Share on Facebook Share on Twitter Share on Google+ Share by Email

Skip to content

Key resources

  • Bibliography
    Bibliography
  • Health promotion
    Health promotion
  • Health practice
    Health practice
  • Yarning places
    Yarning places
  • Programs
    Programs
  • Organisations
    Organisations
  • Conferences
    Conferences
  • Courses
    Courses
  • Funding
    Funding
  • Jobs
    Jobs
Australian Indigenous HealthBulletin
 

Health risk factors

Factors contributing to Indigenous health

Selected health risk and protective factors

The factors contributing to the poor health status of Indigenous people should be seen within the broad context of the social determinants of health [1][2]. These determinants, which are complex and interrelated, include income, education, employment, stress, social networks and support, working and living conditions, gender, and behavioural aspects, all of which are integrated in terms of autonomy and the capacity to participate fully in society [3]. Related to these are cultural factors, such as traditions, attitudes, beliefs, and customs. Together, these social and cultural factors have a major influence on a person's behaviour [1][2].

In addition to indicators of Indigenous social disadvantage, attention also needs to be focused on the 'health risk and protective factors', including those summarised in the following sections. These risk and protective factors are more proximal to adverse health outcomes, but the interpretation of the following information needs to recognise the potential roles of the underlying determinants of health.

Nutrition

The nutritional status of Aboriginal and Torres Strait Islander people is influenced by many factors such as socio-economic disadvantage, and geographical, environmental, and social factors [4][5]. Poor nutrition is an important factor contributing to overweight and obesity, malnutrition, CVD, type 2 diabetes, and tooth decay [5][6]. The National Health and Medical Research Council (NHMRC) guidelines recommend that adults eat fruit and plenty of vegetables every day, selected from a wide variety of types and colours [7]. The guidelines also recommend including reduced fat varieties of milk, yoghurts and cheeses, and to limit the intake of foods and drinks containing added salt.

According to the 2012-2013 AATSIHS, less than one-half of Aboriginal and Torres Strait Islander people aged 15 years or older met the guidelines for daily fruit intake (42%), and only 5% ate enough vegetables each day [8]. Females were more likely than males to have eaten an adequate amount of fruit (44% and 40% respectively) and vegetables (7% and 3% respectively) each day [8]. Levels of fruit and vegetable consumption per day were different for Indigenous people aged 15 years or older living in remote and non-remote areas, 46% of those living in remote areas consumed the recommended number of servings of fruit compared with 41% of people in non-remote areas. Those living in non-remote areas were more likely than those in remote areas to consume adequate amounts of vegetables (5% compared with 3%). After age-adjustment, Indigenous people aged 15 years or older were less likely than non-Indigenous people to be eating adequate amounts of fruit (ratio 0.9) or vegetables (ratio 0.8) each day. Information about milk consumption, salt consumption, food security or the influence of other factors on dietary behaviour are not yet available from the 2012-2013 AATSIHS.

The AATSIHS also examined associations between dietary behaviour and labour force status and educational attainment [8]. After age standardisation, unemployed Indigenous people were less likely to consume adequate amounts of fruit (63%) and vegetables (98%) than those who were employed (54% and 94% respectively) or not in the labour force (60% and 95% respectively). When considering educational levels, Indigenous people who had completed year 12 or equivalent were less likely to consume adequate amounts of fruit (54%) and vegetables (93%) than those who had completed year 10 or below (59% and 95% respectively) .

The National Aboriginal and Torres Strait Islander health measures survey (NATSIHMS) 2012-2013 collected information on three biomarkers of nutrition – vitamin D, anaemia and iodine [9], it was found that:

The AATSIHS 2012-2013 collected information on the fruit and vegetable consumption of children and found that 78% of Aboriginal and Torres Strait Islander children aged 2-14 years were eating adequate amounts of fruit eat day, but only 16% were eating enough vegetables [5]. A higher proportion of girls were meeting the guidelines for fruit intake than boys (81% compared with 76%), but the proportions were similar for vegetable intake (14% and 17% respectively). The rates of fruit and vegetable intake were similar for children in remote and non-remote areas.

The Footprints in time: longitudinal study of Indigenous children reported that levels of isolation affected the diet of children aged 2-7 years in 2010 [10]. Cereals, protein, and fruit and vegetables were the types of food eaten by most children across all locations and 7.1% ate bush tucker. Children in areas of high isolation were more likely to have eaten protein and bush tucker, and less likely to have eaten snacks and dairy food. In 2011, further information was collected on bush tucker, finding that children living in more isolated areas were more likely to eat bush tucker than children living elsewhere, and that the types of foods eaten reflected the availability of foods in the region [11].

Physical activity

Physical activity is important for maintaining good health [12]. Australia’s physical activity and sedentary behaviour guidelines recommend moderate physical activity on most, preferably all, days of the week to improve health and reduce the risk of chronic disease and other conditions [13]. Low levels of activity, including sedentary behaviour, are a risk factor for a variety of health conditions including CVD, type 2 diabetes, certain cancers, depression and other social and emotional wellbeing conditions, overweight and obesity, a weakened musculoskeletal system and osteoporosis [12][13].

According to the 2012-2013 AATSIHS, 46% of Aboriginal and Torres Strait Islander people aged 18 years and over living in non-remote areas had met the target of 30 minutes of moderate intensity physical activity on most days (or a total of 150 minutes per week); this level was 0.9 times higher than for their non-Indigenous counterparts [14]. Two-fifths (40%) of Indigenous adults had exercised for at least 150 minutes over five sessions in the previous week; this level was 0.9 times that of their non-Indigenous counterparts. Over one-quarter (28%) of Indigenous adults had exercised at a moderate level and 10% at a high level; these levels of physical activity were 0.9 and 0.6 times those of their non-Indigenous counterparts. Indigenous adults spent around one third the time on physical activity (39 minutes per day including 21 minutes on walking for transport) compared with children aged 5-17 years [12]. Those who participated in the pedometer study recorded an average of 6,963 steps per day; 17% met the recommended threshold of 10,000 steps or more.

