Determinants of health for Indigenous Australians

Health is related to an individual’s environment and circumstances such as where they live, their education level, income and living conditions along with their access to and use of health services (WHO 2017). For Aboriginal and Torres Strait Islander people, factors such as cultural identity, family and kinship, country and caring for country, knowledge and beliefs, language and participation in cultural activities and access to traditional lands are also key determinants of health and wellbeing (AIHW and NIAA 2020). These factors are interrelated and combine to affect the health of individuals and broader communities.

Determinants and the health gap

An AIHW analysis of results from the Australian Bureau of Statistics (ABS) health survey data estimated that around one-third (34%) of the health gap between Indigenous and non-Indigenous Australians was due to social determinants (employment and hours worked, highest non-school qualification, level of schooling completed, housing adequacy and household income) and just under one-fifth (19%) of the gap was due to ‘health risk factors’ (risky alcohol consumption, high blood pressure, overweight and obesity status, inadequate fruit and vegetable consumption, physical inactivity and smoking). The remaining health gap (of around 47%) includes differences in access to health services and the impact of cultural and historical factors on health (AIHW 2018).

There is significant interaction and overlap between social determinants and health risk factors. For example, in 2018–19, among Indigenous Australian adults, the proportion who did not smoke was higher among those who:

• were employed, compared with those not employed (including those not in the labour force) (66% compared with 48%, respectively)
• had completed Year 12 or equivalent, compared with those with a Year 10 or lower level of school qualification (71% compared with 49%, respectively) (ABS 2019).

Closing the Gap

In July 2020, a new National Agreement on Closing the Gap was endorsed by the Australian governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations. This agreement provides a framework to address the entrenched inequality faced by Aboriginal and Torres Strait Islander people so that their life outcomes are equal to all Australians. The National Agreement has 17 targets including a range of health outcome measures and related determinants. Specifically, the outcome areas relate to education, employment, health and wellbeing, justice, safety, housing, land and waters, and languages (NIAA 2020).

While most of the available data and therefore the analysis focus on the socio-economic and environmental factors, an examination of cultural and historical factors and the impact of colonisation on the health and wellbeing of Indigenous Australians is also important.

Cultural and historical factors

Colonisation has had a devastating impact on Aboriginal and Torres Strait Islander communities and culture. Violence and epidemic disease caused an immediate loss of life, and the occupation of land by settlers and the restriction of Aboriginal people to ‘reserves’ disrupted their ability to support themselves. Together with the forcible removal of Indigenous children from their families and communities, Indigenous Australians have suffered ongoing inter-generational trauma. These factors are recognised as having a fundamental impact on the disadvantage and poor physical and mental health of Indigenous peoples worldwide, through social systems that maintain disparities (see, for example, ANU 2020; Paradies 2016; Paradies and Cunningham 2012).

In contrast, Aboriginal and Torres Strait Islander cultural identity and participation in cultural activities, access to traditional lands along with connection to family and kinship, are recognised as protective factors and can positively influence overall health and wellbeing (AIHW 2017). For example, ABS survey data show that Indigenous Australians who lived on their homelands or traditional Country were more likely to assess their own health as excellent/very good/good (78%) than those who were not allowed to visit their homelands or traditional Country (47%) (ABS 2019).

The importance of culture is recognised in the new National Aboriginal and Torres Strait Islander Health Plan 2021-2031 which sets the policy direction for Indigenous health and wellbeing. The plan notes that implementation across each priority area will need a holistic approach that considers the cultural determinants across the life-course. For example, it notes that to ensure the health and wellbeing of Indigenous Australians, contemporary housing must embed culturally-responsive design, including consideration of kindship, family and community living arrangements (Department of Health 2021).

Socio-economic and environmental factors

The component of the Aboriginal and Torres Strait Islander Health Performance Framework reporting against the determinants of health (Tier 2), covers a range of measures including environmental factors, socio-economic factors and community capacities. Information presented here focuses on those measures where there is more available data on education, employment, income, housing, child protection and justice (AIHW 2020).

Education, employment and income

A person’s educational qualifications can influence their health status and health outcomes. Specifically, higher levels of education can directly impact a person’s health through a greater understanding and application of health information, in addition to better prospects for employment and income which can help people access good quality housing, health food and health care services.

