2.13 Transport

Key facts

Why is it important?

Transport is a key enabler for access to health care, goods and services and supports for Aboriginal and Torres Strait Islander people to achieve education and employment outcomes and maintain cultural obligations to travel to family commitments (Helps et al. 2010; Ivers et al. 2016).

A lack of access to transport is experienced disproportionately by women, children, disabled people, people from minority ethnic groups, older people and people with low socioeconomic status, especially those living in remote rural areas, including Indigenous Australians (Acheson 1998).

Indigenous Australians are also over-represented in transport-related morbidity and mortality, such as road traffic accidents.

The reliability of transport options is also a critical barrier that Indigenous Australians face in accessing appropriate health care, along with logistics, distance and cost (see measure 3.14 Access to services compared with need).

Findings

What does the data tell us?

In the 2018–19 National Aboriginal and Torres Strait Islander Health Survey, 243,663 (30%) Indigenous Australians aged 15 and over reported they needed to go to a health provider in the last 12 months but did not. Of those, 13% reported transport/distance as the reason. For specific types of services, transport/distance was reported as a barrier for those needing to visit a hospital (12%), a doctor (14%), a dentist (10%), counsellors (10%) and other health professionals (9%) (See measure 3.14 Access to services compared with need) (Table D3.14.14).

In the 2014–15 National Aboriginal and Torres Strait Islander Social Survey (Social Survey), 75% (333,967) of Indigenous Australians aged 15 and over reported they could easily get to places when they needed to, an increase from 70% (197,862) in 2002. For non-Indigenous Australians, 84% (15,335,688) reported being easily able to get to places they needed to, which was the same proportion that was reported in 2002 (Table D2.13.5).

Indigenous Australians aged 15 and over were 9.1 times as likely as non-Indigenous Australians to report being unable to get to places they needed to/never going out/being housebound— 8.2% (36,529) compared with 0.9% (170,853) (Table D2.13.1, Figure 2.13.1).

Figure 2.13.1: Perceived ease/difficulty with transport, by Indigenous status, persons aged 15 and over, 2014–15

Source: Table D2.13.1. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Social Survey 2014–15 and General Social Survey 2014.

The ease with which people get around differs by age group. For Indigenous Australians aged 15–24, 70% (95,987) reported that they could easily get to places they needed to. The proportion rose to 79% (106,322) for those aged 45 and over (Table D2.13.1).

In 2014–15, the proportion of Indigenous Australians aged 15 and over who reported easily being able to get to places they need to was highest in New South Wales (81% or 112,086) and lowest in the Northern Territory (60% or 27,741) (Table D2.13.4, Figure 2.13.2).

Figure 2.13.2: Proportion of Indigenous Australians aged 15 and over who reported they were easily able to get to places when needed, by jurisdiction, 2014–15

Source: Table D2.13.4. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Social Survey 2014–15.

The proportion of Indigenous Australians able to easily get to places when needed was highest in both Major cities and Inner regional areas at 79% (122,559 and 75,469, respectively), decreasing to 61% (37,419) in Very remote areas (Table D2.13.3, Figure 2.13.3).

Figure 2.13.3: Proportion of Indigenous Australians aged 15 and over who reported they were easily able to get to places when needed, by remoteness, 2014–15

Source: Table D2.13.3. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Social Survey 2014–15.

In 2014–15, Indigenous Australians aged 15 and over were less likely to have access to a motor vehicle than non-Indigenous Australians (75% or 334,249, compared with 85% or 15,481,738, respectively). The gap was widest in Remote and Very remote areas combined, where 67% (64,365) of Indigenous Australians had access to a vehicle compared with 93% (170,348) of non-Indigenous Australians (Table D2.13.7, Figure 2.13.4). Those living in the Australian Capital Territory reported the highest rates of access to a vehicle (84% or 3,758) and those in the Northern Territory the lowest (66% or 30,702) (Table D2.13.8).

