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7.0 Introduction

While there have been improvements in the health and wellbeing of Aboriginal and Torres Strait Islander Australians in recent years, some long-standing challenges remain. (To acknowledge the separate Indigenous peoples of Australia, the term 'Aboriginal and Torres Strait Islander people' is preferred in AIHW publications—however, the term 'Indigenous' is used interchangeably when referring to Indigenous status or when it assists readability.) Across many indicators, Indigenous Australians remain disadvantaged compared with non-Indigenous Australians.

Many factors contribute to the gap between Indigenous and non-Indigenous health. Social disadvantage, such as lower education and employment rates, is a factor, as well as higher smoking rates, poor nutrition, physical inactivity and poor access to health services.

This chapter presents information on the characteristics and health status of the Indigenous population, including their self-assessed health, common long-term health conditions, life expectancy and death rates. Corresponding results for the non-Indigenous population are included.

Information is also presented on health behaviours, social determinants of health and access to health services specific to the Indigenous population.

The feature articles in the chapter focus on interactions among various groups of factors that affect the health of Indigenous Australians:

  • 'Remoteness and the health of Indigenous Australians' explores the impact of remoteness on Indigenous health in the context of risk factors, health conditions and service use.
  • 'The size and causes of the Indigenous health gap' analyses Indigenous health outcomes to determine the effect of social and behavioural factors on the health gap, and the extent to which individual factors contribute to the gap.

7.1 Profile of Indigenous Australia

Aboriginal and Torres Strait Islander people (Indigenous Australians) are the Indigenous people of Australia. They live in all parts of the nation, from major cities to remote tropical coasts and the fringes of the central deserts. They are not 1 group, but comprise hundreds of groups that have their own distinct set of languages, histories and cultural traditions.

Indigenous Australians can be of Aboriginal origin, Torres Strait Islander origin, or both. The Australian Government defines Indigenous Australians as people who are of Aboriginal or Torres Strait Islander descent, who identify as being of Aboriginal or Torres Strait Islander origin and who are accepted as such in the communities in which they live, or have lived. In most data collections, a person's Indigenous status is based on the first 2 parts of the definition.

How many Indigenous Australians are there?

  • Australia's Indigenous population was estimated to be 669,900 people in 2011, which was 3% of the total population (ABS 2013).
  • In 2011, 90% of Indigenous Australians identified as being of Aboriginal origin only, 6% as Torres Strait Islander origin only, and 4% as both Aboriginal and Torres Strait Islander origin.

What is the age profile of Indigenous Australians?

  • The Indigenous population is much younger than the non-Indigenous population. In 2011, half of the Indigenous population was aged 22 or under compared with 38 or under for the non-Indigenous population.
  • Only 3% of the Indigenous population was aged 65 and over.
  • The younger age profile of Indigenous Australians is mainly due to their higher fertility rates and higher mortality rates at all ages compared with non-Indigenous Australians. The fertility rate for Indigenous women in 2011 was 2.74 babies per woman compared with 1.92 for all Australian women (ABS 2011).

Where do Indigenous Australians live?

  • The majority (79%) of Indigenous Australians live in metropolitan or regional areas. More than one-third live in Major cities (35% or 233,100 people); 22% in Inner regional areas (147,700 people); 22% in Outer regional areas (146,100 people); 8% in Remote areas (51,300 people) and around 14% in Very remote areas (91,600 people).
  • In 2011, most (82%) lived in 4 jurisdictions: New South Wales (31% or 208,500 people); Queensland (28% or 189,000 people); Western Australia (13% or 88,300 people); and the Northern Territory (10% or 68,850 people) (Figure 7.1).
  • The Northern Territory has the highest proportion of Indigenous Australians, with 30% of its population identifying as being of Aboriginal or Torres Strait Islander origin in 2011. In most other jurisdictions, Indigenous people made up less than 5% of the population, with the lowest proportion (less than 1%) in Victoria.

Figure 7.1: Distribution of Indigenous estimated resident population by remoteness and jurisdiction, 2011

Bar chart showing the distribution of Indigenous estimated resident population, by remoteness and jurisdiction, in 2011. NSW and Qld had the biggest populations overall, while the majority of the Indigenous population of the Northern Territory live in very remote areas.

Source: ABS 2013.

What is missing from the picture?

The Indigenous estimated resident population is determined using information from the Census, birth and death registrations, and migration data. These data collections rely on people identifying themselves and their family members as Indigenous. Changes in identification rates between Censuses can affect population counts and the statistics derived from them (see Box 7.1: Counting on the numbers).

Due to the small Indigenous population in some jurisdictions and remoteness areas, it is not always possible to produce specific, reliable statistics. In these cases, statistics are calculated for larger areas, but this might mask differences within the areas. As Indigenous data improves, it may be possible to use combined data from a number of years to analyse differences specific to areas with small Indigenous populations.

Box 7.1: Counting on the numbers—the Indigenous estimated resident population

Much of what we know about the gap between Indigenous and non-Indigenous outcomes relies on statistics calculated using data from the Australian Bureau of Statistics (ABS) Census, surveys and administrative data from service providers. The Australian Institute of Health and Welfare (AIHW) and the ABS strive to collect and present accurate data, as well as ensure service providers are aware of the importance of collecting accurate Indigenous status information. However, they acknowledge that for various reasons not all Indigenous people are identified in the different data sets, which can lead to an undercount.

The Indigenous estimated resident population (ERP) is derived from the Census counts after adjustments for the undercount and for those records where Indigenous status was unknown. In 2011, the Indigenous undercount was estimated to be 17% (114,000 persons) and about 1 million Census records (5%) had an unknown Indigenous status (ABS 2012). The 2011 Indigenous ERP was 669,881 persons—an increase of 152,838 persons, or 30% from the 2006 ERP. The increase was due to a number of factors, including natural population growth, improved Census estimates and changes in Indigenous identification.

How does Indigenous identification affect health statistics?

The Indigenous ERP is important because it is used to calculate population rates for a feature of interest, for example, deaths rates in terms of number of deaths per 100,000 population. Equally as important are correct numbers from other data sources, which provide the frequency of a feature of interest. As the Indigenous ERP has been adjusted for undercount, data from other sources also need to be adjusted for undercount; otherwise calculated rates for the Indigenous population are likely to appear to be lower than the true rates, resulting in an underestimation of the gap or the difference between Indigenous and non-Indigenous rates.

Caution also needs to be exercised when comparing data from 2 different Censuses. For example, Census data show that in 2006, 4.6% of Indigenous Australians needed help with daily activities due to a disability or health condition compared with 5.7% in 2011. This could suggest that the proportion of Indigenous people who needed help increased since 2006. However, the change could be due to more people with a disability being identified as Indigenous in 2011 or due to the population having aged since 2006. While it is likely that all scenarios have contributed, further analysis is needed to separate these effects.

What is the AIHW doing to improve Indigenous identification?

To ensure that Indigenous status information is consistently and correctly recorded, the AIHW has produced national best practice guidelines for collecting Indigenous status in health data sets and has evaluated their implementation across various settings. The AIHW also continues to measure the proportion of Indigenous people who are correctly identified in the data sets and creates correction factors to adjust the data for under-identification.

The AIHW is also using data linkage to improve reporting on the Indigenous population. For example, its Enhanced Mortality Database project seeks to improve estimates of Indigenous mortality and life expectancy using data linkage. In this project, death registrations obtained from the Registries of Births, Deaths and Marriages in each state and territory are linked to deaths in hospital, residential aged care and perinatal data in order to better estimate the likely Indigenous status of death registrations. This linkage has identified 10% more Indigenous deaths that were missing in the death registration data. Future work on the project will include linkage to other data sets, the use of different methods to derive Indigenous status and an assessment of the feasibility of validating AIHW estimates by comparing the Indigenous status in the Enhanced Mortality Dataset with data sets that contain verified Indigenous status information.

Where do I go for more information?

More information on the composition of the Indigenous population is on the Australian Bureau of Statistics website.

More information on the quality of Indigenous data is available. AIHW reports available for free download include

References

ABS (Australian Bureau of Statistics) 2011. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples. ABS cat. no. 4704.0. Canberra: ABS.

ABS 2012. Census of Population and Housing—details of undercount, 2011. ABS cat. no. 2940.0. Canberra: ABS.

ABS 2013. Estimates of Aboriginal and Torres Strait Islander Australians, June 2011. ABS cat. no. 3238.0.55.001. Canberra: ABS.

7.2 Indigenous life expectancy and death rates

Life expectancy and mortality rates are important measures of the health status of a population (see Chapter 3 'Life expectancy' and 'Leading cause of death in Australia'). Indigenous Australians tend to die earlier than non-Indigenous Australians and their death rates are almost twice those of non-Indigenous Australians.