Levels of educational attainment among Indigenous Australians have improved substantially over the past decade. Between 2008 and 2018–19:

• The proportion of Indigenous Australians aged 20–24 who had attained at least a Year 12 or equivalent qualification increased – from 45% to 66% (an estimated 73,900 Indigenous Australians aged 20–24).
• The proportion of Indigenous adults aged 20–64 whose highest education was a certificate III or above increased – from 27% (an estimated 66,000 people) to 45% (an estimated 183,500 people) (ABS 2019).

The employment rate – the number of employed people as a proportion of the working age population – for Indigenous Australians aged 15–64 was 49% (an estimated 243,800 people) in 2018–19. The employment rate (excluding the Community Development Employment Program) remained stable between 2008 and 2018–19, at around 49% (SCRGSP 2020).

The employment rate remains much lower among Indigenous Australians than non-Indigenous Australians (49% compared with 76%) and the employment gap is largest among those aged 25–54 and in more remote areas (AIHW and NIAA 2020b).

An adequate income is fundamental to being able to live a healthy life – it gives a person greater access to nutritious food, better housing, and health and other services, as well as a greater ability for social participation (Galobardes et al. 2006). Based on AIHW analysis of the Census of Population and Housing 2016:

• More than 1 in 3 (37% or 105,400) Indigenous Australian adults lived in households with equivalised gross household incomes (which adjust for differences in income based on differences in household sizes) in the lowest 20% of incomes nationally.
• Average weekly equivalised household income of Indigenous adults was highest among those living in Major cities and lowest among those living in Very remote areas (AIHW and NIAA 2020).

The Aboriginal and Torres Strait Islander Health Performance Framework provides detailed information on the socio-economic factors including literacy and numeracy, education outcomes for young people and participation and attainment of adults, employment and both individual and household income.

Housing

Adequate housing – that is, housing that provides space for all members of the household and is in good structural condition with adequate working facilities – is essential to good health. Housing that is overcrowded or lacks facilities for washing and cleaning increases the risk of infectious disease (Ware 2013).

Indigenous Australians have less access to affordable or secure housing than other Australians and are considerably more likely to live in overcrowded conditions, or to experience homelessness (AIHW 2019). While there have been improvements in overcrowding, home ownership and a reduction in homelessness, there is a continued need for public policy that aims to ensure access to affordable, safe and sustainable housing for Indigenous Australians (AIHW and NIAA 2020a).

According to ABS health survey data, in 2018–19, nearly 1 in 5 (18% or an estimated 145,300) Indigenous Australians were living in overcrowded housing (housing that needs one or more additional bedrooms to adequately house household members). The 2018-19 rate represents a decline in overcrowding since 2004-05 when almost 27% of Indigenous Australians lived in overcrowded households (AIHW and NIAA 2020a).

Functional housing encompasses basic facilities, infrastructure, and habitability. Poorly maintained infrastructure and inadequate basic facilities can lead to the spread of infectious and bacterial diseases.

• In 2018–19, 1 in 3 (33%) Indigenous households were living in housing with one or more major structural problems, such as major cracks in walls or floors, sinking or moving foundations, or major electrical or plumbing problems. This was a similar proportion to 2012–13.
• Those living in Remote and very remote areas were most likely to live in overcrowded housing or homes with major structural problems (AIHW 2020b).

The Aboriginal and Torres Strait Islander Health Performance Framework provides detailed information on housing among Indigenous Australians on housing tenure, overcrowding and homelessness including results from the ABS Census of Population and Housing.

Child protection and justice systems

Experience of maltreatment during childhood has serious and long-term impacts on social and emotional wellbeing and health (Emerson et al. 2015). Indigenous Australians experience of child welfare policies has historically been traumatic, with the policy of forcible removal of children known as the Stolen Generations (HREOC 1997).

Child protection continues to be a very significant issue for Aboriginal and Torres Strait Islander communities:

• In 2019–20, 55,300 Indigenous children received child protection services, a rate of 166 per 1,000 Indigenous children – 8 times the rate for non-Indigenous children (21 per 1,000 non-Indigenous children).
• Children from Remote areas were more likely to be the subject of a substantiation, or be in out-of-home care than those from Major cities (AIHW 2021).
• The number of Indigenous children receiving child protection services rose between 2016–17 and 2019–20, from 49,200 to 55,300. This was reflected in the rate, which rose from 151 to 166 per 1,000 Indigenous children in the same period. For non-Indigenous children, the rates declined slightly from 22 to 21 per 1,000 children, with minor fluctuations during the period (AIHW 2021).

