culturally safe eye care practices, to challenge existing models of eye care delivery and to showcase initiatives based on strengths rather than deficits.

The number of contributions has exceeded expectations, reflecting the growing importance of these fields in optometry. Moreover, several Indigenous scholars, researchers and community partners have led, co-authored and played significant roles in many of the papers presented in this special issue. We acknowledge, deeply respect and appreciate their invaluable contributions, and it is worth considering that some journals now undertake to ‘publish nothing about Indigenous Peoples, without Indigenous Peoples’.²

Understanding the perspectives of Indigenous consumers of eye care should be central to optometry addressing the well-documented and unacceptable inequities in eye health. In this issue, Samuels et al.³ report on insights from Māori community members and eye care practitioners. Key priorities for Māori include the right to cultural safety within clinical settings, the right to accurate and pertinent communication of information, respect for cultural beliefs and acknowledgment of power imbalances within the health-care system.

Significant improvements in access to culturally safe eye care and acknowledgment of the impacts of colonisation, systemic racism and social, cultural, behavioural and economic factors on eye health are overdue in optometry. A starting point is educating the profession. It is now mandatory for cultural safety and Indigenous health to be included in optometry education programmes.⁴ To support programmes, the Optometry Council of Australia and New Zealand (OCANZ) has developed the ‘Optometry Aboriginal and Torres Strait Islander Health Curriculum Framework’⁵ and is developing a Māori framework.

The heads of optometry programmes in Australia and Aotearoa New Zealand, along with Indigenous Allied Health Australia and Ngā Pou Mana, have established the ‘Leaders in Indigenous Optometry Education Network’ (LIOEN) to support educators delivering the curriculum and to drive recruitment and graduation of Indigenous students in optometry.⁶ In this special issue, Anstice et al.⁷ describe how optometry education programmes in Australia and Aotearoa New Zealand have commenced integrating Indigenous health into curricula. For example, helping students learn Indigenous history and context through on-country experiences with Aboriginal Elders, helping students understand about privilege and providing clinical placement opportunities co-designed with Indigenous communities.

However, there are challenges. Although this should be the work of all academics working as allies with Indigenous people, Pecar et al.⁸ provide evidence that there are few academics in optometry who are experienced in this curriculum, many non-Indigenous academics lack confidence and fear being unintentionally culturally unsafe and Indigenous academics are overburdened. University systems need to change, more resources are needed and much more work needs to be done to develop optometrists who provide culturally safe care, encourage Indigenous students to enter optometry programmes and support them to succeed and to eliminate racism both within and beyond the curriculum.

Watene et al.,⁹ representing the OCANZ Indigenous Strategy Taskforce, offer further views on developing a culturally safe optometry workforce. It is suggested that the profession needs to change, not only individual optometrists. As the organisation that establishes accreditation standards and assesses optometry programmes in Australia and Aotearoa New Zealand, OCANZ has demonstrated leadership and commitment to cultural safety by establishing a task force, raising Indigenous voices through appointing an Indigenous Co-Chair and Deputy-Chair of the task force, appointing an Indigenous Board Director, implementing a cultural safety training policy for OCANZ Directors and staff, adding a standalone domain on cultural safety to entry-level accreditation standards and hosting cultural safety workshops for optometry education programmes.

Watene et al.⁹ also remind us that the very small number of optometrists who are Indigenous (less than 0.2% in Australia and 1.6% in Aotearoa New Zealand) should not be burdened with the work that needs to be done as, ‘Expecting the Indigenous practitioner to be the advocate for all First Nations Peoples and rights, once again makes First Nations Peoples responsible for fixing the inequities imposed upon them and their ancestors’.

