Physical environment

Environment is inclusive of the physical envirionment, social issues and cultural ways. The physical environment pages provide details about housing and health-related infrastructure. For information about social issues click here for information about cultural ways click here.

Review of the impact of housing and health-related infrastructure on Indigenous health

Introduction

Aspects of the physical environment interact with social, cultural and economic factors in impacting on health. So, this section, which focuses on the role of housing and health-related essential infrastructure and their relevance to the health status of Indigenous peoples in Australia, should be considered along with the sections providing information about social, cultural and economic aspects.

As well as housing, the aspects of the physical environment summarised in this section include the supply of adequate and safe water, access to electricity, and systems for the effective removal of waste and sewage. These factors are also known as ‘health hardware’ [1, 2]. Other factors of the physical environment, not summarised here, include air quality, noise pollution, residues from pesticides, herbicides and other chemicals.

Before considering the evidence about housing and health-related infrastructure, the following section reviews briefly the impact of these aspects on health.

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Impact of housing and health-related infrastructure on health

The effect of the physical environment on the health status of a population is well recognised – the absence of functional health hardware can have a negative impact on health, particularly with regard to infectious and parasitic diseases (such as diarrhoeal diseases and rheumatic fever), eye and ear infections, skin conditions, and infections of the respiratory tract [3, 4, 5, 6].

Improvements made to the physical environment during the first half of the 20th century led to substantial gains in the health status of the general Australian population. The same improvements have not been achieved in many Indigenous communities, particularly those in remote parts of the country, and thus, many potential health gains have not occurred.
Important aspects of the physical environment that influence the health status of many Indigenous Australians are: general housing characteristics, overcrowded houses, high housing costs relative to income, and inadequate sanitation and water supply [7].

Housing is a particularly significant determinant of the health of Indigenous Australians [8]. Access to adequate shelter is linked to health outcomes in a variety of ways. On a very general level, adequate housing provides shelter from the elements and facilitates the use of and access to other health hardware associated with positive health outcomes. The health effects of housing can be mediated by the design, function, cleanliness and crowding of a dwelling.

Overcrowding is linked with poor health [6], but its actual impact, independent of associated factors (such as poverty, poor housing condition, limited health hardware, and the like), is not entirely clear [9]. Generally, overcrowding is considered to have its main impact on the health of children, particularly in terms of respiratory conditions, skin infections and meningitis, and possibly mental health [6, 9]. Overcrowding also puts increased stress on health infrastructure, such as water supply and sewage disposal systems, and is closely linked to housing standards and conditions.

Inadequate housing standards and limited access to functional health hardware can have a number of negative effects on health outcomes. The breakdown of essential systems such as water supply, sewage disposal and the supply of electricity can lead to health risks and a range of associated health problems.

Access to clean water is essential for healthy living. Diseases associated with the consumption of water of poor quality include gastroenteritis, diarrhoea, typhoid fever and hepatitis [7]. Parasitic diseases associated with contaminated water include giardiasis, dysentery and diarrhoea. Young children are particularly at risk of suffering from potentially severe consequences due to infection with water-borne diseases.

Inadequate water supply may also lead to parasitic infection. Water shortages may restrict water use with negative consequences for personal hygiene and an increased risk of infectious disease associated with the transmission of contaminated human secretions.

The accumulation of human waste and inadequate disposal may lead to contamination of living areas with infected material such as faeces [4, 6]. Organisms such as shigella, E coli, salmonella, and rotavirus contained in this material can cause gastroenteritis. Parasitic infection, hepatitis A, and strongyloidiasis are also associated with inadequate disposal of human waste.

Links between inadequate rubbish disposal and health include: trauma from slipping on wet/dirty surfaces; trauma from glass or other sharp objects and infections from injuries; suffocation of children from plastic bags; fire risk from inflammable materials; and health problems associated with blocked health infrastructure such as sewerage systems [4, 10]. Bore water may be contaminated from waste dumps and undisposed rubbish may lead to an increase in vermin and other disease vectors.

Inadequate power and electricity supply may restrict the capacity of people to carry out healthy living practices such as washing, cooking, food storage, temperature control and lighting. Poor electricity supply or inadequately maintained power supply may also cause trauma and injury [11].

Flooding can pose serious health risks to people living in or near affected areas, including immediate risks such as drowning, interruption of essential services, and damage to health-related infrastructure [4]. Ponding can have serious implications for health, mainly because stagnant water provides breeding grounds for mosquitos that may act as vectors for diseases such as Murray Valley Encephalitis and Ross River Virus.

Home ownership, as such, does not appear to have a direct impact on health outcomes, but the lowest housing costs are experienced by people who own their accommodation. The allocation of a high proportion of income to secure housing reduces the ability to buy other essential goods or services and may thus have an indirect effect on health outcomes [7].

