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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:
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.
Source: ABS 2013.
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.
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.
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
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.
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.
Source: ABS 2013b.
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.
Sources: ABS 2013a; AIHW National Mortality Database; SCRGSP forthcoming.
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.
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.
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').
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.
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.
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.
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.
Sources: ABS 2012, 2013; AIHW 2013.
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.
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.
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.
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.
Source: AIHW 2013.
Source: AHMAC 2012.
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.
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.
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.
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.
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.
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.
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.
Source: AIHW analysis of National Hospital Morbidity Database.
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.
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:
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.
Source: ABS 2011-13 AHS.
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.
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 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%).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
The health gap between Indigenous and non-Indigenous Australians is best illustrated by differences in life expectancy:
These differences in health start at birth and continue throughout life:
Indigenous adults of all ages also died at higher rates than non-Indigenous Australians:
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').
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:
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:
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.)
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.
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.
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:
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).
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).
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).
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'.
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.
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.
Overall, the results highlight the degree of overlap and interaction between social determinants and behavioural risk factors in their impact on the health gap.
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.)
More information on the gap in health status between Indigenous and non-Indigenous Australians is available at Indigenous Observatory.
ABS (Australian Bureau of Statistics) 2013. Life tables for Aboriginal and Torres Strait Islander Australians 2010–2012. ABS cat. no. 3302.0.55.003. Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2011. Contribution of chronic disease to the gap in adult mortality between Aboriginal and Torres Strait Islander and other Australians. Cat. no. IHW 48. Canberra: AIHW.
AIHW 2013. Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses. Cat. no. IHW 94. Canberra: AIHW.
Alexander GC, Casalino LP & Meltzer DO 2003. Patient-physician communication about out-of-pocket costs. Journal of the American Medical Association 290(7):953–8.
Blakely T, Fawcett J, Hunt D, & Wilson N 2006. What is the contribution of smoking and socioeconomic position to ethnic inequalities in mortality in New Zealand? Lancet 368:44–52.
Booth A & Carroll N 2005. The health status of Indigenous and non-Indigenous Australians. Centre for Economic Policy Research Discussion Paper no. 486. Canberra: Australian National University.
Cade J, Upmeier H, Clavert C & Greenwood D 1999. Costs of a healthy diet: analysis from the UK women's cohort study. Public Health Nutrition 2(4):505–512.
DSI Consulting Pty Ltd & Benham D 2009. An investigation of the effect of socio-economic factors on the Indigenous life expectancy gap. Canberra: DSI Consulting Pty Ltd.
Gunasekara I, Carter K & Blakely T 2011. Change in income and change in self-rated health: systematic review of studies using repeated measures to control for confounding bias. Social Science & Medicine 72:193–201.
Statistics New Zealand 2013. New Zealand period life tables: 2010–12. Wellington: Statistics New Zealand. Viewed 18 February 2014.
Thomas DP, Briggs V, Anderson IPS & Cunningham J 2008. The social determinants of being an Indigenous non-smoker. Australian and New Zealand Journal of Public Health 32(2):110–16.
Vos T, Barker B, Stanley L & Lopez AD 2007a. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples: 2003. Brisbane: School of Population Health, University of Queensland.
Vos T, Barker B, Stanley L & Lopez AD 2007b. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples: policy brief. Brisbane: School of Population Health, University of Queensland.
WHO (World Health Organization) 2003. Social determinants of health, the solid facts. 2nd edn. Geneva: WHO.
Zhao Y, Wright J, Begg S & Guthridge S 2013. Decomposing Indigenous life expectancy gap by risk factor: a life table analysis. Population Health Metrics 11:1–9.
Feature articles & snapshot downloads
7.1 Profile of Indigenous Australians (Snapshot) (126KB PDF)
7.2 Indigenous life expectancy and death rates (Snapshot) (159KB PDF)
7.3 How healthy are Indigenous Australians? (Snapshot) (157KB PDF)
7.4 Health behaviours of Indigenous Australians (Snapshot) (162KB PDF)
7.5 Social determinants of Indigenous health (Snapshot) (204KB PDF)
7.6 Indigenous Australians' access to health services (Snapshot) (205KB PDF)
7.7 Remoteness and the health of Indigenous Australians (Feature) (292KB PDF)
7.8 The size and causes of the Indigenous health gap (Feature) (364KB PDF)
Data tables for figures
Data for figures in Australia's health 2014 (Chapter 7) (415KB XLS)
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Australia's health 2014
Australia's health 2014: in brief