Among Aboriginal and Torres Strait Islander adults living in non-remote areas, more males than females met the target of 150 minutes of moderate intensity exercise per week (50% compared with 41%) and had exercised for at least 150 minutes over five sessions in the previous week (44% compared with 36%) [14]. Indigenous males were significantly more likely than Indigenous females to have exercised at moderate intensity (31% compared with 25%) and were twice as likely to have exercised at high intensity (14% compared with 7%) in the previous week. In remote areas, 55% of Indigenous adults exceeded the recommended 30 minutes of physical activity and 21% did not participate in any physical activity on the day prior to the interview [12]. The most common type of physical activity for adults was ‘walking to places’ (71%). One-in-ten (11%) participated in cultural activities, including hunting and gathering bush foods or going fishing.

Among Aboriginal and Torres Strait Islander adults living in non-remote areas, 62% reported that they were physically inactive (sedentary or had exercised at a low level) in the week prior to the survey; this level of physical inactivity was 1.1 times that of their non-Indigenous counterparts [13]. A higher proportion of Indigenous women than Indigenous men were physically inactive (68% compared with 55%); this pattern was evident for all age-groups [14]. Indigenous adults spent an average of 5.3 hours per day on sedentary activities, including 2.3 hours of watching television, DVDs and videos [12].

Aboriginal and Torres Strait Islander children aged 2-4 years living in non-remote areas spent an average of 6.6 hours per day participating in physical activity and spent more time outdoors than their non-Indigenous counterparts (3.5 hours compared with 2.8 hours) [12]. Indigenous children aged 2-4 years spent an average of 1.5 hours on sedentary screen-based activities such as watching TV, DVDs or playing electronic games.

Aboriginal and Torres Strait Islander children aged 5-17 years living in non-remote areas spent an average of two hours per day participating in physical activity (exceeding the recommendation of one hour per day); this was 25 minutes more than their non-Indigenous counterparts [12]. Around half (48%) of Indigenous children met the recommended amount of physical activity, compared with 35% of non-Indigenous children. The most common physical activities among Indigenous children were active play and children’s games (57%) and swimming (18%). Those who participated in the pedometer study recorded an average of 9,593 steps per day, with an average of one-in-four children (25%) meeting the recommended 12,000 steps per day.

Aboriginal and Torres Strait Islander children aged 5-17 years living in non-remote areas spent an average of 2.6 hours per day on sedentary screen-based activities (exceeding the recommended limit of two hours). Indigenous children aged 12-14 years spent half the time that non-Indigenous children spent using the internet or computer for homework (4 minutes compared with 8 minutes per day) and those aged 15-17 years spent nearly one third of the time spent by their non-Indigenous counterparts (8 minutes compared with 20 minutes per day). Indigenous children aged 15-17 years spent more time on screen-based activities than those aged 5-8 years (3.3 hours compared with 1.9 hours).

In remote areas, 82% of Aboriginal and Torres Strait Islander children aged 5-17 years did more than 60 minutes of physical activity on the day prior to the interview [12]. The most common activities were walking (82%), running (53%), and playing football or soccer (33%).

Bodyweight

The standard measure for classifying a person’s weight status is BMI (BMI: weight in kilograms divided by height in metres squared) [15]. Being overweight (BMI 25 to 29) or obese (BMI of 30 or more) increases a person's risk for CVD, type 2 diabetes, certain cancers, and some musculoskeletal conditions. A high BMI can be a result of many factors, alone or in combination, such as poor nutrition, physical inactivity, socioeconomic disadvantage, genetic predisposition, increased age, and alcohol use [16][7][15][17]. Being underweight (BMI less than 18.5) can also have adverse health consequences, including lower immunity (leading to increased susceptibility to some infectious diseases) and osteoporosis (bone loss) [7].

Abdominal obesity, also known as central obesity, is also a risk factor for the development of the metabolic syndrome [18]. Abdominal obesity can be measured by waist circumference alone (a greater than 94cm for men and greater than 80cm for women), or waist-hip ratio (WHR) (greater than or equal to 0.90 for men and greater than or equal to 0.85 for women).

The 2013 NHMRC Australian dietary guidelines recommend that, to achieve and maintain a healthy weight, adults need to be physically active and choose amounts of nutritious foods and drinks to meet their energy needs [7].

Based on measurements of BMI, overweight and obesity contributed 11% to the total burden of disease among Indigenous people in 2003, second only to tobacco use [19]. It is possible, however, that this may be an under-estimate because optimal BMI cut-offs are still uncertain for the Indigenous population (due to differences in body shape and other physiological factors) when calculating diabetes type 2 and cardiovascular risk [20][21][22]. It has been suggested that a BMI of 22 might be more appropriate than 25 as a measure of acceptable BMI for Indigenous people. There is also evidence that measuring the WHR in Indigenous people is more sensitive and easier to measure than BMI [22]. More recently, Hughes and colleagues [23] have developed an equation for calculating fat free mass in adult Indigenous people using the easily acquired variables of resistance1, height, weight, age and gender for use in the clinical assessment and management of obesity.

Based on BMI information collected as a part of the 2012-2013 AATSIHS, 66% of Aboriginal and Torres Strait Islander people aged 15 years or older were classified as overweight (29%) or obese (37%) [8]. A further 30% were normal weight and 4% were underweight. Combined overweight/obesity levels were significantly higher for people living in non-remote areas (67%) than for those living in remote areas (62%). Similar proportions of Indigenous males and females were overweight or obese (65% and 67% respectively), however, a larger proportion of males than females were overweight (31% and 26% respectively) while a greater proportion of females than males were obese (40% and 34% respectively). After age-adjustment, the combined overweight/obesity levels were slightly higher for Indigenous people aged 15 years or older than for their non-Indigenous counterparts (ratio 1.2) and Indigenous people were 1.6 times as likely as non-Indigenous people to be obese (ratio 1.4 for males and 1.7 for females).

Measurements of waist circumference and WHR were taken in the 2012-2013 AATSIHS (not done in the previous health survey) to help determine levels of risk for developing certain chronic diseases [8]. A higher proportion of Indigenous females (81%) than Indigenous males (62%) aged 18 years or older were found to be at increased risk based on waist circumference. Based on WHR, the other measure of abdominal obesity, 81% of males and 73% of females aged 18 years or older were at increased risk of developing chronic diseases. The proportions of Indigenous men and women who were at increased risk of developing chronic diseases based on both measures of waist circumference and WHR increased with age.