Information on Indigenous deaths is reported for New South Wales, Queensland, Western Australia, South Australia and the Northern Territory combined. Other jurisdictions have a small number of Indigenous deaths and identification of Indigenous status in the data is poor, making the data less reliable.

Life expectancy

  • Indigenous boys born between 2010 and 2012 can expect to live to 69.1 years and Indigenous girls to 73.7 years compared with 79.7 for non-Indigenous boys and 83.1 for non-Indigenous girls.
  • Life expectancy at birth has increased by 1.6 years for Indigenous men and 0.6 years for Indigenous women since 2005–2007 (Figure 7.2). It has also increased by 0.8 years for non-Indigenous men and 0.5 years for non-Indigenous women.

Figure 7.2: Life expectancy of Indigenous and non-Indigenous Australians at birth, 2005–2007 to 2010–2012

Line chart showing the trending increase in life expectancy of Indigenous and non-Indigenous Australians at birth between 2005-2007 and 2010-2012.

Source: ABS 2013b.

Death rates

  • Indigenous Australians had higher death rates than non-Indigenous Australians across all age groups during 2007–2011. In the 35–44 age group, Indigenous people died at about 5 times the rate of non-Indigenous people.
  • Between 2001 and 2011, there was a 6% fall in the death rate for Indigenous Australians and a narrowing of the gap between Indigenous and non-Indigenous Australians.

Leading causes of death

  • Between 2007 and 2011, Indigenous Australians were most likely to die from circulatory conditions (26% of all Indigenous deaths), cancer (19%) and external causes such as suicides, falls, transport accidents and assaults (15%).
  • The largest gap in death rates between Indigenous and non-Indigenous Australians was in circulatory disease deaths (22% of the gap) followed by endocrine, metabolic and nutritional disorders (particularly diabetes) (14% of the gap).
  • Indigenous Australians were 5 times as likely as non-Indigenous Australians to die from endocrine, nutritional and metabolic conditions (such as diabetes), and 3 times as likely to die of digestive conditions.

Infant and child deaths

  • There were 10,396 infant deaths between 2001 and 2012, of which 1,315 (13%) were Indigenous infants. The rate of Indigenous infant deaths fell by 62% between 2001 and 2012 and by 23% for non-Indigenous infants (Figure 7.3).
  • Indigenous children aged 0–4 died at more than twice the rate of non-Indigenous children in 2012 (165 per 100,000 compared with 77 per 100,000 population) (SCRGSP forthcoming). Indigenous child death rates fell by 30% from 2001 to 2012 compared with 22% for non-Indigenous children (Figure 7.3).

What is missing from the picture?

Not all Indigenous deaths are identified as such in death registration data. An Australian Bureau of Statistics study that linked 2011 Census records with death registration records found that about 87% of assumed Indigenous deaths were reported as Indigenous in death registration records (ABS 2013b). The level of Indigenous identification varies across states and territories, as well as by remoteness area (see Chapter 7 'Profile of Indigenous Australians').

The AIHW's Enhanced Mortality Database project is using data linkage to improve estimates of Indigenous deaths and life expectancy. Death registrations are linked with hospital, residential aged care and perinatal data to investigate opportunities to improve the measurement of Indigenous deaths.

Figure 7.3: Indigenous and non-Indigenous infant and child (aged 0–4) mortality rates (NSW, Qld, WA, SA and NT), 2001–2012

Two line charts showing the trending decline in Indigenous and non-Indigenous infant and child (aged 0-4) deaths per 1,000 live births in NSW, Qld, WA, SA and NT between 2001 and 2012.

Sources: ABS 2013a; AIHW National Mortality Database; SCRGSP forthcoming.

Where do I go for more information?

More information on the life expectancy and death rates of Indigenous Australians is available at Indigenous Observatory. The report Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses and other recent publications are available for free download.

More information is also available on the ABS website.

References

ABS (Australian Bureau of Statistics) 2013a. Births, Australia 2012. ABS cat. no. 3301.0. Canberra: ABS.

ABS 2013b. Life tables for Aboriginal and Torres Strait Islander Australians, 2010–2012. ABS cat. no. 3302.0.55.003. Canberra: ABS.

SCRGSP (Steering Committee for the Review of Government Service Provision), forthcoming. National Agreement performance information 2012–13: National Indigenous Reform Agreement. Canberra: Productivity Commission.


7.3 How healthy are Indigenous Australians?

Indigenous Australians have poorer health than other Australians. They are more likely to die at younger ages, experience disability and report their health as fair or poor. The reasons for the differences are explored throughout this chapter and include disparities in social and economic factors, in health behaviours and in access to health services (see Chapter 7 'Social determinants of Indigenous health' and Chapter 7 'The size and causes of the Indigenous health gap').

Self-assessed health

  • About 2 in 5 Indigenous Australians aged over 15 (39%) rated their health as excellent or very good, 36% as good and 25% as fair or poor in 2012–13 (Figure 7.4).
  • Indigenous Australians were at least twice as likely as non-Indigenous Australians to rate their health as fair or poor, and almost half as likely to rate their health as excellent or very good.
  • Compared with 2004–05, Indigenous Australians were 10% less likely to rate their health as excellent or very good in 2012–13 and 13% more likely to rate their health as fair or poor (ABS 2013).

Figure 7.4: Self-assessed health status of Indigenous Australians, by sex, 2012–13

Column chart showing the self-assessed health status of Indigenous Australians aged, by sex, in 2012-13. 'Good' was the most popular choice with approximately 33% of males and 38% of females choosing this option.

Source: ABS 2013.

Long-term health conditions

  • About 2 in 3 Indigenous Australians (67%) reported that they had at least 1 long-term condition in 2012–13. After adjusting for differences in the age structure of the populations, the rate was similar to that for non-Indigenous Australians in 2011–12.
  • One-third (33%) of Indigenous Australians reported having 3 or more long-term conditions.
  • The most commonly reported long-term conditions among Indigenous Australians were vision problems, respiratory diseases (including asthma), back pain and arthritis, ear and hearing problems, circulatory disease and diabetes. Indigenous Australians were nearly twice as likely as non-Indigenous Australians to report having asthma and 3.3 times as likely to report having diabetes (Figure 7.5).

Figure 7.5: Most common long-term conditions reported by Indigenous Australians, 2012–13, and corresponding proportion among non-Indigenous Australians, 2011–12

Bar chart showing the most common long-term conditions reported by Indigenous Australians in 2012-13, and the corresponding proportion among non-Indigenous Australians in 2011-12. Long-sighted/hyperopia was the most commonly reported condition in both instances.

Source: ABS 2013.

Disability

  • About 6% of Indigenous Australians reported needing assistance with daily activities in the 2011 Census.
  • After adjusting for differences in age structure and response rates, Indigenous Australians aged under 65 were more than twice as likely as non-Indigenous Australians to require assistance with daily activities.
  • The difference between Indigenous and non-Indigenous Australians was most pronounced in the 40–59 age group, with Indigenous people almost 3 times as likely to require assistance with daily activities as non-Indigenous people of that age.

What is missing from the picture?

The latest published information on the burden of disease experienced by Indigenous Australians is based on data from 2003. The AIHW is working on a study that uses 2011 data to measure the burden of disease experienced by the Indigenous and total Australian populations. This study will provide updated information on the impact of diseases and injuries on Indigenous Australians, and is expected to be released in early 2016.

Where do I go for more information?

More information on the health status of Indigenous Australians is available at Indigenous Observatory. Recent AIHW reports and publications available for free download include Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses and Australia's welfare 2013.

Reference

ABS (Australian Bureau of Statistics) 2013. Australian Aboriginal and Torres Strait Islander Health Survey: first results, Australia, 2012–13. ABS cat. no. 4727.0.55.001. Canberra: ABS.


7.4 Health behaviours of Indigenous Australians

Health risk behaviours, such as smoking, poor nutrition, physical inactivity and alcohol consumption contribute to poorer health status (see Chapter 5 'Behavioural risk factors'). Of the behavioural risk factors covered here, smoking is the most concerning as rates are significantly higher in the Indigenous population than in the non-Indigenous population.

The following information is based on results from the 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey (ABS 2013). Trends over time are available for smoking and long-term risky alcohol consumption; however, they are not available for the other risk factors presented here because of differences in the questions asked in the 2012–13 survey and previous surveys.

Smoking

  • Two out of 5 Indigenous Australians aged 15 and over (41%) were current daily smokers in 2012–13, which, after adjusting for age, was more than twice the rate of smoking among non-Indigenous Australians in 2011–12.
  • Smoking rates are highest among Indigenous people aged 25–34.
  • The proportion of Indigenous adults who smoke daily decreased between 2002 and 2012–13 from 51% to 44% (Figure 7.6).
  • For non-Indigenous adults, the proportion fell from 22% in 2001 to 16% in 2011–12.
  • After adjusting for age, the difference between the proportion of Indigenous and non-Indigenous smokers has narrowed from 27% in 2001 to 25% in 2012–13.