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Housing

Based on a variety of information collected by the Australian Bureau of Statistics (ABS), there are probably around 150,000 Indigenous households in Australia (a household is considered Indigenous if it includes at least one Indigenous resident aged 15 years or older).

Information about Indigenous housing
The five-yearly Australian Census of Housing and Population is the only source of information about all households in Australia [12], but the level of detail available is less than that from two other ABS sources: the Australian Housing Survey (AHS), which collected in 1999 information about people living in private dwellings throughout Australia except those living in ‘sparsely settled or remote areas’ [13]; and the Community Housing and Infrastructure Needs Surveys (CHINS), which collected in 1999 and 2001 information on Indigenous organisations that provide housing to Indigenous people and information about housing in discrete Indigenous communities throughout Australia [12]. The AHS reported information about approximately 145,500 Indigenous households, the 2001 CHINS about more than 21,000 households (almost 4,900 in urban areas and around 16,500 in discrete communities), and the 2001 Census about more than 144,700 households with at least one Indigenous resident across Australia.

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Household size

According to the 2001 Australian Census of Housing and Population, Indigenous households are generally larger in terms of the number of occupants than other Australian households. The average size of an Indigenous household was 3.5 persons compared with 2.6 persons per non-Indigenous household (Table 1) [7]. The average size of Indigenous households increased with remoteness of residence, ranging from 3.2 persons per household in the major cities to 5.3 in very remote areas.

  Indigenous households Other households
Dwellings Number of persons per dwelling Number of persons per dwelling
Major cities 54,916 3.2 2.6
Inner regional 33,347 3.3 2.5
Outer regional 32,756 3.4 2.5
Remote 10,193 3.6 2.5
Very remote 13,520 5.3 2.5
All regions 144,732 3.5 2.6
Source: ABS & AIHW, 2003

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Overcrowding

The proportion of households requiring additional bedrooms provides some indication of overcrowding: 15% of Indigenous households were considered as requiring at least one additional bedroom, compared with around 4% of other households [7]. The proportions of Indigenous households requiring additional bedrooms ranged from 11% in major cities to 42% in very remote areas.

The actual extent of overcrowding will reflect not only usual residents, but also temporary visitors. Seventy-three per cent of discrete Indigenous communities in remote and very remote parts of Australia reported, in the 2001 Community Housing and Infrastructure and Needs Survey (CHINS), experiencing temporary increases in community size lasting two weeks or more in the previous 12 months [12]. Seventy-one per cent of such temporary expansion was due to cultural reasons, 45% to holiday visitors, and 33% to sporting and other recreational events. In 20% of the communities, the number of temporary visitors was equal to or exceeded the number of permanent dwellers. Such temporary increase in community-size is a substantial factor in temporary overcrowding in Indigenous communities, thus posing increased risks to the health of the people involved.

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Condition of housing

Nineteen per cent of Indigenous households in non-remote areas reported their accommodation to be in high need of repairs, compared with 7% of non-Indigenous households [13]. In remote and very remote areas, in which 70% of dwellings are managed by Indigenous Housing Organisations (IHO), 19% needed major repairs and 10% needed replacement [12]. For dwellings managed by IHOs, there was virtually no change between 1999 and 2001 in the proportions requiring major repairs or replacement.

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Form of tenure

The form of housing tenure may have indirect implications for health outcomes. Forms of tenure are home ownership (with and without mortgage) and renting (from private, government or non-government landlords). According to the 2001 Census, 63% of Indigenous households were renting their accommodation compared with 27% of non-Indigenous households. Only 13% of Indigenous households owned their homes outright compared with 40% of non-Indigenous households [7].

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Water

Access to clean water is essential for healthy living. Ideally, the quantity supplied fully meets domestic needs for drinking, personal hygiene, bathing and food preparation. The water quality with regard to micro-organisms and chemical residues and other disease-inducing agents is of major importance to health outcomes.

Bore water was reported to be the main source of drinking water for 62% of the total number of discrete Indigenous communities included in the 2001 CHINS [12]. Smaller communities (less than 50 people) were less likely to be connected to a town supply (8%) compared with larger communities (more than 50 people), which where more likely to be connected to a town supply (34%). Town water is the main source of water for 17% of the total discrete Indigenous population living in communities.

In 2001, water restrictions affecting discrete Indigenous communities were significant, with 35% of Indigenous communities (with a usual population of 50 or more) having experienced water restrictions within the previous year [12]. This is consistent with the water restrictions recorded for Indigenous communities in the 1999 CHINS survey [14]. A large proportion of water restrictions (61%) was due to equipment failure [12]. Seasonal temperature increases (in the dry season) accounted for 18% of water shortages and drought for only 5%.