Detailed information from the 2012-2013 AATSIHS is not yet available, but the 2004-2005 NATSIHS found that Indigenous people aged 18 years or more being overweight or obese was associated with [24]:

In 2004-2005, around 4.4% of Indigenous people aged 15 years or older were underweight, with about 2.8% of Indigenous men and 6.0% of Indigenous women having a BMI of less than 18.5 [24]. Indigenous adults were also more likely to be underweight if:

According to the 2012-2013 AATSIHS, based on BMI information, around 30% of Aboriginal and Torres Strait Islander children aged 2-14 years were overweight (20%) or obese (10%), 62% were in the normal weight range, and 8% were underweight [8]. Similar proportions of Indigenous boys and girls aged 2-14 years were overweight or obese (28% and 32% respectively). After age-adjustment, the combined overweight/obesity levels were slightly higher for Indigenous children aged 2-14 years than those for their non-Indigenous counterparts (ratio 1.2) mainly due to higher obesity rates in Indigenous boys (10% compared with 6%) and girls (11% compared with 7%).

A 2012 study of Indigenous children aged 5 to 17 years in the Torres Strait found that 46% were overweight or obese and 35% had central obesity [25]. Females had higher levels of central obesity (50%) than males (18%). The study also found a consistent association between overweight/obesity and low levels of physical activity.

A study in central Australia found that 21% of Indigenous children aged 3 to 17 years were overweight and 5.4% were obese (there was no difference between males and females) [26]. In comparison, the National health survey 2007-2008 reported 17% of all Australian children aged 5 to 17 years were overweight and 8% obese [27].

Hardy and colleagues [28] found that from 1997 to 2010, overweight/obesity and WHR increased more rapidly in Aboriginal and Torres Strait Islander children than in non-Indigenous children aged 5-16 years in NSW. They identified lack of daily breakfast, excessive screen time and soft drink consumption as the major risk factors and suggested that encouraging strategies to limit screen time held promise.

Immunisation

Vaccination has been very successful in contributing to improvements in Aboriginal and Torres Strait Islander health and child survival in recent decades, with national immunisation coverage rates for Indigenous children improving since 2008 [29]. However, some vaccine-preventable diseases are still experienced at higher rates among Indigenous people than among non-Indigenous people [30]. From 2005, the National immunisation program for all children included vaccines for hepatitis B, diphtheria-tetanus-pertussis (DTP), Haemophilus influenzae type B (Hib), measles, mumps, rubella (MMR) and polio [31]. More recently vaccines have been included for pneumococcal disease, meningococcal C, varicella (chickenpox), rotavirus, HPV, and influenza. In 2013, the National HPV vaccination program was extended to include both females and males aged 12-13 years old, along with a catch up program for males aged 14-15 years old (during 2013-2014) [29].

Some vaccine-preventable diseases are experienced at higher rates among Indigenous people than among non-Indigenous people [30]. Additional vaccines are specifically recommended for Indigenous people, depending on age, location and health risk factors. These include vaccinations for bacille Calmette-Guérin (BCG) for neonates living in areas of high TB incidence, hepatitis A for children living in NT, Qld, SA and WA, hepatitis B for adults not previously vaccinated, influenza, pneumococcal conjugate for children living in NT, Qld, SA and WA and pneumococcal polysaccaride for persons aged 15-49 years old with underlying conditions increasing the risk of IPD and all persons aged 50 years and older.

Childhood vaccination

According to the Australian Childhood Immunisation Register (ACIR), the national coverage for full immunisation for Indigenous children increased from 2008-2012 for the following age-groups:

Coverage estimates at 31 December 2013 indicated that Indigenous children had slightly lower coverage for all vaccines at 1 year of age than other children (86% of Indigenous children fully immunised compared with 90% of other children); coverage for Indigenous and other children was similar at 2 years of age (91% and 92% respectively), and at 5 years of age coverage for Indigenous children was greater than for other children (93% and 92% respectively) [32]. In most states/territories (except SA and ACT), Indigenous children’s vaccination rates were similar or higher than for non-Indigenous children. Vaccination coverage estimates were significantly lower for SA than for other jurisdictions:

In terms of specific vaccines, in 2011, the greatest differences in coverage nationally, was for Hib which was 8.7% lower among Indigenous children than among non-Indigenous children (ratio 0.9) [31].

Adult vaccination

Vaccination against influenza and pneumonia is recommended for Aboriginal and Torres Strait Islander people aged 50 years and over and for non-Indigenous people aged 65 years and over [32]. Influenza immunisation in the previous 12 months for Indigenous adults aged 50 years and older in 2012-2013 was reported by: 51% of those aged between 50-64 years old, 74% of those aged 65 years and above, and overall 57% of those aged 50 years and older. No new data are available on vaccination rates for non-Indigenous adults.

Vaccination rates for pneumoncoccus in the last 5 years for Indigenous people were: 23% of 50-64 year olds, 44% of 65 year olds and older, and 29% overall of 50 years and older [32].

Breastfeeding

Breast milk is the natural and optimum food for babies and provides all the energy and nutrients that an infant needs for the first six months of life [33]. Breastfeeding promotes sensory and cognitive development. It protects the infant against infectious and chronic diseases; exclusive breastfeeding aids a quicker recovery from illness and reduces infant deaths from common childhood illnesses such as diarrhoea or pneumonia. The Australian dietary guidelines’ recommendation is to ‘encourage, support and promote breastfeeding’ [7]. The WHO recommends exclusive breastfeeding for six months followed by complementary feeding with continued breastfeeding for up to two years or beyond [33]. Breastfeeding also contributes to the health of the mother by reducing the risk of ovarian and breast cancers.

According to the 2010 Australian national infant feeding survey, breastfeeding initiation levels were similar among Indigenous and non-Indigenous mothers (87% and 90%, respectively), but levels of exclusive breastfeeding declined more rapidly among Indigenous mothers [34]. At 5 months of age, only 11% of Indigenous babies were exclusively breastfed, compared with 27% of non-Indigenous babies. Around 60% of Indigenous children aged 0-6 months were being breastfed at the time of the survey, compared with 68% of non-Indigenous babies.