Figure 7.6: Percentage of current daily smokers in Australia by Indigenous status, people aged 15 and over (age-standardised), 2001–2002 to 2011–2013

Column chart showing that Indigenous Australian have a much higher rate of current daily smokers than non-Indigenous (41% compared with over 15% non-Indigenous in 2011-2013). Data are shown for 2001-02, 2007-08 and 2011-13 for age-standardised people aged 15 and over. There was a decline in daily smokers in both groups over this period.
  1. Data from 2001 National Health Survey and 2002 National Aboriginal and Torres Strait Islander Social Survey.
  2. Data from 2008 National Aboriginal and Torres Strait Islander Social Survey and 2007–08 National Health Survey.
  3. Data from 2011–12 Australian Health Survey and 2012–13 National Aboriginal and Torres Strait Islander Health Survey.

Sources: ABS 2012, 2013; AIHW 2013.

Risky alcohol consumption

  • A similar proportion of Indigenous Australians (in 2012–13) and non-Indigenous Australians (2011–12) reported drinking at lifetime risky levels in the week before being surveyed (19.2% compared with 19.5%).
  • The proportion of Indigenous Australians who reported drinking at lifetime risky levels did not change significantly between 2001 and 2012–13 (19% and 20% respectively).
  • Indigenous men reported drinking at levels exceeding the 2009 National Health and Medical Research Council (NHMRC) guidelines in a single occasion (more than 4 standard drinks) at slightly higher rates (10% more) than non-Indigenous men. The rate for Indigenous women was 30% higher than for non-Indigenous women, which was found to be statistically significant (Figure 7.7).

Figure 7.7: Proportion of Australians aged 18 and over who exceeded 2009 NHMRC guidelines for alcohol consumption, by risk, sex and Indigenous status, 2011–12 and 2012–13

Column chart showing the proportion of Australians aged 18 and over who exceeded 2009 NHMRC guidelines for alcohol consumption, by risk, sex and Indigenous status in 2011-12 and 2012-13.

Source: ABS 2013.

Illicit substance use

  • In 2012–13, more than 1 in 5 Indigenous people aged 15 and over (22%) reported that they had used an illicit substance in the previous 12 months.

Overweight and obesity

  • Almost one-third (30%) of Indigenous children aged 2–14 and two-thirds (66%) of Indigenous people aged 15 and over were overweight or obese in 2012–13.
  • Combined overweight/obesity rates were similar for Indigenous and non-Indigenous people aged 15 and over; however, the more concerning obesity rates among Indigenous people were 1.5 times higher than among non-Indigenous people.

Nutrition

  • Indigenous Australians aged 15 and over were 10% less likely than non-Indigenous Australians to report eating an adequate amount of fruit each day, which was statistically significant. There was no significant difference in vegetable consumption between the 2 groups (7% and 8% respectively consumed 5 or more serves of vegetables daily).

Physical activity

  • About 3 in 5 Indigenous Australians aged 18 and over (62%) reported no or low-level physical activity, which was 10% higher than the rate among non-Indigenous Australians.

What is missing from the picture?

The information presented here is based on preliminary data from the 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey. The Australian Bureau of Statistics plans to release further data in the second half of 2014 that will incorporate the results from the sample of respondents who also participated in the 2012–13 National Aboriginal and Torres Strait Islander Nutrition and Physical Activity Survey and the 2012–13 National Aboriginal and Torres Strait Islander Health Measurements Survey. This means that the preliminary data will be revised and the results updated.

Where do I go for more information?

More information on the health behaviours of Indigenous Australians is available at Indigenous Observatory. The report Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses and other recent publications are available for free download.

References

ABS (Australian Bureau of Statistics) 2012. Australian Health Survey: first results, 2011–2012. ABS cat. no. 4364.0.55.001. Canberra: ABS.

ABS 2013. Australian Aboriginal and Torres Strait Islander Health Survey: first results, Australia, 2012–13. ABS cat. no. 4727.0.55.001. Canberra: ABS.

AIHW (Australian Institute of Health and Welfare) 2013. Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses. Cat. no. IHW 94. Canberra: AIHW.


7.5 Social determinants of Indigenous health

Social determinants of health are social and economic factors that can have a positive or negative effect on the health of individuals and communities by affecting the environment and conditions in which they live. They can also affect people's health by influencing their behaviours and decisions (see Chapter 7 'Health behaviours of Indigenous Australians'). For example, people living in houses without safe drinking water may be at risk of diarrhoeal diseases, and those on low incomes may not eat fresh fruit and vegetables regularly if they cannot afford them. The social disadvantages Indigenous people experience in relation to housing, education, income and employment have contributed to the differences in health outcomes between Indigenous and non-Indigenous Australians.

Housing

  • The 2011 Census data show that about 36% of Indigenous households were home owners or purchasers and 59% were renters, compared with 68% and 29% of non-Indigenous households respectively.
  • About 12% of Indigenous households were considered overcrowded in 2011, compared with 3% of non-Indigenous households. Levels of overcrowding in remote Indigenous households fell from 22% in 2006 to 20% in 2011 (FaHCSIA 2013).
  • The rate of homelessness for Indigenous Australians was 14 times as high as the rate for non-Indigenous Australians in 2011 (ABS 2012b).
  • Despite making up 3% of the population, Indigenous people represented 22% of people accessing specialist homelessness services in 2012–13.

Education

  • In each state and territory, average National Assessment Program—Literacy and Numeracy (NAPLAN) scores for Indigenous students across all learning areas in Years 3, 5, 7 and 9 were substantially lower than those for non-Indigenous students in 2013 (ACARA 2013).
  • One area where there has been significant improvement is reading among Year 5 Indigenous students, where the proportion who met or exceeded the national minimum standard increased from 65% in 2012 to 83% in 2013, compared with 93% to 97% for non-Indigenous students (ACARA 2013).
  • Almost half (49%) of Year 7/8 Indigenous students stayed at school until Year 12 in 2011, compared with 81% of non-Indigenous students. However, there has been a significant rise in retention rates for Indigenous students from Year 7/8 to Years 10, 11 and 12 between 1998 and 2011 (Figure 7.8).
  • The proportion of Indigenous people aged 20–24 with a Year 12 or equivalent qualification increased from 47% in 2006 to 54% in 2011 (COAG Reform Council 2013).

Figure 7.8: Retention rates of Indigenous schoolchildren, Australia, 1998–2011

Line chart showing the trending increase in the retention rates of Indigenous school children in Australia between 1998 and 2011. Data are shown representing retention through Year 7/8 to Year 10, retention through Year 7/8 to Year 11 and retention through Year 7/8 to Year 12.

Source: AIHW 2013.

Income and employment

  • Half of all Indigenous people aged 15 and over had a personal weekly income of $362 or less in 2011 compared with $582 or less for non-Indigenous people.
  • In 2011, 42% of Indigenous Australians aged 15 and over were employed compared with 61% of non-Indigenous people.
  • Unemployment rates were 17% for Indigenous Australians and 5% for non-Indigenous Australians (ABS 2012a).

Impact on health

  • Indigenous Australians were more likely to assess their health as good or excellent if they had higher incomes and education levels, and owned their home (Figure 7.9).

Figure 7.9: Relationship between social determinants of health and self-assessed health status of good/excellent, Indigenous Australians, 2008

Column chart showing the relationship between social determinants of health and self-assessed health status of good/excellent for Indigenous Australians in 2008. Determinants shown are household income, highest year of school and housing tenure type.

Source: AHMAC 2012.

What is missing from the picture?

The relationship between social determinants and health is complex and can be difficult to measure (see Chapter 7 'The size and causes of the health gap'). For example, several social determinants may interact to create certain health outcomes, so separating the effects of each is not straightforward.

Also, the time taken for investments in education, employment and housing to affect a person's health can vary from immediate to many years.

Where do I go for more information?

More information on the social determinants of Indigenous health is available at Indigenous Observatory. Recent AIHW reports and other publications available for free download include Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses, The health and welfare of Australia's Aboriginal and Torres Strait Islander people: an overview 2011, A profile of homelessness for Aboriginal and Torres Strait Islander people and Specialist homelessness services 2012–2013.

References

ABS (Australian Bureau of Statistics) 2012a. Census of Population and Housing: characteristics of Aboriginal and Torres Strait Islander Australians, 2011. ABS cat. no. 2076.0. Canberra: ABS.

ABS 2012b. Census of Population and Housing: estimating homelessness, 2011. ABS cat. no. 2049.0. Canberra: ABS.

ACARA (Australian Curriculum, Assessment and Reporting Authority) 2013. NAPLAN achievement in reading, persuasive writing, language conventions and numeracy: national report for 2013. Sydney: ACARA.

AHMAC (Australian Health Ministers' Advisory Council) 2012. Aboriginal and Torres Strait Islander Health Performance Framework 2012 Report. Canberra: AHMAC.