Most Indigenous Australians have never been imprisoned (ABS 2016). But they have had contact with the criminal justice system – as both offenders and victims – at much higher rates than non-Indigenous Australians (SCRGSP 2016):

• Although only about 6% of young people aged 10–17 in Australia are Indigenous, half (2,448 or 50%) of young people aged 10–17 under youth justice supervision on an average day in 2018–19 were Indigenous.
• Almost half (48%) of those aged 10–17 under community-based supervision were Indigenous, while over half (58%) of those in detention were Indigenous (AIHW 2020).
• As at 30 June 2021, 13,039 Indigenous adults were in prison at a rate of 2,412 per 100,000 population. Indigenous prisoners made up 30% of all prisoners, with 78% having experienced prior adult imprisonment (ABS 2021).

Health risk factors

Health risk factors, including overweight and obesity, alcohol consumption, smoking, dietary behaviours and physical inactivity, increase the likelihood of a person developing a chronic disease, or interfere with the management of existing conditions. Many health risk factors are preventable and modifiable and significant reduction is associated with improved health outcomes.

Overweight and obesity

A poorer quality diet – lacking in important nutrients and high in processed food – can contribute to obesity. Diet can be affected by what foods are affordable and readily available. For example, fresh fruit and vegetables can be difficult to access by people with low incomes and in more remote areas (Thurber et al. 2017).

Excess weight is a major risk factor for many diseases, such as cardiovascular disease, type 2 diabetes, kidney disease, some musculoskeletal conditions, and cancers. In 2018–19, 71% (381,800) of Aboriginal and Torres Strait Islander people aged 15 and over were overweight or obese (Figure 1). This was higher than in 2012–13 (66%). The rise was driven by an increase in non-remote areas (ABS 2013, 2019).

Alcohol consumption

Between 2001 and 2018–19, there was an increase in the proportion of Indigenous Australians aged 18 and over reporting that they ‘had not consumed alcohol in the last 12 months or have never consumed alcohol’, from 19% to 26%.

In 2018–19, survey data estimated that a greater number (37%) of Indigenous Australians aged 18 and over in Remote areas reported that they did not consume alcohol in the last 12 months or have never consumed alcohol than did Indigenous adults in the non-remote areas (23%).

Harmful use of alcohol is a problem for the Australian community as a whole. Long-term excessive alcohol consumption is associated with a variety of adverse health and social consequences. High levels of alcohol consumption can increase the risk of lifetime harm. This happens when more than two standard drinks are consumed on average every day. Exceeding alcohol risk guidelines can contribute to the risk of cancer, chronic liver disease and cardiovascular disease, among other health outcomes (NHMRC 2020).

About 1 in 5 (20% or 97,100) Indigenous adults reported drinking alcohol at levels exceeding the lifetime risk guideline in the previous week (Figure 1). This was the same as in 2012–13 (AIHW and NIAA 2020a).

Tobacco smoking

Smoking is a major risk factor for cardiovascular disease, cancer, and respiratory disease (AIHW 2022). The proportion of Indigenous Australians aged 15 and over who smoke every day has fallen substantially over the past decade. In 2018–19, 37% of Indigenous Australians aged 15 and over (about 200,400) smoked every day, compared with 45% in 2008 (Figure 1). The largest falls in daily smoking rates have occurred among younger Indigenous Australians.

In 2018–19, 85% of Indigenous Australians aged 15–17 reported that they had never smoked, compared with 72% in 2008. The decline in daily smoking rates among Indigenous adults has occurred in non-remote areas – there has been no significant change over this period in daily smoking rates among Indigenous adults in remote areas (AIHW and NIAA 2020a).

Where do I go for more information?

For more information, see:

• Aboriginal and Torres Strait Islander Health Performance Framework
• Australian Bureau of Statistics National Aboriginal and Torres Strait Islander Health Survey, 2018–19
• Australia's health 2018 ‘Chapter 6.7 Sizes and sources of the Indigenous health gap’

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