The more comprehensive 2004-2005 NATSIHS found that more than four-fifths (84%) of Indigenous mothers aged 18-64 years reported having breastfed their children [35]. The proportion of women who breastfed their children was higher in remote areas (92%) than in non-remote areas (80%).

According to the 2004-2005 NATSIHS, two-thirds (66%) of Indigenous children aged 0-3 years living in non-remote areas were reported to have been breastfed for some period of time [35]. This level is slightly lower than the 72% found among non-Indigenous children. A similar proportion of Indigenous and non-Indigenous infants had been breastfed for 6-12 months (19% and 22%, respectively) and for 12 months or more (11% and 14%, respectively). Around 13% of Indigenous children aged 0-3 years were being breastfed at the time of the survey compared with 16% of non-Indigenous children in the same age-group.

The findings of the 2000-2002 WAACHS suggest that mothers of Indigenous children were more likely to breastfeed for longer than mothers in the general population, particularly those living in more remote areas [36].

The Footprints in time – the longitudinal study of Aboriginal children collected data from 11 sites (rural, remote and urban) around Australia in 2008-2009 [37]. Data on breastfeeding from this study showed that 80% of Indigenous children had been breastfed at some time during their early years, and 22% of Indigenous infants had been breastfed for at least 12 months. This study found that children living in more remote areas had been breastfed for a slightly longer period of time than those living in other areas.

Tobacco use

Tobacco use increases the risk of chronic disease, including CVD, many forms of cancer, and lung diseases, as well as a variety of other health conditions [38]. Tobacco use is also a risk factor for complications during pregnancy and is associated with preterm birth, LBW, and perinatal death. Environmental tobacco smoke (passive smoking) is of concern to health, with children particularly susceptible to resultant problems that include middle ear infections, asthma, and SIDS.

In 2003, tobacco use was the leading cause of burden of disease and injury among Indigenous people, responsible for 12% of the total burden of disease [19]. Tobacco use accounted for one-in-five deaths in the Indigenous population.

Extent of tobacco use among Indigenous people

The 2012-2013 AATSIHS found that 44% of Indigenous people aged 15 years and over reported that they were current smokers [39]. This represents a significant reduction from levels reported in the NATSISS 2008 (47%), and 2002 (51%) [40][41]. The NATSISS found almost two-thirds (62%) of Indigenous current daily smokers reported trying to quit or reduce their smoking in the 12 months prior to interview [42].

In 2012-2013, the proportion of Indigenous men who were current smokers (46%) was similar to the proportion of Indigenous women (42%) [39]. After age-adjustment, Indigenous people were 2.5 times more likely to smoke than non-Indigenous people (44% compared with 17%, respectively).

In 2012-2013, Indigenous people living in remote areas reported a higher proportion of current smokers (53%) than those living in non-remote areas (41%). The age-group with the highest proportion of current smokers in remote areas was the 18-24 years age-group (65%). The overall proportion of current smokers in remote areas in 2012-2013 has not changed significantly since 2002 [43][44].

When comparing smoking prevalence in non-remote areas over the ten years between the AATSIHS 2012-2013 and the NATSISS 2002, the most significant reductions have been found in the younger age-groups: 47% less people are smoking among 15-17 year olds (17% down from 32%); and 27% less people are smoking among 18-24 year olds (41% down from 56%) [43][44]. This drop in smoking among these age-groups is reflected in the increased prevalence of ‘never smoked’. The 2012-2013 AATSIHS found that more than one-third (37%) of Indigenous people had never smoked, compared with 34% in 2008 and 33% in 2002.

High rates of smoking have been reported for Indigenous mothers [45]. In 2011, half of Indigenous mothers (50%) reported smoking during pregnancy, compared with 13% of non-Indigenous mothers. The proportion of smoking cessation for Indigenous women during the second 20 weeks of pregnancy was 11%, compared with 20% among non-Indigenous women.

In 2008, 16% of Indigenous children aged 0-3 years and 23% of Indigenous children aged 4-14 years lived with someone who usually smoked inside the house [46][47]. For Indigenous people aged 15 years and older the proportion was 26% [42].

Alcohol use

Alcohol-related harm includes chronic diseases, accidents and injury, and is not limited to the user but extends to families and the broader community [48]. Consumption of alcohol in pregnancy can affect the unborn child leading to fetal alcohol spectrum disorder (FASD), an umbrella term that describes a range of conditions (comprising abnormalities such as growth retardation, characteristic facial features, and central nervous system anomalies (including intellectual impairment)) [49]. These disorders are incurable, and wholly preventable.

In 2003, the burden of disease attributable to alcohol use among Indigenous people was more than twice that among other Australians (5.4% compared with 2.3%) [50][51]. Of 11 selected risk factors, alcohol was the fifth leading cause of the burden of disease among Indigenous people [50]. The highest levels of disease burden attributable to alcohol use among Indigenous people were for injury (22%), mental disorders (16%), and cancers (6.3%).

Surveys have shown consistently that Indigenous people are less likely to drink alcohol than non-Indigenous people, but those who do drink are more likely to consume it at harmful levels [31][52][53].

Extent of alcohol use among Indigenous people

In the 2012-2013 AATSIHS, 23% of Aboriginal and Torres Strait Islander people aged 18 years or older had never consumed alcohol or had not done so for more than 12 months [53]. After age-adjustment, abstinence was 1.6 times more common among Indigenous people than among non-Indigenous people. Most of the difference in abstinence between the Indigenous and non-Indigenous population was attributable to those Indigenous people who drank alcohol 12 months or more ago - that is, those Indigenous and non-Indigenous drinkers who have since given up (16% and 7%, respectively). Similar proportions of Indigenous and non-Indigenous people have never consumed alcohol (10% and 9%, respectively).

The 2012-2013 AATSIHS found that 17% of Indigenous men and 28% of Indigenous women aged 18 years or older had never consumed alcohol or had not done so in the previous 12 months [53]. After age-adjustment, abstinence was 1.7 times and 1.5 times more common among Indigenous men and women than among non-Indigenous men and women (20% and 32% compared with 12% and 21%, respectively). Again, this difference in abstinence between Indigenous men and women and non-Indigenous men and women is attributable to those who drank alcohol 12 months or more ago (15% and 17% compared with 6% and 9%, respectively).