AIHW (Australian Institute of Health and Welfare) 2013. Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses. Cat. no. IHW 94. Canberra: AIHW.

COAG (Council of Australian Governments) Reform Council 2013. Indigenous reform 2011–12: comparing performance across Australia. Sydney: COAG Reform Council.

FaHCSIA (Department of Families, Housing, Community Services and Indigenous Affairs) 2013. National Partnership on Remote Indigenous Housing: progress review (2008–2013). Canberra: FaHCSIA.


7.6 Indigenous Australians' access to health services

Due to their poorer health, Indigenous Australians could be expected to access health services at a much higher rate than non-Indigenous Australians. However, the most recent comparable data suggests that their overall access to health services is only marginally higher (AHMAC 2012). To improve Indigenous health, strategies to increase access to health services are required alongside improvements in behavioural and social factors.

Understanding Indigenous Australians' access to health services is important in evaluating whether the health system is adequately meeting their needs. Indigenous Australians may access mainstream or Indigenous-specific primary health care services, which offer prevention, diagnosis and treatment of ill health in a range of settings (see Chapter 8 'Primary health care in Australia'). Indigenous-specific services are funded by the Australian Government and/or state and territory governments, and are available through hospitals, community clinics, Aboriginal Community Controlled Health Services and other health-care facilities.

Comprehensive data on Indigenous Australians' use of mainstream and Indigenous-specific health services are lacking, which makes it difficult to determine patterns in the use of health services. Service use may be underestimated if consultations are not claimed for on Medicare, or are not funded by the Australian Government (such as when they are funded by state and territory governments). Incomplete identification of Indigenous people in mainstream health services data can also lead to an underestimation of service use.

Access to health services

  • In 2012–13, more than 1 in 5 Indigenous Australians (22%) accessed a general practitioner (GP) or specialist in the 2 weeks before the Australian Aboriginal and Torres Strait Islander Health Survey.
  • About 1 in 4 Indigenous Australians aged 15 and over (26%) reported having problems accessing health services in 2008. Of these, about 20% had problems accessing dentists, 10% accessing doctors and 7% accessing hospitals. The greatest barriers were long waiting times or services being unavailable when required (52%), and cost was a barrier for about 1 in 3 (32%).

Use of selected health services

  • Medicare Benefits Schedule (MBS) claim rates for GP visits were 17% higher for Indigenous than non- Indigenous Australians in 2010–11, but claim rates for specialist services were 39% lower (Figure 7.10).
  • Rates of MBS Health Checks among Indigenous Australians rose significantly from 2006 to 2011 for all age groups (Figure 7.11).
  • In 2010–11, Pharmaceutical Benefits Scheme (PBS) expenditure per Indigenous Australian was around 80% of the level of expenditure per non-Indigenous Australian ($291 compared with $366). In 2001–02, PBS expenditure per Indigenous Australian was around 33% of the amount spent per non-Indigenous Australian, suggesting a narrowing of the gap since then.
  • Aboriginal and Torres Strait Islander primary care services provided 2.6 million episodes of health care to about 445,000 clients in 2011–12. Compared with 2010–11, there was a 5% increase in episodes of care and a 3% increase in the number of clients.

Figure 7.10: Medicare services claimed per 1,000 people by Indigenous status (age-standardised), 2010–11

Bar chart showing Medicare services claimed per 1,000 people by Indigenous status (age-standardised) in 2010-11. The most commonly claimed services was non-referred GP. The other services shown are: pathology, imaging, allied health, specialist and miscellaneous diagnostics.

Source: AIHW 2013.

Hospitalisations by principal diagnosis

  • Indigenous Australians were hospitalised for potentially preventable conditions nearly 4 times as often as non-Indigenous Australians between July 2010 and June 2012.
  • Excluding dialysis, the leading cause of hospitalisation for Indigenous Australians was injury, poisoning and certain other consequences of external causes (38 hospitalisations per 1,000 people). Respiratory and digestive conditions were the next most common causes (31 and 26 hospitalisations per 1,000 people, respectively).
  • After adjusting for age differences, Indigenous Australians were over twice as likely to be hospitalised for mental and behavioural disorders as non-Indigenous Australians, and nearly 3 times as likely to be hospitalised for respiratory conditions (Figure 7.12).

Figure 7.11: Rate of MBS health checks for Indigenous Australians, by age, 2006–2011

Line chart showing the trending increase in the rate of MBS health checks for Indigenous Australians between 2006-2011 for the age groups: 0-14 years, 15-54 years and 55 years and older.

Source: AIHW 2013.

What is missing from the picture?

While service use and spending patterns give some indication of the demand for health services, they do not provide information on whether services are accessible to all who need them, nor do they give a complete picture of whether the health needs of Indigenous Australians are being met. Even though Indigenous Australians may have physical access to a service, financial, social and cultural factors can influence whether they access the service or not. There is also a possibility that the available service may not be the most suitable one for their health needs.

Where do I go for more information?

More information on how Indigenous Australians interact with the health system is available at Indigenous Observatory. Recent AIHW reports and other publications available for free download include Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses, Aboriginal and Torres Strait Islander health services report 2011-12 and Expenditure on health for Aboriginal and Torres Strait Islander people 2010–11.

Figure 7.12: Age-standardised rates of the leading causes of hospitalisation (excluding dialysis) for Indigenous Australians and corresponding rates among non-Indigenous Australians, July 2010 to June 2012

Bar chart showing the age-standardised rates of the leading causes of hospitalisation (excluding dialysis) for Indigenous Australians, and corresponding rates among non-Indigenous Australians, between July 2010 and June 2012.'Injury, poisoning and other consequences of external causes' was the leading cause among Indigenous people, while digestive problems were the leading cause among non-Indigenous.

Source: AIHW analysis of National Hospital Morbidity Database.

References

AHMAC (Australian Health Ministers' Advisory Council) 2012. Aboriginal and Torres Strait Islander Health Performance Framework 2012 Report. Canberra: AHMAC.

AIHW (Australian Institute of Health and Welfare) 2013. Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses. Cat. no. IHW 94. Canberra: AIHW.


7.7 Remoteness and the health of Indigenous Australians

Numerous studies have demonstrated that Australians living in remote or very remote areas have, on average, higher rates of risky health behaviours such as smoking, poorer access to health services, and worse health than people living in regional or metropolitan areas (AIHW 2012).

Poorer health with increasing remoteness may be influenced by environmental or geographical factors such as long distances to access services (which can also be an issue for urban fringes), communities being cut off on occasion because of flooding, or poorer access to healthy food sources (Harrison et al. 2010; Humphreys & Wakerman 2008) (see Chapter 5 'Health in regional and remote areas'). Evidence also shows higher rates of poor housing and overcrowding in remote areas, which have a negative impact on health (AIHW 2011).

These differences in health may also be due to the characteristics of the populations in more remote areas. For example, there is a strong association between socioeconomic status and health—the lower someone's socioeconomic status, the worse their health is likely to be. Given that a higher proportion of remote residents are disadvantaged compared with those who live in metropolitan or regional areas, their health may be worse as a result of socioeconomic disadvantage rather than just environmental or geographical factors related to remoteness.

The relationship of remoteness to health is particularly important for Indigenous Australians, as they are more likely to live outside metropolitan areas than non-Indigenous Australians. In 2011, just over one- third of Indigenous Australians lived in Major cities (34.8%), compared with over 70% of non-Indigenous Australians. Only 1.7% of non-Indigenous Australians lived in Remote or Very remote areas, compared with about one-fifth of Indigenous Australians (7.7% in Remote and 13.7% in Very remote areas). Indigenous Australians represent 16% and 45% of all people living in Remote and Very remote areas respectively.

Indigenous Australians have lower life expectancies, higher rates of chronic and preventable illnesses, poorer self-reported health, and a higher likelihood of being hospitalised than non-Indigenous Australians (AIHW 2013; Bramley et al. 2004; Freemantle et al. 2007). Therefore, differences in health with increasing remoteness could also be explained by the poorer health of the Indigenous population living in these areas.

To summarise the discussion so far, differences in health by remoteness could be due to remoteness factors such as distance or access to services, or the lower socioeconomic status of people who live in remote areas (Indigenous and non-Indigenous), or the higher proportions of Indigenous people who live in remote areas—or a combination of all 3.

This article presents available data on how health conditions and risk factors differ by remoteness and Indigenous status, using both self-reported survey data as well as data on hospitalisations. We also focus on access to general practitioner services by remoteness and Indigenous status, and highlight the AIHW's work in developing an area-based index of access to services relative to the health needs of the Indigenous and non-Indigenous populations in those areas.

How do health conditions and risk factors differ by remoteness and Indigenous status?

