Community attitudes and Indigenous health disparities: evidence from Australia's Voice referendum

Background: Community attitudes influence health outcomes especially for racially diverse and minority groups exposed to the detrimental effects of racism and discrimination. Using the results from Australia's national referendum to establish an Aboriginal and Torres Strait Islander Voice to Parliament ('the Voice') as a proxy for attitudes to Indigenous Australians, this study examined health outcomes for Indigenous and non-Indigenous Australians according to levels of opposition to the Voice.

Methods: The regional share of votes against the Voice was linked to 2021 data from the Household, Income and Labour Dynamics in Australia survey, a large, national probability sample (n∽17,000) of Australian adults. Adjusting for regional-level confounders, we used logistic regression analyses to predict health outcomes, healthcare use, and risk-taking behaviours among Indigenous and non-Indigenous Australians for different levels (quartiles) of opposition to the Voice.

Findings: Greater opposition to the Voice was associated with widening Indigenous disparities in health, healthcare use, and health behaviours. Indigenous Australians living in regions with the highest opposition to the Voice (top quartile: $\ge$ 72% community voting 'No') were more likely to report fair/poor health [OR 2.28 (95% CI 1.45-3.58)] and poor mental health [OR 2.24 (95% CI 1.48-3.39)], were less likely to have visited any healthcare provider [OR 0.52 (95% CI 0.36-0.75)], and were more likely to smoke [OR 4.21 (95% CI 2.78-6.38)] or engage in risky drinking [OR 2.66 (95% CI 1.60-4.43)] relative to non-Indigenous Australians.

Interpretation: Indigenous Australians living in communities with greater opposition to the Voice experience poorer health relative to non-Indigenous Australians. Disparities in health may be partially due to poorer healthcare access and increased risk-taking behaviours, which may be associated with racism. These findings align with discrimination-related stress processes and potentially reduced availability of culturally inclusive healthcare. Health and social policy should consider how broader societal level conditions shape Indigenous health disparities in Australia.

Funding: This work is supported by the Australian Research Council (project ID FT200100630), the University of Melbourne Faculty Research Grant, and the National Health and Medical Research Council of Australia Investigator Grant (project ID 1201937).