Social Science & Medicine 284 (2021) 114230 Available online 16 July 2021 0277-9536/© 2021 Elsevier Ltd. All rights reserved. Re-examining the gap: A critical realist analysis of eye health inequity among Aboriginal and Torres Strait Islander Australians Aryati Yashadhana a, b, c, d, * , Ted Fields a , Anthea Burnett a, e , Anthony B. Zwi c a Vision Cooperative Research Centre, Sydney, Australia b Centre for Health Equity Training Research & Evaluation (CHETRE), UNSW, Australia c School of Social Sciences, UNSW, Australia d Ingham Institute for Applied Medical Research, Australia e School of Optometry & Vision Science, UNSW, Australia A R T I C L E INFO Keywords: Aboriginal health Culture Eye health Equity Diabetes ABSTRACT The prevalence of diabetes among Aboriginal and Torres Strait Islander (hereafter ‘Aboriginal’) Australians is three times greater than non-Aboriginal Australians, contributing to a greater risk of blindness from treatable and preventable ocular conditions, most prominently cataract and diabetic retinopathy. In rural and remote Aboriginal communities, blindness prevalence is higher, and ocular treatment coverage and uptake are lower. In collaboration with Aboriginal Community Based Researchers (CBRs), this study explored complex contingent factors that shape access to eye health services among rural and remote Aboriginal Australians living with diabetes. Interviews (n = 126) and focus groups (n = 12) were conducted with patients, primary care clinicians, and CBRs, in four rural communities in the Northern Territory and New South Wales. Factors internal and external to health systems were examined, drawing on Bourdieu’s concepts of habitus, and doxa to understand agency and decision-making among patients and clinicians. The study used the ontology of critical realism, categorising contingent factors as underlying structures (generative mechanisms), and applying a decolonising approach that centred causal relationships and tensions between dominant (Western biomedical neoliberalism) and non-dominant (Aboriginal) value systems. Three forms of marginalisation; linguistic, economic, and cultural, were identifed as the generative mechanisms that inhibit equitable eye health outcomes. Marginality is linked to structural factors that position Aboriginal culture as a barrier, and is reinforced through biomedical health systems, and the agents who operate in and infuence them. In order to address eye health inequity, a shift in how Aboriginal cultural sovereignty is understood within health systems is needed, to position it as a strength that can facilitate eye care accessibility, and to support enhanced cultural responsivity among clinicians and service providers. 1. Introduction The Lancet Global Health Commission on Global Eye Health (Burton et al., 2021) outlined ‘access and equity’ as one of the grand challenges in global eye health; highlighting the need for increased efforts to develop and implement services that prioritise Indigenous peoples and those living in rural and remote communities. In Australia, eye health inequity is refected in prevalence rates of vision impairment and blindness, which are three times higher among Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Aboriginal) Austra- lians when compared to non-Aboriginal Australians, with 90% of con- ditions being preventable or treatable (Foreman et al., 2016). The difference in health and socioeconomic outcomes between Aboriginal and non-Aboriginal Australians, is often referred to as ‘the gap’. History plays an important role in understanding the social and cultural gradient that shapes health inequities faced by Aboriginal peoples. It is important to acknowledge that the ongoing dispossession of Aboriginal peoples from ancestral lands, food sources, cultural sys- tems, languages, and families, continues to shape health outcomes. Ef- forts to close the gap are founded in the reasoning that when the biomedical outcomes of Aboriginal Australians match their non- Aboriginal counterparts, equity has been achieved. It is now widely recognised that closing the gap, requires attention, not only to biomedical outcomes such as the presence or absence of disease and * Corresponding author. Centre for Health Equity Training Research & Evaluation 1 Campbell Street, Liverpool, NSW, Australia. E-mail address: a.yashadhana@unsw.edu.au (A. Yashadhana). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed https://doi.org/10.1016/j.socscimed.2021.114230 Received 19 March 2021; Received in revised form 18 June 2021; Accepted 13 July 2021