The most recent data on self-reported health-related behaviours and conditions for Indigenous Australians were collected in the 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey (AATSIHS) (ABS 2013a), which is part of the larger 2011–13 Australian Health Survey (AHS) which collected data on all Australians, except those living in Very remote areas. Tables 7.1 and 7.2 present data from these surveys by remoteness for all Australians and Indigenous Australians. At this point, the AHS data by remoteness have only been reported for all Australians, not for non-Indigenous Australians.

Table 7.2 highlights 2 key findings:

  1. Across almost every indicator, Indigenous Australians are disadvantaged compared with all Australians. The largest differences are in smoking status, psychological distress, and cardiac/ circulatory diseases. The 1 indicator in which the rates are lower for Indigenous Australians is for overweight/obesity in regional and remote areas.
  2. While there are differences by remoteness in the indicators for both populations, the impact of remoteness is relatively low. For all Australians, the largest difference between those living in Outer regional and Remote areas and those in Major cities is for smoking, with a ratio of 1.5. For Indigenous Australians, the largest difference between those in Outer regional and Remote areas and those in Major cities is 1.3 for diabetes.

However, while Tables 7.1 and 7.2 allow comparisons across similarly defined outcomes and geographic areas, the aggregation of Outer regional with Remote areas may mask important differences. The picture is also incomplete because it leaves out those living in Very remote areas, since those data were not collected in the AHS.

Table 7.1: Health-related characteristics by remoteness for all Australians (excluding those living in Very remote areas), 2011–13

Risk factors
Characteristic % of all Australians (2011–13 AHS) - Major cities % of all Australians (2011–13 AHS) - Inner regional % of all Australians (2011–13 AHS) - Outer regional & Remote % of all Australians (2011–13 AHS) - Total
Overweight/obese(a) 60.2 68.7 69.5 62.8  
Current daily smoker(a) 14.7 18.4 22.4 16.1  
Health conditions
Characteristic % of all Australians (2011–13 AHS) - Major cities % of all Australians (2011–13 AHS) - Inner regional % of all Australians (2011–13 AHS) - Outer regional & Remote % of all Australians (2011–13 AHS) - Total
High/very high psychological distress (K-10)(a)(b)   10.6 11.4 10.8 10.8  
Diabetes mellitus 4.5 5.1 4.9 4.6  
Heart, stroke and vascular disease 4.6 5.6 5.9 5.0  
Health service use
Characteristic % of all Australians (2011–13 AHS) - Major cities % of all Australians (2011–13 AHS) - Inner regional % of all Australians (2011–13 AHS) - Outer regional & Remote % of all Australians (2011–13 AHS) - Total
Consulted GP in last 2 weeks 20.8 19.7 19.5 20.4  
Admitted to hospital in last 12 months 11.3 13.2 11.7 11.8  
  1. Aged 18 and over.
  2. From COAG Reform Council (2013).

Source: ABS 2011-13 AHS.

Table 7.2: Health related characteristics by remoteness for Indigenous Australians (excluding those living in Very remote areas), 2012–13

Risk factors
Characteristic % of Indigenous Australians (2012–13 AATSIHS) - Major cities % of Indigenous Australians (2012–13 AATSIHS) - Inner regional % of Indigenous Australians (2012–13 AATSIHS) - Outer regional & Remote % of Indigenous Australians (2012–13 AATSIHS) - Total
Overweight/obese(a)   65.4 70.1 66.0 65.6  
Current daily smoker(a)   36.2 40.9 41.9 41.0  
Health conditions
Characteristic % of Indigenous Australians (2012–13 AATSIHS) - Major cities % of Indigenous Australians (2012–13 AATSIHS) - Inner regional % of Indigenous Australians (2012–13 AATSIHS) - Outer regional & Remote % of Indigenous Australians (2012–13 AATSIHS) - Total
High/very high psychological distress (K-10)(b)(c)   32.1 30.4 30.8 30.1  
Diabetes mellitus(d)   6.9 6.5 9.1 8.2  
Heart, stroke and vascular disease(e)   10.6 11.7 12.4 12.0  
Health service use
Characteristic % of Indigenous Australians (2012–13 AATSIHS) - Major cities % of Indigenous Australians (2012–13 AATSIHS) - Inner regional % of Indigenous Australians (2012–13 AATSIHS) - Outer regional & Remote % of Indigenous Australians (2012–13 AATSIHS) - Total
Consulted GP in last 2 weeks(f)   24.4 21.4 20.8 21.9  
Admitted to hospital in last 12 months 18.3 17.2 16.6 18.0  
  1. Aged 15 and over.
  2. Aged 18 and over.
  3. From COAG Reform Council (2013).
  4. The AATSIHS refers to diabetes/high sugar levels.
  5. The AATSIHS refers to heart and circulatory problems.
  6. The AATSIHS includes specialists along with GPs.

Source: ABS 2013a.

Table 7.3 presents more detailed data for Indigenous Australians by remoteness and includes those living in Very remote areas.

This shows that smoking rates and the prevalence of diabetes and heart conditions are highest among those living in Remote or Very remote areas. There is no clear gradient of use of health services across the 5 remoteness categories.

In contrast, the lowest rates of overweight and obesity for Indigenous Australians were found among those living in Very remote areas. Levels of high or very high psychological distress and the proportion of Indigenous Australians reporting asthma were also lowest for those living in Remote or Very remote areas.

Table 7.3: Health-related characteristics by remoteness, Indigenous Australians (2012–13 AATSIHS)

Risk factors
Characteristic % of Indigenous Australians - Major cities % of Indigenous Australians - Inner regional % of Indigenous Australians - Outer regional % of Indigenous Australians - Remote % of Indigenous Australians - Very Remote % of Indigenous Australians - Total
Overweight/obese 65.4 70.1 66.2 65.6 58.8 65.6  
Current daily smoker 36.2 40.9 39.8 47.4 51.1 41.0  
Health conditions
Characteristic % of Indigenous Australians - Major cities % of Indigenous Australians - Inner regional % of Indigenous Australians - Outer regional % of Indigenous Australians - Remote % of Indigenous Australians - Very Remote % of Indigenous Australians - Total
High/very high psychological distress (K-10) 32.1 30.4 33.3 24.8 23.0 30.1  
Asthma 21.1 20.8 15.8 13.7 7.8 17.5  
Diabetes/high sugar levels 6.9 6.5 8.9 9.7 12.1 8.2  
Heart and circulatory problems 10.6 11.7 10.0 19.1 15.7 12.0  
Health service use
Characteristic % of Indigenous Australians - Major cities % of Indigenous Australians - Inner regional % of Indigenous Australians - Outer regional % of Indigenous Australians - Remote % of Indigenous Australians - Very Remote % of Indigenous Australians - Total
Consulted GP/specialist in last 2 weeks 24.4 21.4 19.9 23.6 18.5 21.9  
Consulted other health professional in last 2 weeks 20.2 16.5 16.0 14.8 23.7 18.5  
Admitted to hospital in last 12 months 18.3 17.2 16.6 16.6 21.5 18.0  

Source: ABS 2013a.

How does access to, and use of, health services vary by remoteness and Indigenous status?

Information on service access and use gleaned from survey data can be limited due to the infrequency in which the surveys are conducted, their sample size, and individuals' imperfect recall and interpretation of survey questions. Another potential source of information is data collected by health service providers. Data sets collected in the course of health service delivery can facilitate comparisons of patterns by remoteness and Indigenous status. Depending upon the data set, the benefits of this type of data are consistency in the measurement of the outcome of interest and large enough numbers to disaggregate the Indigenous and non-Indigenous populations.

An important contributor to population health is the availability and accessibility of health services. For example, high quality primary health care services (see Chapter 8 'Primary health care in Australia') are essential for preventive care and screening, managing acute and chronic illnesses, and providing a link to specialist services. These services are delivered by a range of practitioners (for example, general practitioners, dentists, nurses, Aboriginal Health Workers) across a variety of locations (for example, community health centres, general practices, and allied health practices). A lack of access to primary health care services in areas with geographically dispersed populations (such as Remote and Very remote areas) may therefore affect the overall health and wellbeing of the populations living in those areas.

General practitioner services

General practitioners (GPs) play an important role in the delivery and coordination of health care in Australia. In 2012–13, 84% of Australians had consulted a GP at least once in the previous year (ABS 2013a). This section presents information on access to general practitioners by Indigenous status and remoteness. It is important to note, however, that there are other types of primary health care services delivered by health professionals other than GPs, particularly in remote Australia, which both Indigenous and non-Indigenous Australians use. Examples include some services delivered by Aboriginal Community Controlled Health Services, and Aboriginal Medical Services.

Recent data show that the proportion of Australians who reported being able to access an 'urgent' appointment with a GP within 4 hours was higher in Major cities (66.5%) than in other areas (57.3%). The proportion of Australians who delayed or did not see a general practitioner due to cost was 5.4% in 2012–13, with the lowest rates being in Major cities (5.1%) and higher rates of approximately 6.2% across regional and remote areas (ABS 2013b).