Box 7: Assessing risks from use of alcohol

In 2009, the NHMRC introduced revised guidelines that depart from specifying 'risky' and 'high risk' levels of drinking [48]. The revised guidelines seek to estimate the overall risk of alcohol-related harm over a lifetime and to reduce the level of risk to one death for every 100 people. For men and women:

  • guideline one states that to reduce the risk of alcohol-related harm over a lifetime no more than two standard drinks should be consumed on any day
  • guideline two states that to reduce the risk of injury on a single occasion of drinking no more than four standard drinks should be consumed
  • guideline three recommends that the safest option is not drinking alcohol for those aged under 15 years and delaying alcohol use for as long as possible for those aged 15 to 17 years
  • guideline four recommends that the safest option for pregnant and breastfeeding women is not to drink alcohol.
Short term and single occasion risk

The 2012-2013 AATSIHS reported that 22% of the Aboriginal and Torres Strait Islander population (aged 18 years and over) drank at short-term low risk in relation to the 2001 guidelines (four or less standard drinks on a single day for women and six or less standard drinks per day for men) and a similar proportion (18%) did not exceed the 2009 guidelines (four or less standard drinks on a single day for both males and females) [53]. Levels of single occasion drinking risk were similar for both Indigenous and non-Indigenous populations (according to the 2009 guidelines). After age-adjustment, 52% of Indigenous people and 45% of non-Indigenous people drank at risk on a single occasion (ratio 1.1). However, (according to the 2001 guidelines) Indigenous people were 1.4 times more likely to drink at levels of ‘high risk’ of short term harm. Indigenous men were 1.5 times more likely than Indigenous women to exceed the guidelines for drinking at risk on a single occasion (68% compared with 46%, respectively). The proportion of Indigenous people exceeding the guidelines for single occasion risk was lower in very remote areas compared with other areas [32].

Lifetime risk

According to the 2013 NDSHS, there was a significant decline in the proportion of Indigenous people exceeding the NHMRC guidelines for lifetime risk (drinking no more than two standard drinks on any single day for males and females) [54]. Findings from the 2012-2013 AATSIHS show that among Aboriginal and Torres Strait Islander drinkers aged 18 years and over, 20% drank at levels exceeding the 2009 guidelines for long-term/lifetime drinking risk [55]. After age-adjustment, lifetime drinking risk was similar for both Indigenous people and non-Indigenous people (ratio 1.0). However, Indigenous people were 1.4 times more likely to drink at ‘high risk’ levels of long term harm (2001 guidelines). Indigenous men were 2.7 times more likely than Indigenous women to exceed the guidelines for risk of long term harm (29% compared with 11%, respectively).

A lower proportion of Aboriginal and Torres Strait Islander people in very remote areas have been found to exceed the guidelines for lifetime risk when compared with other areas (specifically inner regional and remote areas) [32].

Alcohol and pregnancy

According to the 2008 NATSISS, 80% of mothers of Indigenous children aged 0-3 years did not drink during pregnancy, 16% drank less alcohol than usual, and 3.3% drank the same or more alcohol during pregnancy [31]. The proportion of mothers who drank the same or more alcohol during pregnancy was greatest in Tas/ACT (6.0%), followed by Vic (5.4%), and WA (5.0%).

Hospitalisation

Among Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in the two-year period July 2008 to June 2010, 2% of all hospitalisations were for a principal diagnosis related to alcohol use (excluding dialysis) [31]. After age-adjustment, Indigenous males were hospitalised at five times and Indigenous females at four times the rates of their non-Indigenous counterparts. Almost nine-tenths (86%) of hospitalisations related to alcohol use were for mental and behavioural disorders due to alcohol use, including acute intoxication, dependence syndrome, and withdrawal state. The hospitalisation rate for alcoholic liver disease among Indigenous people was six times the rate for non-Indigenous people.

Hospitalisation rates with a principal diagnosis related to alcohol use for Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in 2008-10 varied by level of remoteness. Rates were highest for Indigenous people living in remote areas (14 per 1,000) and lowest for those living in very remote areas (7 per 1,000) [31].

Mortality

There were 382 Indigenous deaths related to alcohol use in NSW, Qld, WA, SA and the NT in the five-year period 2006-2010 [31]. After age-adjustment, death rates for Indigenous males and females were five and eight times higher, respectively, than those for their non-counterparts. Almost seven-tenths (68%; 261 deaths) of deaths were attributed to alcoholic liver disease, with a death rate six times higher for Indigenous people than for non-Indigenous people. The death rate for alcohol-related deaths attributed to mental and behavioural disorders was seven times higher, and the rate for alcohol-related deaths attributed to alcohol poisoning five times higher than for non-Indigenous people.

Illicit substance use

Illicit substance use describes the use of those drugs that are illegal (e.g. cannabis, heroin, ecstasy, and cocaine), the use of volatile substances (e.g. petrol, glue, and solvents), and the non-medical use of prescribed drugs [32]. Illicit substance use is a risk factor for ill-health, increasing the likelihood of infection with bloodborne viruses, and contributing to mental illness, poisoning and self-inflicted injury, and can cause death [32][56].

Illicit substance use accounted for 2.0% of the overall burden of disease in Australia in 2003; it accounted for 8.0% of the mental health burden of disease, and 3.6% of the injury burden of disease [51]. For the same year, illicit substance use was responsible for 3.4% of the burden of disease among the Indigenous population; the highest level of disease burden attributable to illicit substances was for mental health (13%) and injury (3.6%) [50].

Extent of illicit substance use among Indigenous people

The 2012-2013 AATSIHS reported that more than half (52%) of Indigenous people aged 15 years and older had never used illicit substances [57]. Similar proportions were reported in the 2008 NATSISS (57%) [24]. Proportions for never using illicit substances were higher for Indigenous females than for Indigenous males [24][57].