As expected, Indigenous Australians aged 15 and over who reported they could easily get to places they needed to were more likely to report having no problems accessing selected services (82%) in 2014–15. They were also more likely to report having no disability/long-term health condition (80%), to report low/moderate levels of psychological distress (82%) and to rate their health as excellent/very good/good (78%) than those who could not easily get to places they needed to (Table D2.13.6).

Figure 2.13.4: Proportion of persons aged 15 and over with access to a motor vehicle, by remoteness and Indigenous status, 2014–15

Source: Table D2.13.7. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Social Survey 2014–15 and General Social Survey 2014.

The Census of Population and Housing (Census) reports on the number of motor vehicles at private dwellings on census night. Results from the 2016 Census shows that there are more persons per vehicle at Indigenous households than at ‘Other’ households. At private dwellings, for Indigenous Australians aged 17 and over, there were 1.3 people per vehicle, compared with 1.1 people per vehicle for Other Australians (people who have declared they are non‑Indigenous and those whose Indigenous status is unknown) (Table D2.13.11).

In the 2014–15 Social Survey, 29% (129,187) of Indigenous Australians aged 15 and over reported having used public transport in the previous 2 weeks. Of those who hadn’t used it, 33% (104,503) lived in an area in which there was no public transport available (Tables D2.13.9, D2.13.10). For Indigenous Australians, the use of public transport was lower in Remote areas (13%, or 12,790) than in Non-remote areas (34%, or 116,232) (Table D2.13.9).

In 2017–18, transport services were provided to clients by 86% (331) of Commonwealth-funded Indigenous primary health care services, which accounted for 7.8% (474,721) of client contacts (AIHW 2019a).

What do research and evaluations tell us?

Studies have shown an endemic lack of licensing access for Indigenous Australians related to financial hardship, unmet cultural needs and an inequitable system, resulting in a barrier to social inclusion that Indigenous Australians frequently encounter (Cullen Patricia et al. 2016b).

Driving without a license for Indigenous Australians has been linked to increased risk of transport-related injury and unsafe transport behaviours (Clapham et al. 2017).

An evaluation of the DriveSafe Northern Territory Remote driver-licensing program found that while public transportation may compensate for the lack of private transport in Non-remote areas, a higher proportion of Indigenous Australians in both Remote and Non-remote areas have less access to a motor vehicle compared with non-Indigenous Australians. Indigenous Australians also experience barriers to obtaining a driver’s licence, including financial hardship; literacy and language issues; identification requirements; the need to practise driving which requires access to a car and access to an experienced driver, and being able to afford petrol; and cyclical defaults on traffic fines (Cullen P. et al. 2016a).

Research has found that 35% of Indigenous Australians were subjected to racism while using public transport (Ferdinand et al. 2012). This, along with the availability of public transport, impedes access to services.

Studies show that limited or no public transport options significantly affects the capacity to access specialist health care, particularly for patients with chronic health conditions (Teng et al. 2014) or for expectant mothers requiring birthing services (Parker et al. 2014) and in rural and remote areas (AIHW 2019b; Kelly et al. 2014).

The literature provides information on the barriers to accessing health services faced by Indigenous Australians living in urban and regional communities. These barriers can be categorised as obstacles of availability (including physical accessibility such as lack of transport); affordability, appropriateness and cultural acceptability (Ware 2013). While transport is a key enabler of access to health services, it also poses risks to health if the mode of transport is unsafe, such as if the vehicle is not in good working order or if the driver is under the influence of alcohol or drugs (Fitts et al. 2013; Symons et al. 2012).

A review of the relationship between transport and disadvantage in Australia showed how transport and disadvantage intersect and why some groups are especially vulnerable to transport disadvantage, including Indigenous Australians. The review highlighted that transport options for Indigenous Australians in remote communities and communities located in fringe urban areas are limited. It also showed that a significant proportion of Indigenous Australians living in remote areas have no access to public transport and one-third have no access to a car. It noted that for those cars that are available in remote Indigenous communities, they are heavily used, and because they are often purchased second hand and used in rough terrain, maintenance is expensive and they often have a short lifespan. The review also found that similarly, in non-remote locations, car access may be a concern for Indigenous Australians who typically have much lower access rates than non-Indigenous Australians. Furthermore, in Non-remote areas, 18% reported having no public transport and 2% were unable to reach places when needed (ABS 2010; Rosier & McDonald 2011).