Directly comparable results are not available for Indigenous Australians. However, AATSIHS data indicate that 12.3% of Indigenous Australians living in remote areas reported that they have difficulty accessing doctors, compared with 8.6% of Indigenous Australians in non-remote areas (ABS 2013a). In a reverse of the situation for all Australians, cost of health services was more likely to be cited as a problem for Indigenous Australians in non-remote areas (37.5%) compared with those in remote areas (16.5%).

Area-based index of access to GPs relative to needs

The AIHW is developing an index that captures the extent to which the Indigenous, non-Indigenous and total populations of small geographic areas have access to health care relative to their health needs. (The areas are known as Statistical Area Level 1, or SA1s.)

This index applies to access to GP services only at this stage (as noted earlier, there are other types of providers delivering primary health care services, especially in remote areas). The index is based on methodology developed by McGrail and Humphreys (2009), and uses the physical (geospatial) locations of health services and the populations they serve, the number of GPs working at each service location, and the size and specific health needs of the 3 population groups in each SA1 (AIHW 2014).

Access is determined by considering estimated drive times between GP service locations and SA1 centroids (centre points), as well as the number of GPs working at each service location. Access is considered 'unhindered' by distance for travel times up to 10 minutes, gradually declining to 'no access' for travel times greater than 60 minutes.

The estimated demand for primary health care in each SA1 population is based on the size of the population and its per capita health needs, the latter determined by known associated demographic and socioeconomic predictors.

It is important to note that service availability is only 1 aspect, albeit a major aspect, of accessibility— the extent to which available services are used is also important, and whether this varies by remoteness and Indigenous status. This in turn can depend on potential barriers to access such as the cultural competence of services or variations in individual access to public transport—which the index does not take into account.

Figure 7.13 presents average scores for access to health-care services provided by GPs for all SA1s in each remoteness area. Higher values represent better access to GP services taking both travel time and competition from other populations using the same GPs into account. The results show that, as expected, the best access is in the Major cities and the worst access is in Very remote areas.

Figure 7.13: Access to health services provided by GPs by remoteness area, total population, Australia, 2011

Column chart showing that access to health services provided by GPs becomes more difficult in remote areas (2011). Data are presented as an average access to primary health care score.

Source: AIHW forthcoming.

The access relative to needs index, which incorporates information on need as well as access, as described earlier, can be calculated separately for Indigenous and non-Indigenous populations. Again, higher values represent better access to services relative to health needs.

The average access relative to health needs index scores for Indigenous Australians (see Figure 7.14) are highest in Major cities and lowest (by a pronounced margin) in Very remote areas. A similar pattern was found for the non-Indigenous population, except for a less pronounced decline in access relative to needs in Very remote areas, due to the relatively lower health needs of the non-Indigenous population in these areas.

Figure 7.14: Index of access to GPs relative to need, Indigenous Australians, 2011

Column chart showing that access to health services provided by GPs relative to need becomes more difficult in remote areas for Indigenous Australians (2011). Data are presented as an average access relative to need index score.

Source: AIHW forthcoming.

Hospitalisations

The most recent data from the AIHW National Hospital Morbidity Database (see Chapter 8 'Overview of public and private hospitals') show that there is great variation in total hospitalisation rates (including dialysis) by remoteness for the Indigenous population. Between July 2010 and June 2012, after adjusting for differences in Indigenous under-identification in hospital separations data (AIHW 2013), the highest hospitalisation rates for Indigenous Australians were for those living in Remote areas, followed by those living in Very remote areas and Outer regional areas (they may have been hospitalised in Major cities, but live in these areas) (Figure 7.15). The rates of hospitalisation for Indigenous Australians living in Remote areas were 1.9 as high as for Indigenous Australians living in Major cities.

There is much less variation by remoteness for hospitalisation rates for non-Indigenous Australians, and the pattern is different with the lowest rates recorded in Very remote and Remote areas.

Analyses of hospitalisation rates by principal diagnoses suggest that there are regional differences in the most common conditions for which Indigenous Australians are hospitalised. For example, Indigenous Australians in Remote and Very remote areas have higher rates of hospitalisation for injuries, infectious diseases, dialysis, respiratory illnesses, circulatory conditions, and skin-related conditions compared with Indigenous Australians living in Major cities. Hospitalisation rates are lower for Indigenous Australians in Remote and Very remote areas for mental and behavioural disorders, cancer, diseases of the nervous system, and congenital anomalies, compared with Indigenous Australians living in Major cities.

Figure 7.15: Adjusted age-standardised hospitalisation rates by Indigenous status and remoteness, July 2010–June 2012

Column chart showing the trending increase in adjusted age-standardised hospitalisation rates for Indigenous Australians with increasing remoteness. Other Australians, conversely, saw a trending decline. Data are shown for July 2010 to June 2012.

Source: AIHW analysis of National Hospital Morbidity Database.

Hospitalisations for potentially preventable conditions

While total hospitalisation rates provide information on service use and are thus a measure of met need for services, a subset of hospitalisations provide an indirect indicator of the lack of access to, or use of, primary care services. Admissions for potentially preventable conditions reflect hospitalisations that might have been prevented through the timely and appropriate provision and use of primary care or other non-hospital services (Li et al. 2009). It is important to note that hospitalisations for potentially preventable conditions are not a direct measure of the effectiveness of primary health care; however, comparisons of this indicator between population groups and geographic areas provide useful information for improvements in factors such as prevention or treatment of conditions.

Hospitalisations for potentially preventable conditions include hospitalisations for vaccine-preventable diseases (such as influenza and pneumonia), those for chronic conditions (such as asthma, congestive heart failure and diabetes), and those for acute conditions (such as dehydration and gastroenteritis).

Data from the AIHW National Hospital Morbidity Database show that between July 2010 and June 2012 there were 81,516 hospitalisations for potentially preventable conditions for Indigenous Australians, which equates to 11.7% of all Indigenous hospitalisations. This percentage is 1.6 times that of non-Indigenous Australians (7.2%).

The highest proportion of hospitalisations for potentially preventable conditions for Indigenous Australians was in Major cities (23.9%), followed by Remote areas (22.6%). The highest proportion of hospitalisations for potentially preventable conditions was also in Major cities for non-Indigenous Australians, although the proportion was much higher (65.3%).

Figure 7.16 demonstrates that, overall, the age-standardised hospitalisation rate for potentially preventable conditions is 3.5 times as high for Indigenous Australians as non-Indigenous Australians. The rates vary considerably for the Indigenous population by remoteness, with much higher rates for Remote and Very remote areas. There is less variation for the non-Indigenous population, but the highest rates are still found in Remote areas.

Figure 7.16: Age-standardised hospitalisation rates for potentially preventable conditions by Indigenous status and remoteness, July 2010–June 2012

Column chart showing age-standardised hospitalisation rates for potentially preventable conditions by Indigenous status and remoteness. Data are shown for July 2010 to June 2012.

Note: These rates are calculated using the 2011 Estimated Resident Population (ERP) by remoteness, and thus differ from previously published hospitalisation rates using the 2006 ERP by remoteness applied to population projections from the 2006 Census of Population and Housing.

Source: AIHW analysis of National Hospital Morbidity Database.

For the Indigenous population, the likelihood of a potentially preventable hospitalisation is 4.3 times as high for those in Remote areas compared with those in Major cities. For the non-Indigenous population, the highest rate is only 1.4 times as high (for those in Remote areas compared with those in Major cities). Therefore, it appears that remoteness has a stronger impact for the Indigenous population than for the non-Indigenous population, although some of the effect may be due to under-identification of Indigenous status in hospitalisation data in Major cities.

The results of an additional statistical analysis by AIHW showed that the odds that a hospitalisation was potentially preventable was 1.5 times as high for Indigenous Australians compared with non-Indigenous Australians (even after controlling for the age, sex, and remoteness of the person who was hospitalised). Indigenous status therefore appears to have a larger effect than remoteness on whether a hospitalisation was for a potentially preventable condition.

What's missing from the picture?

One of the difficulties in examining whether the patterns of Indigenous and non-Indigenous Australians' health behaviours/outcomes by remoteness status are similar is a lack of comparable data. Data on health-related behaviours/risk factors and the prevalence of particular conditions are collected through national surveys, but some questions differ for the populations, the data are not reported by detailed remoteness categories, or results are reported for different age groups.

The AIHW is working on comprehensive analyses to estimate the impact of remoteness on gaps between the Indigenous and non-Indigenous populations in terms of disability prevalence, disability service use, and reasons for hospitalisation. We will also be examining differences within remoteness categories, as not all Remote or Very remote areas are the same.

Where do I go for more information?

More information on the gap in health status between Indigenous and non-Indigenous Australians is available at Indigenous Observatory where recent publications are available for free download.