According to the 2012-2013 AATSIHS, 22% of Indigenous people aged 15 years and over had used an illicit substance in the 12 months prior to interview [14], a slight decrease from that reported in the 2008 NATSISS (23%) [24] and the 2004-2005 NATSIHS (28%) (among Indigenous people aged 18 years or over) [35]. While not directly comparable, the level among Indigenous people from 2012-2013 is approximately 1.5 times that reported in the 2013 National drug strategy household survey (NDSHS) among the total Australian population aged 14 years or over (15%) [54]. The 2012-2013 AATSIHS found that illicit substance use in the previous 12 months was highest among younger age-groups: 15-24 years (28%), 25-34 years (27%), 35-44 years (23%), and 45-54 (19%) [57].

The 2012-2013 AATSIHS found that the illicit substance most commonly used by Indigenous people aged 15 years and over in the previous 12 months was cannabis (19%) [57], with a similar level reported in the 2008 NATSISS (17%) [31]. The use of pain killers and sedatives (3.9%), amphetamines (2.3%) decreased slightly when compared with the 2008 NATSISS (4.5% and 4.0%, respectively).

In the 2012-2013 AATSIHS, the proportion of users of illicit substances grouped under ‘other drugs’ (including heroin, cocaine, petrol, LSD/synthetic hallucinogens, naturally occurring hallucinogens, ecstasy/designer drugs, methadone and other inhalants) was 2.8% [57].

In 2012-2013, males were around 1.5 times more likely than females to have used an illicit drug in the previous 12 months (27% and 18%, respectively) [57]. The higher proportions of use by males were found for all drug types, except pain killers/sedatives where proportions were similar (3.6% and 4.1%, respectively). Around twice as many Indigenous males as Indigenous females had used cannabis (24% compared with 14%), amphetamines (2.9% compared with 1.8%), and ‘other drugs’ (3.7% compared with 1.9%).

In 2012-2013, use of illicit drugs in the previous 12 months was greater among Indigenous people aged 15 years or over living in non-remote areas than among those living in remote areas (23% compared with 19%) (this was the case for all drug types except kava) [57]. These proportions are similar to those reported in the 2008 NATSISS (24% and 17%, respectively) [31]. Likewise, in 2012-2013, the proportion of Indigenous people who had ever used illicit substances was higher for those living in non-remote areas (48%) than in remote areas (36%) [57]. These proportions are similar to those reported in the 2008 NATSISS (47% and 31%, respectively) [31].

The 2008 NATSISS found that among Indigenous people aged 15 years or over, a higher proportion of 'recent illicit substance users' were current daily smokers (68%) compared with those who had 'never used illicit substances' (35% were current daily smokers) [31]. A higher proportion of 'recent illicit substance users' reported risky/high-risk drinking (7.3% reported risky/high-risk consumption over 3 days and 8.9% reported risky/high-risk consumption over 7 days) compared with those who had 'never used illicit substances' (3.0% reported risky/high-risk drink consumption over 3 days and 3.7% reported risky/high-risk drink consumption over 7 days).

Higher proportions of Indigenous people who had experienced stressors in the last 12 months were more likely to be 'recent substance users' than those who 'never used illicit substances'. For those who reported recent substance use, 6.4% reported a stressor of ‘witness to violence’ and 5.9% reported a stressor of abuse or violent crime. For those who had never used illicit substances, 2.8% reported a stressor of ‘witness to violence’ and 1.8% reported a stressor of abuse or violent crime. According to the 2008 NATSISS, 95% of mothers of Indigenous children aged 0-3 years did not use illicit substances during pregnancy [31]. The proportion of mothers of Indigenous children who did use illicit substances during pregnancy was highest in Vic (9.3%), followed by WA (8.5%), and lowest in NSW and Qld (both 3.9%).

Hospitalisation

Between July 2012 and June 2013, there were 3,552 hospital separations related to substance use among Indigenous people in Australia (Derived from [32]). The national age-standardised hospitalisation rates for conditions relating to substance use were higher for Indigenous people than for non-Indigenous people [32]. The leading causes of substance use-related hospitalisations for the Indigenous and non-Indigenous populations were ICD 'Mental/behavioural disorders’ and ICD ‘Poisoning’. Indigenous people were hospitalised at 3.1 times the rate for non-Indigenous people due mental and behavioral disorders. Indigenous people were hospitalised at 2.7 times the rate for non-Indigenous people for ICD ‘Accidental poisoning’ and 2.3 times the rate for poisoning. Substance use-related hospitalisation rates for Indigenous people were higher in major cities and decreased with remoteness of residence.

Mortality

The rate of drug-induced deaths was around 1.5 times higher for Indigenous people living in NSW, Qld, WA, SA and the NT than for their non-Indigenous counterparts in 2008-2012 (Table 35) [32]. The rate for Indigenous males (10.8 per 100,000) was higher than for Indigenous females (8.9 per 100,000).

Table 35: Rates of drug induced deaths, by Indigenous status, and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA, and the NT, 2008-2012
JurisdictionIndigenous rateNon-Indigenous rateRate ratio
Source: Derived from Steering Committee for the Review of Government Service Provision, 2014 [32]
Notes:
  1. Rates are per 100,000 (indirect standardisation)
  2. Non-Indigenous does not include deaths where Indigenous status is not stated
  3. Separate rates for the NT were not provided due to low numbers of deaths
NSW 12.6 6.2 2.0
Qld 7.2 6.3 1.1
WA 8.7 7.1 1.2
SA 22.3 6.8 3.3
NSW, Qld, WA, SA and the NT 9.9 6.4 1.5

Sixty-three of the deaths of Indigenous people living in NSW, Qld, WA, SA and the NT in 2003-2007 were attributed to drug use [58]. More than one-half (52%) of these deaths were due to accidental poisoning from narcotics, and 17% from accidental poisoning from organic solvents. In comparison, there were 993 drug-related deaths among their non-Indigenous counterparts, 53% of which were due to accidental poisoning from narcotics and 28% from accidental poisoning from antidepressants.

