To what extent could eliminating racial discrimination reduce inequities in mental health and sleep problems among Aboriginal and Torres Strait Islander children?

BackgroundRacism is a fundamental cause of health inequities for Aboriginal and Torres Strait Islander children. We aimed to examine the potential to reduce inequities in Aboriginal and Torres Strait Islander childrens mental health and sleep problems through eliminating interpersonal racial discrimination. MethodsWe drew on cross-sectional data from the Speak Out Against Racism (SOAR; N=2818) and longitudinal data from the Longitudinal Study of Australian Children (LSAC; N=8627). The SOAR survey was completed in 2017 and the LSAC followed children from 2004 to 2014 in the kindergarten cohort and from 2008 to 2018 in the birth cohort. Exposure was measured by Aboriginal and Torres Strait Islander status (Aboriginal and Torres Strait Islander or Anglo-European), as a proxy measure of structural racism (SOAR: 10-15 years; LSAC: 4-5 years). Mediator was measured by interpersonal racial discrimination (yes/no) (SOAR: 10-15 years; LSAC: 12-13 years). Outcomes were measured by mental health problems (yes/no) and sleep problems (yes/no) (SOAR: 10-15 years; LSAC: 14-15 years). An interventional effects approach was conducted, adjusting for baseline and intermediate confounders. FindingsAboriginal and Torres Strait Islander children had higher prevalence of mental health problems (SOAR: 40.1% versus 13.5%; LSAC: 25.3% versus 7.6%) and sleep problems (SOAR: 28.5% versus 18.4%; LSAC: 14.0% versus 9.9%) than their Anglo-European peers. Hypothetical interventions to eliminate Aboriginal and Torres Strait Islander childrens experiences of interpersonal racial discrimination could reduce up to 42.4% of mental health inequities (equivalent to 11.2% absolute reduction) and up to 48.5% of sleep inequities (equivalent to 4.7% absolute reduction). InterpretationTargeted policy interventions that eliminate racial discrimination against Aboriginal and Torres Strait Islander children have high potential to reduce inequities in mental health and sleep problems. Addressing racism and racial discrimination needs a multi-component and multi-level approach directed by Aboriginal and Torres Strait Islander communities. FundingNational Health and Medical Research Council of Australia RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSWe searched four databases (Medline, PsycINFO, PubMed, and ERIC) via The University of Melbourne Library on 05, October 2023, for all publications since inception that used the interventional effects approach to quantify the extent to which intervening on racial discrimination could reduce disparities in health and wellbeing outcomes between Indigenous and non-Indigenous populations worldwide. This search did not identify any published studies, so we broadened our search to include studies with any population using a refined list of search terms: ("racism") AND (("interventional effects") OR ("causal mediation")) AND (("health") OR ("wellbeing")). This search yielded a total of six studies, with all studies using causal mediation analysis to investigate racial and ethnic disparities (e.g., Black-White, Asian-White, Hispanic-White) in a range of health outcomes including mortality, preterm birth, substance misuse, and dementia among US adults. Mediators examined included hospital type, maternal cardiometabolic risk factors, area deprivation index, psychological distress, racial discrimination in medical settings, and systemic inflammation, with the proportion mediated ranging from 1.5% to 65.8%. However, no studies were identified that investigated the role of interpersonal racial discrimination in mediating racial and ethnic disparities in health among children. Added value of this studyThis study is the first to use an interventional effects approach to estimate the extent to which intervening on interpersonal racial discrimination could reduce inequities in mental health and sleep problems among Aboriginal and Torres Strait Islander children. We used both cross-sectional and longitudinal surveys to examine our research question, allowing us to explore common developmental associations within different samples across different study designs. We found that eliminating everyday experiences of racial discrimination could reduce almost half of the inequities in mental health (up to 42.4%) and sleep difficulties (up to 48.5%) experienced by Aboriginal and Torres Strait Islander children compared to their Anglo-European peers. Implications of all the available evidenceOur findings confirm the well-established relationship between exposure to racism and poor mental health and sleep problems among Aboriginal and Torres Strait Islander children. The consistent benefit observed across cross-sectional and longitudinal studies suggests that targeted policy interventions that eliminate interpersonal racial discrimination have high potential to reduce inequities in mental health and sleep problems experienced by Aboriginal and Torres Strait Islander children. Critically, interpersonal racial discrimination is only one expression of the wider system of racism that impacts Aboriginal and Torres Strait Islander children. Multi-component and multi-level anti-racism actions directed by Aboriginal and Torres Strait Islander communities are needed to address racism in all its forms to achieve health equity and to realise fundamental human rights.