Information on the quality of Indigenous identification in hospitalisation data can be found in the following AIHW report: Indigenous identification in hospital separations data: quality report.

References

ABS (Australian Bureau of Statistics) 2013a. Australian Aboriginal and Torres Strait Islander Health Survey: first results, Australia, 2012–13. ABS cat. no. 4727.0.55.001. Canberra: ABS.

ABS 2013b. Patient experiences in Australia: summary of findings, 2012–13. ABS cat. no. 4839.0. Canberra: ABS.

ABS. 2013c. Deaths, Australia, 2012. ABS cat. no. 3302.0. Canberra: ABS.

AHMAC (Australian Health Ministers' Advisory Council) 2012. Aboriginal and Torres Strait Islander Health Performance Framework 2012 Report. Canberra: AHMAC.

AIHW (Australian Institute of Health and Welfare) 2011. The health and welfare of Australia's Aboriginal and Torres Strait Islander people: an overview. Cat. no. IHW 42. Canberra: AIHW.

AIHW 2012. Australia's health 2012. Cat. no. AUS 156. Canberra: AIHW.

AIHW 2013. Indigenous identification in hospital separations data—quality report. Cat. no. IHW 90. Canberra: AIHW.

AIHW forthcoming. Indigenous people's access to health care relative to need in Australia: a geospatial index. Canberra: AIHW.

AIHW: Henley G & Harrison JE 2013. Injury of Aboriginal and Torres Strait Islander people due to transport, 2005–06 to 2009–10. Injury research and statistics series no. 85. Cat. no. INJCAT 161. Canberra: AIHW.

Bramley D, Hebert P, Jackson R & Chassin M 2004. Indigenous disparities in disease-specific mortality, a cross-country comparison: New Zealand, Australia, Canada, and the United States. The New Zealand Medical Journal 117:1207.

COAG (Council of Australian Governments) Reform Council 2013. Healthcare 2011–12: comparing outcomes by remoteness. Supplement to the report to the Council of Australian Governments. Sydney: COAG Reform Council.

Freemantle J, Officer K, McAullay D & Anderson I 2007. Australian Indigenous health—within an international context. Darwin: Cooperative Research Centre for Aboriginal Health.

Harrison M, Lee A, Findlay M, Nicholls R, Leonard D & Martin C 2010. The increasing cost of healthy food. Australian and New Zealand Journal of Public Health 34:179–86.

Humphreys J & Wakerman J 2008. Primary health care in rural and remote Australia: achieving equity of access and outcomes through national reform: a discussion paper. Canberra: National Health and Hospitals Reform Commission.

Li SQ, Gray NJ, Guthridge S La & Pircher SBLM 2009. Avoidable hospitalisation in Aboriginal and non-Aboriginal people in the Northern Territory. Medical Journal of Australia 2009 190(10):532–36.


7.8 The size and causes of the Indigenous health gap

Indigenous Australians generally experience worse health than non-Indigenous Australians. While this health gap and its likely causes have been well documented, less progress has been made in measuring the effect of particular causes on the size of the gap. There are various statistical techniques that can be used to determine the relative contributions of various influences to the health gap, the results of which are discussed in this article. Before presenting the results, however, it is worthwhile reviewing how large the gap is, and the factors that have been put forward as the main causes.

How large is the gap?

The health gap between Indigenous and non-Indigenous Australians is best illustrated by differences in life expectancy:

  • For females, Indigenous life expectancy at birth in 2010–2012 was 73.7 years, compared with 83.1 years for non-Indigenous females, a gap of 9.5 years.
  • The difference was slightly greater for males, with Indigenous life expectancy estimated to be 69.1 years compared with 79.7 years for non-Indigenous males, a gap of 10.6 years.

These differences in health start at birth and continue throughout life:

  • Babies born to Indigenous mothers are more likely to be underweight than babies born to non-Indigenous mothers.
  • Indigenous children die at more than twice the rate of non-Indigenous children. Between 2007 and 2011, 212 out of every 100,000 Indigenous children aged 0–4 died compared with 95 out of every 100,000 non-Indigenous children.

Indigenous adults of all ages also died at higher rates than non-Indigenous Australians:

  • The difference was greatest in the 35–44 year age group, where Indigenous people died at almost 5 times the rate of non-Indigenous people.
  • Among non-Indigenous Australians, 81% of deaths occur after the age of 65, while only 35% of Indigenous deaths occur after that age (Figure 7.17; see also Chapter 7 'Indigenous life expectancy and death rates').

What causes the gap?

Chronic disease

Chronic diseases occur more often and at a much younger age among Indigenous Australians compared with non-Indigenous Australians (see Chapter 7 'How healthy are Indigenous Australians?' and Chapter 4 'Chronic diseases—Australia's biggest health challenge').

Figure 7.17: Age distribution of proportion of deaths, by age and Indigenous status, NSW, Qld, SA, WA and NT, 2007–2011

Two bar charts showing age distribution of proportion of deaths by age and Indigenous status. Data are shown for 2007 and 2011 and are sourced from NSW, Qld, SA, WA and NT.

Note: Indigenous data for Vic, Tas and ACT were of insufficient quality for the reporting period.

Some researchers have attributed about two-thirds of the Indigenous–non-Indigenous health gap to chronic diseases such as cardiovascular disease, diabetes, mental disorders and chronic lung disease (Vos et al. 2007a). The main causes of deaths among Indigenous Australians in the 2007–2011 period were:

  • circulatory disease (26%)
  • cancer (19%)
  • external causes (including suicide and transport accidents) (15%)
  • endocrine, metabolic and nutritional disorders (including diabetes) (9%)
  • respiratory diseases (8%).

Behavioural risk factors and social determinants

Indigenous Australians have been disadvantaged across many areas of life which continue to affect their health today. Disadvantages such as poor education, unemployment, low income, discrimination and poor quality housing are often referred to as the 'social determinants of health'. Social determinants can affect health outcomes both directly and indirectly. For example, a direct effect might be where a person on a low income is not able to afford, and therefore benefit from, health services with high out-of-pocket costs. Indirectly, social factors may increase a person's likelihood of engaging in risky health behaviours such as smoking and/or excessive alcohol consumption (Thomas et al. 2008).

AIHW analysis of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) and the 2004–05 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) showed that:

  • people who had completed Year 12 were significantly less likely to smoke than those who had not completed Year 12 (22 percentage points difference for males and 19 for females)
  • people who were employed were also less likely to smoke than those who weren't (11 percentage points difference for males and 17 for females) (Figure 7.18)
  • Year 12 completion was associated with lower probability of risky alcohol consumption and sedentary lifestyles.

Figure 7.18: Impact of social determinants on smoking rates, Indigenous Australians aged 20–64

Column chart showing the impact of social determinants on smoking rates for Indigenous Australians aged 20-64.

Source: AIHW analysis of 2008 NATSISS (unpublished).

(See Chapter 7 'Social determinants of Indigenous health', Chapter 7 'Health behaviours of Indigenous Australians', and Chapter 7 'How healthy are Indigenous Australians?' for more information.)

Access to health services

Poorer access to timely and effective health services is another factor which contributes to the health gap. Reasons commonly given by Indigenous Australians for not being able to access health care include waiting times being too long, care not available at the time requested, lack of services in the area, transport and distance issues, lack of affordable services, and services not culturally appropriate.

Social determinants can restrict an individual's ability to access health services. For example, inadequate formal education can limit peoples' knowledge of their own health needs and their ability to navigate through the health system. Cost is a commonly reported barrier to accessing health services by Indigenous Australians (AHMAC 2012), and low levels of income can discourage people from seeking medical care and paying for ongoing medical costs (Alexander et al. 2003). Analysis of the 2004–05 NATSIHS shows that Indigenous Australians in the lowest income quintiles were less likely than those in the highest income quintiles to visit a doctor or dentist in the last 2 weeks. A similar pattern was found for labour force status, education and housing tenure (AHMAC 2012).

Poorer access to, or use of, non-hospital health care services may underlie relatively high rates of potentially preventable hospitalisations for Indigenous Australians (hospitalisations that could have been prevented by access to appropriate non-hospital health services). During 2010–2012, Indigenous Australians were 3.5 times as likely to have a potentially preventable hospitalisation as non-Indigenous Australians (see Chapter 7 'Remoteness and the health of Indigenous Australians').

Indigenous Australians are also less likely to have a procedure recorded during a hospital episode than other Australians. In the 2 years to June 2012, only 60% of Indigenous hospitalisations were associated with a reported procedure (excluding dialysis), compared with 82% for other Australians. Analysis by principal diagnosis showed that differences in procedure rates between Indigenous and other Australians were greatest for diseases of the nervous, digestive, musculoskeletal, respiratory, and genitourinary systems (AHMAC 2012).