References

  1. Carson B, Dunbar T, Chenhall RD, Bailie R, eds. (2007) Social determinants of Indigenous health. Crows Nest, NSW: Allen and Unwin
  2. Wilkinson R, Marmot M (2003) Social determinants of health: the solid facts. Denmark: World Health Organization
  3. Marmot M (2004) The status syndrome: how social standing affects our health and longevity. New York: Holt Paperbacks
  4. Gracey MS (2007) Nutrition-related disorders in Indigenous Australians: how things have changed. Medical Journal of Australia; 186(1): 15-17
  5. National Health and Medical Research Council (2000) Nutrition in Aboriginal and Torres Strait Islander peoples: an information paper. Canberra: National Health and Medical Research Council
  6. National Public Health Partnership (2001) National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-2010 and first phase activities 2000-2003. Canberra: National Public Health Partnership
  7. National Health and Medical Research Council (2013) Australian Dietary Guidelines: providing the scientific evidence for healthier Australian diets. Canberra: National Health and Medical Research Council
  8. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012–13. Canberra: Australian Bureau of Statistics
  9. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: biomedical results, 2012-13. Canberra: Australian Bureau of Statistics
  10. Footprints in Time (2012) Footprints in Time: the longitudinal study of Indigenous children: key summary report from Wave 3. Canberra: Department of Families, Housing, Community Services and Indigenous Affairs
  11. Footprints in Time (2013) Footprints in Time: the longitudinal study of Indigenous children: report from Wave 4. Canberra: Department of Families, Housing, Community Services and Indigenous Affairs
  12. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: physical activity, 2012–13. Canberra: Australian Bureau of Statistics
  13. Australia's physical activity and sedentary behaviour guidelines (2014) Australian Government Department of Health
  14. Australian Bureau of Statistics (2013) Australian Aboriginal and Torres Strait Islander health survey: first results, Australia, 2012-13. Canberra: Australian Bureau of Statistics
  15. World Health Organization (2013) Obesity and overweight: fact sheet no 311. Retrieved March 2013 from http://www.who.int/mediacentre/factsheets/fs311/en/
  16. Australian Institute of Health and Welfare (2012) Australia's health 2012. Canberra: Australian Institute of Health and Welfare
  17. Eat for Health: Australian dietary guidelines summary (2013) National Health and Medical Research Council
  18. World Health Organization (2011) Waist circumference and waist–hip ratio: report of a WHO expert consultation .
  19. Vos T, Barker B, Stanley L, Lopez A (2007) The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003. Brisbane: Centre for Burden of Disease and Cost-Effectiveness, University of Queensland
  20. Daniel M, Rowley K, McDermott R, O'Dea K (2002) Diabetes and impaired glucose tolerance in Aboriginal Australians: prevalence and risk. Diabetes Research and Clinical Practice; 57: 23-33
  21. Li M, McDermott RA (2010) Using anthropometric indices to predict cardio-metabolic risk factors in Australian Indigenous populations. Diabetes Research and Clinical Practice; 87(3): 401-406
  22. Gracey M, Burke V, Martin DD, Johnston RJ, Jones T, Davis EA (2007) Assessment of risks of "lifestyle" diseases including cardiovascular disease and type 2 diabetes by anthropometry in remote Australian Aborigines. Asia Pacific Journal of Clinical Nutrition; 16(4): 688-697
  23. Hughes JT, Maple-Brown LJ, Piers LS, Meerkin J, O'Dea K, Ward LC (2015) Development of a single-frequency bioimpedance prediction equation for fat-free mass in an adult Indigenous Australian population. European Journal of Clinical Nutrition; 69(1): 28–33
  24. Australian Institute of Health and Welfare (2011) Aboriginal and Torres Strait Islander health performance framework 2010: detailed analyses. Canberra: Australian Institute of Health and Welfare
  25. Valery PC, Ibiebele T, Harris M, Green AC, Cotterill A, Moloney A, Sinha AK, Garvey G (2012) Diet, physical activity, and obesity in school-aged Indigenous youths in northern Australia. Journal of Obesity; 2012: 893508 Retrieved 28 March 2012 from http://www.hindawi.com/journals/jobes/2012/893508/abs/
  26. Shultz R (2012) Prevalences of overweight and obesity among children in remote Aboriginal communities in central Australia. Rural and Remote Health; 12: 1872 Retrieved 9 March 2012 from http://www.rrh.org.au/articles/showarticlenew.asp?ArticleID=1872
  27. Australian Bureau of Statistics (2009) National Health Survey: summary of results, 2007-2008 (reissue). Canberra: Australian Bureau of Statistics
  28. Hardy LL, O’Hara BJ, Hector D, Engelen L, Eades SJ (2014) Temporal trends in weight and current weight-related behaviour of Australian Aboriginal school-aged children. Medical Journal of Australia; 200(11): 667-671
  29. Haupt I, Fisher R, Weber J, Dunn K (2014) Review of the National Partnership Agreement on Essential Vaccines. Canberra: Sapere Research Group and Sironis Health
  30. The Australian immunisation handbook: 10th edition 2013 (updated January 2014) (2014) Australian Government Department of Health and Ageing
  31. Australian Institute of Health and Welfare (2013) Aboriginal and Torres Strait Islander health performance framework 2012: detailed analyses. Canberra: Australian Institute of Health and Welfare
  32. Steering Committee for the Review of Government Service Provision (2014) Overcoming Indigenous disadvantage: key indicators 2014. Canberra: Productivity Commission
  33. World Health Organization (2013) Exclusive breastfeeding. Retrieved 2013 from http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/
  34. Australian Institute of Health and Welfare (2011) 2010 Australian national infant feeding survey: indicator results. Canberra: Australian Institute of Health and Welfare
  35. Australian Bureau of Statistics (2006) National Aboriginal and Torres Strait Islander Health Survey: Australia, 2004-05. Canberra: Australian Bureau of Statistics
  36. Zubrick SR, Lawrence DM, Silburn SR, Blair E, Milroy H, Wilkes T, Eades S, D'Antoine H, Read AW, Ishiguchi P, Doyle S (2004) The health of Aboriginal children and young people [volumes 1-4]. Perth: Telethon Institute for Child Health Research