Optometry Australia has also demonstrated a commitment to promoting cultural safety through its Reconciliation Action Plan, an Aboriginal and Torres Strait Islander Eye Health Advisory Group and providing opportunities for continuing professional development. In this issue, Members of the Optometry Australia Aboriginal and Torres Strait Islander Eye Health Advisory Group share lessons learned from delivering eye care services to communities during the COVID-19 pandemic.⁹ With disruption to face-to-face service delivery, other models of eye care were implemented to meet community needs, including telehealth. Estevez et al.¹⁰ observe that effective models were underpinned by establishing relationships, consistent communication, local eye health coordinators, and community-led or co-designed responses, all long-standing recommendations prior to the pandemic. Lam et al.¹¹ also argue that training local coordinators and local health workers could improve inadequate rates of diabetes eye health screening in the Northern Territory of Australia.

Inadequate and inequitable access to eye care is not unique to Australia. In this issue, Ramke et al.¹² provide data showing that people living in areas of high deprivation in Aotearoa New Zealand have longer distances to travel to access eye care services compared with people living in other areas. Black et al.¹³ describe an initiative of the School of Optometry and Vision Science, University of Auckland, not only intended to provide more equitable access to affordable eye care through a mobile service (Aotearoa Vision Bus) but also intended to provide training for optometry students, promote the profession of optometry to Māori communities, strengthen community partnerships and conduct research needed to inform future service delivery.

Lessons from the Lions Outback Vision service – a model addressing inequities in remote Western Australia for more than a decade – are explored by Chia and Turner.¹⁴ The model includes telehealth and collaboration between ophthalmologists and visiting optometrists. Factors that have enabled this model include a focus on coordination of services (through Rural Eye Health Coordinators), engagement with government funding agencies to align financial incentives and reducing barriers to telehealth through service design (e.g., on-call teleophthalmology services to complement scheduled appointments), health promotion and support initiatives.

Chia and Turner¹⁴ make the case that optometrist-facilitated collaborative care models can be applied in urban areas to address long waitlists for ophthalmology services. Such models are well established internationally, and there are some examples of glaucoma and diabetes clinics in Australia demonstrating reduced waitlists and costs. Likewise, Webber et al. report on a model of collaborative care between a children’s hospital ophthalmology department and community-based optometrists – the Paediatric Optometry Alignment Program – which has led to reduced hospital waiting times.¹⁵

However, scaling collaborative models is complex. In this issue, Maurin et al.¹⁶ argue that current public funding in Australia is insufficient to justify the business case for private optometry practice providing collaborative glaucoma care. Inadequate remuneration is just one of the many barriers that can thwart translation of evidence into clinical practice. Although there are individual practitioners behaviours that might require modification, optometrists also need a supportive work environment and a positive organisational culture.

Also presented in this issue is research relevant to eye care services for children. Early detection and prevention of vision problems in children are imperative to optimise learning and mitigate potentially life-long negative impacts of vision impairment. Improved community-led eye care service models are especially needed for Indigenous children. In this issue, Cox et al.¹⁷ provide the first insights into ocular biometry and emmetropisation in Aboriginal and/or Torres Strait Islander children and non-Indigenous Australian children in a rural location. Additionally, Read et al.¹⁸ present data that one in three Indigenous children living in a very remote location of Australia has vision problems and that the rates of previous eye examination are as low as 10%.

The solution is not as simple as vision screening. Gordon-Shaag et al.¹⁹ present data from vision screenings for preschool children in Israel indicating that only half of parents proceed with full eye examinations where recommended. The situation is likely to be worse in communities where there may not be regular eye care services available.

Optometry must stand up and take responsibility for the right of all people to have access to culturally safe health services. This special issue highlights there is much momentum, with multiple strength-based initiatives and approaches designed to improve access to culturally safe eye care services. However, there is more work to be done. First and foremost, we must do more to develop meaningful reciprocal relationships, where how inequities in Indigenous eye health are tackled is self-determined (tino rangatiratanga) by Indigenous partners. Likewise, we must put consumers and communities at the heart of all efforts to resolve public health needs in eye care.

Disclosure statement

No potential conflict of interest was reported by the authors.