Many Indigenous Australians live in Remote areas where they strive to maintain their communities and cultural traditions. Consequently, health services and other infrastructure can be limited, and they face significant transport and access challenges. Many patients requiring regular dialysis treatment must relocate to where treatment is accessible. The South Australian Mobile Dialysis Truck facilitates patients who have relocated to return to their community for short periods while continuing treatment. A recent qualitative evaluation of the dialysis truck explored the impact on the health and wellbeing of Indigenous dialysis patients, and the facilitators and barriers to using the service.

• The rates of End-Stage Kidney Disease (ESKD) among Indigenous Australians in remote areas are very high; however, haemodialysis is often not available in these areas. Dialysis patients must therefore leave their Country (with its traditions and supports) and relocate to metropolitan or regional centres (for dialysis 3 times per week), disrupting their kinship and the cultural ties that are important for their wellbeing. The South Australian Mobile Dialysis Truck is a service that visits remote communities for 1 to 2 week periods; allowing patients to return to ‘Country’, while continuing treatment. This reunites patients with their friends and family, and provides a chance to take part in cultural activities.
• The evaluation illustrated how a mobile health delivery strategy can improve the social and emotional wellbeing of Indigenous ESKD patients who have had to relocate for dialysis, and build positive relationships and trust between metropolitan nurses and remote patients. This trust fostered improved engagement with associated health services, which has significant clinical implications. The dialysis truck was consistently reported as having a positive impact on patients, providing them with an opportunity to return home to participate in Country and culture and spend time with family, and alleviating the pain and grief from separation and displacement. The dialysis truck was also shown to be beneficial to non-Indigenous nurses in terms of cultural knowledge and competency, including learning from their patients.
• Recommendations arising from the evaluation were directed at modifying barriers noted by staff and patients towards the success of trips by the dialysis truck. This includes the arrangement of appropriate transport and accommodation for patients that need it.
• The evaluation noted that potential areas for future research could include collecting data from patients who had not been on trips, to elicit their experiences and compare data on quality of life. Quantitative data could also be sought on hospital admissions and Royal Flying Doctor Service retrievals, as the evaluation suggested that these are reduced in the presence of the dialysis truck (Conway et al. 2018).

Implications

Patient transport assistance designed to assist patients with chronic illnesses to access health care on a regular basis is an important aspect of health service delivery. This is particularly the case for Indigenous households where private and public transport options are often restricted. Patient transport assistance is provided by voluntary groups, Aboriginal Community Controlled Health Organisations, hospitals and ambulance services. Further research is required into the effectiveness and efficiency of this transport assistance.

Schemes to assist patients with travel and associated accommodation are operating in various jurisdictions. An evaluation of the effectiveness and efficiency of these schemes is required.

Other approaches to providing medical care have also been adopted to alleviate poor access to health care as a result of distance and lack of transport, such as support for specialist services flying into remote localities.

More research is required into the various barriers to accessing appropriate health care including the reliability of transport options. This will hopefully lead to further understanding of how this challenge has a broader  influence on the social and economic circumstances of both health service users who need to travel significant distances while unwell, and on carers who support attendance at services for antenatal care, young children, people with a disability, or people suffering from chronic health conditions, mental health or substance use issues (Lee et al. 2014).

Culturally secure transport can assist Indigenous Australians in accessing health services that are far from home. Additionally, services provided closer to home, in possibly non-standard settings or providing some services through home visitation, can also improve access (Ware 2013).

Although research and documented practice wisdom can suggest strategies to improve access to health care, including transport options, individual service providers need to consider what will best meet the needs of their clients. Community and client engagement is needed to understand what barriers clients face in accessing health care so these can be addressed at the local level (Ware 2013).

More research is required into the complex relationship between transport and disadvantage in Australia, including the relationship between transport difficulty and social disadvantage of Indigenous Australians (Rosier & McDonald 2011).

Hospitalisation and deaths due to injuries from transport accidents also remain a concern (see measure 1.03 Injury and poisoning).