  37. Department of Families Housing Community Services and Indigenous Affairs (2009) Footprints in time: the longitudinal study of Indigenous children - key summary report from Wave 1. Canberra: Department of Families, Housing, Community Services and Indigenous Affairs
  38. Australian Health Ministers’ Advisory Council (2012) Aboriginal and Torres Strait Islander health performance framework: 2012 report. Canberra: Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing
  39. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012–13: table 10 smoker status by age, Indigenous status and sex [data cube]. Retrieved 6 June 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&472705500610.xls&4727.0.55.006&Data%20Cubes&848805EF76A00F55CA257CEE0010D8F0&0&2012%9613&06.06.2014&Latest
  40. Australian Bureau of Statistics (2010) National Aboriginal and Torres Strait Islander social survey, 2008: Table 10. Indigenous persons aged 15 years and over, by age groups by sex [data cube]. Retrieved from http://abs.gov.au/AUSSTATS/SUBSCRIBER.NSF/log?openagent&4714.0_aust_010_2008.xls&4714.0&Data%20Cubes&6959208EE47E867DCA25770B0016F56D&0&2008&21.04.2010&Previous
  41. Australian Bureau of Statistics (2004) National Aboriginal and Torres Strait Islander Social Survey, 2002. Canberra: Australian Bureau of Statistics
  42. Australian Bureau of Statistics (2010) The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples, Oct 2010. Canberra: Australian Bureau of Statistics
  43. Australian Bureau of Statistics (2013) Australian Aboriginal and Torres Strait Islander health survey: first results, Australia, 2012-13: Table 12 Smoker status by remoteness areas and age [data cube]. Retrieved 27 November 2013 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&table%2012%20smoker%20status%20by%20age%20by%20remoteness,%202002,%202008%20and%202012-13%20-%20australia.xls&4727.0.55.001&Data%20Cubes&0B71BC8F738DB083CA257C2F00145EB9&0&2012-13&27.11.2013&Late
  44. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012–13: table 11 smoker status by age by remoteness, 2002, 2008 and 2012–13 [data cube]. Retrieved 6 June 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&472705500611.xls&4727.0.55.006&Data%20Cubes&2DFC3927395AF56DCA257CEE0010D921&0&2012%9613&06.06.2014&Latest
  45. Li Z, Zeki R, Hilder L, Sullivan EA (2013) Australia's mothers and babies 2011. Canberra: Australian Institute of Health and Welfare
  46. Australian Bureau of Statistics (2010) National Aboriginal and Torres Strait Islander social survey, 2008: Table 11. Indigenous children aged 4-14 years, by sex [data cube]. Retrieved 21 April 2010 from http://www.abs.gov.au/AUSSTATS/SUBSCRIBER.NSF/log?openagent&4714.0_aust_011_2008.xls&4714.0&Data%20Cubes&F3D13C41FD47C376CA25770B0016F79E&0&2008&21.04.2010&Previous
  47. Australian Bureau of Statistics (2009) National Aboriginal and Torres Strait Islander social survey, 2008; Table 09. Indigenous children aged 0-3 years, by state or territory of usual residence [data cube]. Retrieved from http://abs.gov.au/AUSSTATS/SUBSCRIBER.NSF/log?openagent&47140do009_2008.xls&4714.0&Data%20Cubes&CAAA9C3AC720772ACA25765E001541A1&0&2008&30.10.2009&Previous
  48. National Health and Medical Research Council (2009) Australian guidelines to reduce health risks from drinking alcohol. Canberra: National Health and Medical Research Council
  49. Western Australian Department of Health (2010) Fetal alcohol spectrum disorder model of care. Perth, WA: Health Networks, Western Australian Department of Health
  50. Vos T, Barker B, Stanley L, Lopez A (2007) Burden of disease and injury in Aboriginal and Torres Strait Islander peoples: summary report. Brisbane: Centre for Burden of Disease and Cost-Effectiveness: School of Population Health, University of Queensland
  51. Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez A (2007) The burden of disease and injury in Australia 2003. Canberra: Australian Institute of Health and Welfare
  52. Australian Institute of Health and Welfare (2011) 2010 National Drug Strategy Household Survey report. Canberra: Australian Institute of Health and Welfare
  53. Australian Bureau of Statistics (2013) Australian Aboriginal and Torres Strait Islander health survey: first results, Australia, 2012-13: Table 14 Alcohol consumption - Short-term or Single occasion risk by age, Indigenous status and sex [data cube]. Retrieved 27 November 2013 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&table%2014%20alcohol%20consumption%20-%20sh-term%20or%20single%20occ%20risk%20-age,%20indigenous%20status,%20sex,%202012-13%20-%20australia.xls&4727.0.55.001&Data%20Cubes&0E985E680C399BF7CA257C2F
  54. Australian Institute of Health and Welfare (2014) National Drug Strategy Household Survey detailed report: 2013. Canberra: Australian Institute of Health and Welfare
  55. Australian Bureau of Statistics (2013) Australian Aboriginal and Torres Strait Islander health survey: first results, Australia, 2012-13: Table 13 Alcohol consumption - Long-term or Lifetime risk by age, Indigenous status and sex [data cube]. Retrieved 27 November 2013 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&table%2013%20alcohol%20consumption%20-%20long-term%20or%20lifetime%20risk%20by%20age,%20indigenous%20status%20and%20sex,%202012-13%20-%20australia.xls&4727.0.55.001&Data%20Cubes&D5ABABF005F0BEF3C
  56. Degenhardt L, Hall W (2012) Extent of illicit drug use and dependence, and their contribution to the global burden of disease. The Lancet; 379(9810): 55-70
  57. Australian Bureau of Statistics (2013) Australian Aboriginal and Torres Strait Islander health survey: first results, Australia, 2012-13: Table 15 Substance use by age, remoteness and sex [data cube]. Retrieved 27 November 2013 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&table%2015%20substance%20use%20by%20age,%20remoteness%20and%20sex,%202012-13%20-%20australia.xls&4727.0.55.001&Data%20Cubes&E6B1092ED1C8DC69CA257C2F00145F58&0&2012-13&27.11.2013&Latest
  58. Australian Institute of Health and Welfare (2011) Substance use among Aboriginal and Torres Strait Islander people. Canberra: Australian Institute of Health and Welfare

Endnotes

  1. When an electrical current is passed through the body, fatty tissue offers more resistance than lean tissue. The resistance to the flow of electricity is used to calculate the proportion of body fat in the individual.
 

Table of Contents

collapseCollapse
expand Expand
    Last updated: 11 May 2015
     
    Return to top
    spacing
    general box

    Contribute

    Share your information » Give us feedback » Sign our guestbook »
    spacing
    spacing