The 2004–05 NATSIHS included questions about unmet need (individuals who felt they needed to visit a health professional but didn't). Analysis of the data for Indigenous Australians showed that individuals with a greater number of health conditions had more unmet need than those with fewer health conditions (Figure 7.19). However, as this information was not available for non-Indigenous Australians, a health gap analysis could not be done.

Estimating the relative contributions to the gap

Previous analyses

Several Australian studies have attempted to measure the contribution of a range of factors to the gap. Booth and Carroll (2005) analysed the contribution of social determinants to the poorer health of Indigenous Australians, measured in terms of self-assessed health status. They concluded that between one-third and one-half of the health gap was due to social determinants. However, the contributions of health risk factors or access to health services to the health gap were not separately calculated.

Figure 7.19: Unmet need by number of conditions, Indigenous Australians, 2004–05

Line chart showing the trending increase in the unmet need for a doctor and unmet need for a hospital with increasing number of conditions. Data are shown for Indigenous Australians during 2004-05.

Source: AIHW analysis of 2004–05 NATSIHS.

DSI Consulting Pty Ltd and Benham (2009) also looked at social determinants only, and found that up to one-third of the difference in life expectancy could be attributed to differences in income, school education, employment status and overcrowded housing.

Zhao and others (2013) looked at both social determinants and health behaviours and found that socioeconomic disadvantage explained between 42% and 53% of the gap in life expectancy; however, their study was limited to the Northern Territory.

Studies of indigenous populations in other countries have found similar results. In New Zealand, the gap between Māori and non-Māori life expectancy in 2010–12 was 7.3 years (Statistics New Zealand 2013). One study (Blakely et al. 2006) found that socioeconomic factors accounted for around one-third of the mortality difference between Māori and non-Māori.

The most recent Indigenous Burden of Disease study for Australia (Vos et al. 2007b) found that 49% of the health gap could be explained by 11 behavioural risk factors:

  • smoking (17%)
  • obesity (16%)
  • physical inactivity (12%)
  • high blood cholesterol (7%)
  • high blood pressure (6%)
  • low fruit and vegetable intake (5%)
  • alcohol (4%)
  • illicit drugs (4%)
  • intimate partner violence (3%)
  • child sexual abuse (2%)
  • unsafe sex.

Some overlap exists between the effects of these risk factors, which is why the sum of the individual risk factor estimates is not the same as the estimate for all the risk factors combined. This work is currently being updated by the AIHW with the first results expected to be published in early 2016.

Many studies have found a strong association between socioeconomic status and health, and longitudinal studies show that low socioeconomic status is a cause of poor health; however, there is still uncertainty as to the magnitude of this impact. This is particularly the case where income is used as a proxy for low socioeconomic status—studies that are able to better control for a larger number and variety of potential causal factors report less evidence of a significant causal relationship between income and health (Gunasekara et al. 2011).

AIHW analysis

Recent AIHW work has aimed to build on the work of others to quantify the relative contributions of behavioural risk factors, access to health services, and social determinants to the health gap. Currently, the AIHW is using national data from the 2004–05 NATSIHS and National Health Survey (NHS). While nearly a decade old, these data remain the best available sources of information on both health determinants and health outcomes. Summary information from the work is presented here. The work will be updated once detailed results from the 2012–13 AATSIHS become available (expected in the second half of 2014).

Measuring 'health'

For the purposes of this study, health was measured using a composite score combining scores for self-assessed health status, self-reported long-term conditions, and emotional wellbeing (see Box 7.2 for more detail). This composite measure reflects the World Health Organization's definition of health, which is 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' (WHO 1948).

Box 7.2: Composite health measure

A self-assessed health score forms the base of the 'good health' composite measure. The score ranges between 5 and 1, corresponding to 'excellent', 'very good', 'good', 'fair' and 'poor'.

A morbidity score (developed for use with hospital data) is based on the influential and widely used Charlson Index, and includes 29 conditions of the circulatory, respiratory, nervous, endocrine, urinary and musculoskeletal systems, as well as cancer. All conditions are given a weight of 1 and subtracted from the health score.

Emotional distress is quantified as the sum of 5 individual Kessler-scores based on how often respondents had the following thoughts in the last 4 weeks: that everything is an effort; nervous; without hope; restless or jumpy; or so sad that nothing could cheer them up. There are 5 response options for each thought, reflecting how often each feeling was experienced over the 4 weeks, ranging from none of the time to all of the time. The resulting emotional distress score ranged from 0 to 20.

In order to combine the emotional distress score with self-assessed health and morbidity, it needed to be transformed to give similar weighting to both the physical and psychological dimensions of health and to allow individuals with lower levels of emotional distress to increase their health measure. A value of 2 is subtracted from the original 0–20 emotional distress score, and this figure is divided by 2. The resulting emotional distress score is subtracted from the health score.

'Good health' was defined as having a combined score of self-assessed health, morbidity and emotional distress of 3 or more.

Using this composite health measure, one-fifth (21%) of Indigenous Australians were estimated to be in 'good health', compared with two-fifths (40%) of non-Indigenous Australians (Figure 7.20). Conversely, about four-fifths of Indigenous Australians and three-fifths of non-Indigenous Australians were estimated to be in 'not good health'.

Figure 7.20: Distribution of composite health measure by Indigenous status

Column chart showing the distribution of composite health measure (those in 'good health' and those in 'not good health') by Indigenous status.

Source: AIHW analysis of 2004–05 NATSIHS.

What are the causes of the health gap?

A statistical model was developed to separately estimate the impact of demographic factors, social determinants and behavioural risk factors on the health gap, or in this model, the difference in probability of good health, in percentage points.

The first step was to estimate the impact of key demographic variables on the size of the health gap. This step adjusted the baseline measure for population differences such as age, which might otherwise misrepresent the size of the health gap (as younger populations tend to be healthier). Sex, remoteness and marital status were also adjusted for. The overall result was a reduction in the baseline gap to 15.8 percentage points (the original gap being 19 percentage points, the difference in the proportion of non-Indigenous and Indigenous Australians experiencing 'good health'—40% and 21% respectively).

The core analysis suggested that social determinants explained a larger proportion of the health gap than did behavioural risk factors.

  • Individually, social determinants were estimated to be responsible for nearly one-third (31%) of the health gap compared with 11% for behavioural risk factors.
  • Interactions between social determinants and behaviours risk factors were estimated to explain an additional 15% of the health gap.
  • Together, the factors explained over half (57%) of the gap (Figure 7.21).

Figure 7.21: Proportion of the health gap explained

Pie chart showing that 'other factors' were most responsible for the health gap (with 43%), followed by: social determinants (31%); interaction of social determinants and behavioural risk factors (15%); and behavioural risk factors (11%).

Source: AIHW analysis of 2004–05 NATSIHS.

Detailed analysis was undertaken to look at the relative contributions of individual variables within the model. In terms of social determinants, household income, highest level of school, and employment status had the largest estimated impact on the health gap. However, there were significant associations between these individual variables. Smoking status, body mass index, and binge drinking were the most important behavioural risk factors contributing to the health gap.

Another way to look at the impact of social determinants and behavioural risk factors on the health gap is to look at reductions in the size of the health gap after controlling for these factors.

  • The baseline health gap, after adjusting for age, sex, remoteness and marital status, was 15.8 percentage points.
  • The health gap decreased to 11.8 percentage points when behavioural risk factors were controlled for.
  • This decreased even further to 8.5 percentage points when social determinants were added.
  • The health gap decreased to 6.8 percentage points after adding interactions between social determinants and behavioural risk factors (Figure 7.22).

Overall, the results highlight the degree of overlap and interaction between social determinants and behavioural risk factors in their impact on the health gap.

Figure 7.22: Sequential impact of behavioural risk factors and social determinants on the size of the health gap

Column chart showing the sequential impact of behavioural risk factors and social determinants on the size of the health gap, sourced from the AIHW analysis of 2004-05 NATSIHS.

Source: AIHW analysis of 2004–05 NATSIHS.

What is missing from the picture?

It is likely that a lack of access to health services explains a significant proportion of the health gap. As discussed in this article and others in Australia's health 2014, many Indigenous Australians experience problems accessing timely and appropriate health services—due in part to a lack of accessible, affordable, or culturally appropriate services. The evidence suggests a complex relationship between health service access, social disadvantage, health behaviours, and health outcomes.

The AIHW is developing an area-based index of access to GPs relative to needs (see Chapter 7 'Remoteness and the health of Indigenous Australians'); however, providing a full picture on the level of access that Indigenous Australians have to health services remains notoriously difficult. Even where there are service-level data on frequency of visits, the extent of overutilisation or underutilisation is often unknown. Survey data can be more useful than service data in that they provide information on the wider population, rather than only those accessing services. (For more information, see Chapter 7 'Indigenous Australians' access to health services', and Chapter 8, which looks at the major types of health services available in Australia.)

Where do I go for more information?

More information on the gap in health status between Indigenous and non-Indigenous Australians is available at Indigenous Observatory.

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