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Australian Indigenous HealthBulletin
 
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spacing1Plain language review of cardiovascular health among Indigenous Australians

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Preface

This Plain language review of cardiovascular health among Indigenous Australians is based on the Review of cardiovascular health among Indigenous Australians (2013) by Caitlin Gray, Alex Brown and Neil Thomson.

Introduction

Cardiovascular health involves the heart, arteries, veins and other components of the circulatory system. Cardiovascular disease (CVD) is a term used to include all of the major diseases of the heart and circulatory system:

as well as key risk factors such as:

CVD is usually caused by damage to the blood supply of the heart, brain, and/or legs, with the exception of RHD, which involves damage to the heart valves as a result of (usually) repeated episodes of acute rheumatic fever (ARF) caused by bacterial infections.

Many of the CVDs share common risk factors including:

Many of these risk factors are largely preventable and, if addressed, could reduce the extent (size) and burden (impact) of CVD among Indigenous1 people. Other risk factors include socioeconomic and psychosocial factors. The exception is RHD (including ARF), which is specifically associated with poor living conditions.

What is known about cardiovascular disease among Indigenous people?

Cardiovascular disease (CVD) is a major health problem for all Australians, but the extent and burden are much greater for Indigenous people than they are for other Australians. CVD is the leading cause of premature (early) death, and death overall, for Indigenous people, as it is for all Australians [4][5][6][7][8].

Box 1: Measures of CVD

Prevalence: the proportion (percentage) of people with CVD. The proportion can relate to specific populations, such as the total population, the male population, the female population and those in specific age-groups (such as females aged 40-44 years).

Hospitalisation rates: the number of episodes of hospitalisations for a specific population in one year per 1,000 people in that population.

Death rates: the number of deaths for a specific population in one year per 100,000 people in that population.

The following statistics and Figure 1 [5] show the differences between Indigenous and non-Indigenous people for CVD in 2004-2005:

Figure 1 Prevalence (%) of CVD, by Indigenous status and selected age groups, Australia, 2004-2005

Prevalence (%) of CVD, by Indigenous status and selected age groups, Australia, 2004-2005

Source: Australian Bureau of Statistics, 2008 [5]

What do we know about the hospitalisation of Indigenous people for CVD?

In 2008-09, hospitalisation for CVD was more common among Indigenous people than non-Indigenous people across all age groups, with the greatest disparity (differences) being seen in the young and middle adult years. Overall hospitalisation rates for CVD were almost twice as high for Indigenous people than they were for non-Indigenous people [9].

The more detailed information available for the two-year period July 2006 to June 2008 show that hospitalisations of Indigenous people for CVD:

Figure 2 Hospitalisation rates for CVD, by Indigenous status and age group, NSW2, Vic, Qld, WA, SA and the NT, 2006-2008

Hospitalisation rates for CVD, by Indigenous status and age group, NSW, Vic, Qld, WA, SA and the NT, 2006-2008

Source: Australian Institute of Health and Welfare, 2011 [10]

What do we know about deaths of Indigenous people because of CVD?

CVD was the leading cause of death among Indigenous people between July 2006 and June 2008, at a rate almost twice as high as that for non-Indigenous people. Death rates for CVD are higher among Indigenous people than among non-Indigenous people across all age groups: the greatest disparity occurs among those aged 35-54 years [10]. In 2010, CVD accounted for 668 deaths among Indigenous people, which is just over one-quarter (26%) of all deaths among Indigenous people [8]. CHD and CBVD were the two most common causes of death from CVD.

Coronary heart disease (CHD):

Cerebrovascular disease (CBVD):

The more detailed information available for the five-year period 2004-2008 show that the rates of deaths among Indigenous people from CVD were almost double the rates among non-Indigenous people [10]. CVD accounted for the most deaths among Indigenous people for all age groups [10]. As is the case for non-Indigenous people, CVD death rates increase with age, particularly from the middle adult years (Figure 3) [10].

Figure 3 Death rates from CVD among Indigenous people, by selected age groups, NSW, Qld, WA, SA and the NT, 2004-2008

Death rates from CVD among Indigenous people, by selected age groups, NSW, Qld, WA, SA and the NT, 2004-2008

Source: Australian Institute of Health and Welfare, 2011 [10]

What is known about specific CVD conditions among Indigenous people?

Coronary heart disease

Coronary heart disease (CHD) is a disorder of the blood vessels (arteries) that supply oxygen-rich blood to the heart muscle. If the oxygen supply to the heart muscles is restricted, the heart cannot pump blood around the body properly. The following statistics show that the burden of CHD is higher among Indigenous people than non-Indigenous people:

Cerebrovascular disease

Cerebrovascular disease (CBVD) refers to conditions of the blood vessels that supply blood to the brain. A stroke, the most common form of CBVD, occurs when blood flow to a part of the brain is reduced or stops. This can be caused by a blocked or burst blood vessel. A part of the brain may be permanently damaged and no longer work properly. This may result in a long-lasting disability, depending on the area of the brain where this happens. The following statistics show that the burden of CBVD is greater for Indigenous people than for non-Indigenous people:

Hypertension

Hypertension (high blood pressure) refers to the elevation of blood pressure over a prolonged period of time. High blood pressure causes the heart to work harder, and can cause damage to the heart, making it weak and enlarged. The following statistics show that the burden from hypertension is greater for Indigenous than for non-Indigenous people:

Deaths from hypertension are not common, but it is a major risk factor for fatal CVD, including CHD and CBVD [11].

Acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever (ARF) is a disease that can cause damage to the heart valves, muscle and lining, as well as the connective tissue in the brain and other parts of the body such as joints. ARF, which generally develops about two to three weeks after an infection of the pharynx (throat) by the streptococcus bacterium, can lead to rheumatic heart disease (RHD), causing long-term damage to the heart valves and muscle. ARF and new cases of RHD are now almost exclusively experienced by Indigenous people in Australia, particularly among Indigenous children and young adults. The following statistics show the burden that Indigenous people suffer from this disease. During a four-year period from 2006 to 2009, in the NT, there were 216 notifications3 of new and recurrent (repeated) cases of ARF [10]:

In Australia in 2009-10, there were 2,666 hospitalisations for ARF and RHD:

During 2007-2009, in Australia, there were 897 deaths with RHD reported as the underlying cause. Deaths from RHD:

This is consistent with the higher prevalence and hospitalisation rates of RHD among females.

What do we know about risk factors contributing to CVD among Indigenous people?

The factors contributing to the increased levels of CVD among Indigenous people are complex, and reflect broad historical, cultural and economic factors, as well as behavioural (based on an individual’s behaviour) and biomedical (based on genetics and lifestyle) risk factors [2].

Behavioural and biomedical risk factors for CVD include:

Indigenous people were more likely than non-Indigenous people to have multiple (many) risk factors. Indigenous people also had higher levels of all the risk factors for CVD than non-Indigenous people. This was particularly so for diabetes, which was four times more common for Indigenous people than for non-Indigenous people and smoking which was twice as common.

Social and emotional wellbeing (SEWB) is an important contributing factor to the development, management and outcome of CVD among Indigenous people. SEWB factors have a particular bearing on the cause and expected outcome of CHD, and have now been recognised to be of similar importance as the behavioural and biomedical risk factors [2][14][15]. The SEWB factors include:

These aspects are related to social and cultural factors (known as the social and cultural determinants of health):

These ‘upstream’ factors mentioned above can influence behaviour, which can then contribute to biomedical risk factors. For example low socioeconomic status may contribute to behaviours such as physical inactivity or poor nutrition, which in turn can contribute to high blood pressure and high cholesterol levels [2]. Many Indigenous people with CVD have other health problems and multiple behavioural and biomedical risk factors, which together can magnify the risk of CVD.

What do we know about the care received by Indigenous people with CVD?

Current levels of care

Despite higher prevalence and hospitalisation rates of CVD, Indigenous people do not receive the same level of care for CVD as do non-Indigenous people [10][19][20][21]. This difference is seen in services relating to:

In 2010, Indigenous people hospitalised with CVD were less likely than non-Indigenous people to receive a procedure4 (57% compared with 74%) [10].

Greater need for care

The high level and earlier onset of CVD in the Indigenous population are likely to lead to greater need for cardiac care [21]. Reflecting this, the need for improved care has been recognised for Indigenous people in the following health care settings:

How can CVD be prevented?

Much of the impact of CVD is preventable, in terms of both initial onset of the disease (primary prevention) and management and control of established disease (secondary prevention and rehabilitation) [1][2][22]. Due to the largely preventable nature of the disease, and the associated high levels of health burden and costs in Australia, CVD has attracted substantial attention. This has contributed to advances in cardiovascular health in mainstream Australia, but this has not been translated fully to the Indigenous population, evidenced through the continuing high prevalence, and hospitalisation and death rates of Indigenous people from CVD [23][24][25].

What are the main problems faced by Indigenous people living with CVD?

Indigenous people are culturally diverse, with cultural differences providing unique access issues for health care services [16][26]. Health service planning should consider the needs of individual communities and the rates of disease, rather than adopting a ‘one size fits all’ approach. Therefore, while primary prevention strategies might vary little across communities, the level of resourcing for screening and treatment programs should depend on the disease burden (amount of loss of healthy life) [27].

Other barriers to adequate care that are experienced by Indigenous people include:

Key developments

Some key developments that have taken place in the area of Indigenous Australian cardiovascular health include:

Future directions

Comprehensive primary health care programs and increased training and support for health care providers will provide a basis for addressing the inequalities in health care for Indigenous people. More accessible and culturally appropriate primary health care should enable Indigenous people with CVD to be identified earlier in the course of their illness and have comorbidities (two or more illnesses) treated in a more timely manner [33][39]. This would be better achieved by more involvement of Indigenous patients in decision-making and greater development of key services including:

Summary

Indigenous people experience poorer cardiovascular health than do other Australians. CVD makes the largest contribution to the differences in health between Indigenous and non-Indigenous people. The factors contributing to the high levels of CVD and the associated hospitalisation and mortality levels among Indigenous people are complex. The high levels of behavioural and biomedical risk factors seen among Indigenous people are clearly associated with the high levels of CVD, but these factors cannot be seen in isolation; they must be viewed within a ‘social and cultural determinants’ context. As with other areas of Indigenous health, historical, socio-cultural, and economic aspects are the ‘upstream’ factors within which the behavioural and biomedical risk factors and the actual impacts of CVD should be viewed. The factors that contribute to the development of CVD among Indigenous people are very important, and key developments that address these factors will contribute to ‘closing the gap’ in health between Indigenous and other Australians.

Endnotes

  1. The term Indigenous is used in this review to refer generally to the two Indigenous populations of Australia –Aboriginal people and Torres Strait Islander people.
  2. In this review the following acronyms are used for the states and territories: New South Wales (NSW); Victoria (Vic); Queensland (Qld); Western Australia (WA); South Australia (SA); Tasmania (Tas); Australian Capital Territory (ACT); and Northern Territory (NT).
  3. Notification – In NT, WA and Qld records are kept by a government authority of all confirmed cases of ARF.
  4. Procedure – a course of action (such as measuring, diagnosing or treating) intended to achieve a result in the care of persons with a medical condition

References

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