The policy context is at Policies and strategies.

References

• ABS (Australian Bureau of Statistics) 2010. The health and welfare of Aboriginal and Torres Strait Islander Peoples 2010. Canberra.
• Acheson D 1998. Independent inquiry into inequalities in health: report. HM Stationery Office.
• AIHW (Australian Institute of Health and Welfare) 2019a. Aboriginal and Torres Strait Islander health organisations: Online Services Report—key results 2017–18. Aboriginal and Torres Strait Islander health services web report. Cat. no. IHW 212. . Canberra: AIHW.
• AIHW 2019b. Rural and remote health Cat. no. PHE 255. Web report, Canberra: Australian Institute of Health and Welfare.
• Clapham K, Hunter K, Cullen P, Helps Y, Senserrick T, Byrne J et al. 2017. Addressing the barriers to driver licensing for Aboriginal people in New South Wales and South Australia. Australian and New Zealand journal of public health 41:280-6.
• Conway J, Lawn S, Crail S & McDonald S 2018. Indigenous patient experiences of returning to country: a qualitative evaluation on the Country Health SA Dialysis bus. BMC health services research 18:1010.
• Cullen P, Chevalier A, Byrne J, Hunter K, Gadsde T & Ivers R 2016a. ‘It’s exactly what we needed’: A process evaluation of the DriveSafe NT Remote driver licensing program. Canberra, Australia.
• Cullen P, Clapham K, Hunter K, Treacy R & Ivers R 2016b. Challenges to driver licensing participation for Aboriginal people in Australia: a systematic review of the literature. International Journal for Equity in Health 15:134.
• Ferdinand A, Paradies Y & Kelaher M 2012. Mental Health Impacts of Racial Discrimination in Victorian Aboriginal Communities: The Localities Embracing and Accepting Diversity (LEAD) Experiences of Racism Survey. Melbourne: The Lowitja Institute.
• Fitts MS, Palk GR & Jacups SP 2013. Alcohol restrictions and drink driving in remote Indigenous communities in Queensland, Australia. Montreal, Canada.
• Helps Y, Moodie D & Warman G 2010. Aboriginal People Travelling Well: Community Report. Melbourne: The Lowitja Institute.
• Ivers RQ, Hunter K, Clapham K, Helps Y, Senserrick T, Byrne J et al. 2016. Driver licensing: descriptive epidemiology of a social determinant of Aboriginal and Torres Strait Islander health. Australian & New Zealand Journal of Public Health 40:377-82.
• Kelly J, Dwyer J, Willis E & Pekarsky B 2014. Travelling to the city for hospital care: access factors in country Aboriginal patient journeys. Australian Journal of Rural Health 22:109-13.
• Lee KS, Harrison K, Mills K & Conigrave KM 2014. Needs of Aboriginal Australian women with comorbid mental and alcohol and other drug use disorders. Drug & Alcohol Review 33:473-81.
• Parker S, McKinnon L & Kruske S 2014. 'Choice, culture and confidence': key findings from the 2012 having a baby in Queensland Aboriginal and Torres Strait Islander survey. BMC health services research 14:196.
• Rosier K & McDonald M 2011. The relationship between transport and disadvantage in Australia. Communities and Families Clearinghouse Australia Resource sheet.
• Symons M, Gray D, Chikritzhs T, Skov SJ, Saggers S, Boffa J et al. 2012. A longitudinal study of influences on alcohol consumption and related harm in Central Australia: With a particular emphasis on the role of price. Perth: NDRI.
• Teng THK, Katzenellenbogen JM, Hung J, Knuiman M, Sanfilippo FM, Geelhoed E et al. 2014. Rural–urban differentials in 30-day and 1-year mortality following first-ever heart failure hospitalisation in Western Australia: a population-based study using data linkage. BMJ Open 4:e004724.
• Ware VA 2013. Improving the accessibility of health services in urban and regional settings for Indigenous people.  (ed., Australian Institute of Health and Welfare & Australian Institute of Family Studies). Canberra: Closing the Gap Clearinghouse.