Testing the water quality at certain intervals is essential to ensure that it is free of hazardous micro-organisms, chemicals and other potentially health threatening agents. Information gathered from 213 of 216 discrete Indigenous communities with 50 or more residents who were not connected to town water, found that 20% of these communities did not have their water tested within the previous year [12]. Twenty six per cent of the communities had drinking water of poor quality and failed testing at least once within the previous year.

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Sewerage and drainage

According to the 2001 CHINS, 7% of discrete Indigenous communities had no organised sewerage system [12]. Septic tanks with leach drains were the predominant form of sewerage system used in 49% of all discrete Indigenous communities (comprising 20% of the total Indigenous population). Larger communities (200 people or more) were more likely to use water-borne systems (47% of the population of all communities).

Sewerage system failure, such as overflows or leakages, can have serious implications for the health of community residents. Forty-eight per cent of 327 discrete Indigenous communities reported a sewage overflow or leakage within the year leading up to the 2001 CHINS. Blocked drains, equipment failure and design and installation problems were the main causes for sewerage system failures in Indigenous communities with a population of 50 or more [12].

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Rubbish disposal

Regular, organised rubbish disposal is an important factor in community health. It can prevent chemical- and food poisoning, physical trauma from sharp and insecure objects and infectious diseases associated with vector agents such as vermin and insects [4].

A total of 94% of the 327 discrete Indigenous communities with a usual population of 50 or more included in the 2001 CHINS had organised rubbish collections in place [12]. In 309 (97%) of these communities, rubbish collection was carried out on a weekly basis. Rubbish was disposed of in an unfenced tip in 53% of all communities – this may allow rubbish to be spread by dogs and other vectors or blown from the tip.

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Electricity and gas

Access to electricity and gas allows for the operation of health-related infrastructure, such as lighting, heating and cooling, water heating, refrigeration of foods, power supply for kitchen appliances, communication, education, and the use of other electrical equipment.

Seven per cent of all discrete Indigenous communities with populations under 100 people included in the 2001 CHINS had no organised electricity supply [12]. Most of these communities had 20 or fewer residents. A total of 681 people live in communities without an organised supply of electricity. Six per cent of communities of 100 or less residents with permanent houses had access to an organised electricity supply, with only one or two houses without connection to electricity.

Generators were the main source of organised electricity for 66,451 people living in 647 discrete Indigenous communities (53% of the discrete communities) included in the 2001 CHINS [12]. Communities with a population of more than 50 people were more likely to be connected to the state electricity grid (46%) than were communities with less than 50 residents (12%). Overall, 36,909 people living in 260 communities (21%) received their electricity through the state grid or another form of transmitted electricity [12].

A total of 267 discrete Indigenous communities (82% of the 327 discrete Indigenous communities with 50 or more residents) experienced electricity interruptions within the year prior to the 2001 CHINS [12]. Five or less power cuts within that period were reported to have occurred in 37% of the affected communities. One-fifth of the affected communities experienced 20 or more electricity interruptions within the year prior to the 2001 CHINS. The main causes for electricity interruptions were storms, equipment breakdown and planned outages for maintenance reasons (42%).

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Flooding and ponding

Flooding can be described as situations in which ‘watercourses overflow and inundate either part or all sections of the community’ [4]. Flooding of areas was reported in the 2001 CHINS by 31% of the discrete Indigenous communities with 50 or more residents [12]. The flooding lasted for at least four weeks in 24% of the communities.

Ponding, which is defined as the formation of ‘pools of still water that remain stagnant for a period of one week or more and cover an area of at least 10 square metres’ [4], is reported to have occurred in 42% of the discrete Indigenous communities with 50 or more residents in the year prior to the 2001 CHINS [12]. In 46% of affected communities, ponding occurred more than five times during that year and 39% of communities experienced ponding.

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Addressing environmental health in Indigenous communities

Healthy living practices

The provision of housing and associated infrastructure is essential to improve the health of Indigenous people [3] and will facilitate healthy living practices, which also play a key role in health outcomes [6]. Healthy living practices include: personal hygiene, washing clothes, removing waste, improving nutrition, reducing crowding, separating dogs and children, controlling dust, controlling temperature and reducing trauma.

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Environmental health workers

Indigenous environmental health workers play a vital role in promoting healthy living practices, and maintaining infrastructure to ensure long-term, effective use [6].
The National Environmental Health Strategy - developed in 1999 by the National Environmental Health Forum (now the enHealth Council) under the auspices of the National Public Health Partnership [15] - acknowledges that Indigenous environmental health workers are central to promoting and enhancing environmental health in Indigenous communities [16].

Indigenous environmental health workers are integral to efforts to manage environmental health needs associated with housing, water quality, refuse, food safety and sanitation [17]. Their duties involve taking an active role in the maintenance and inspection of their community’s infrastructure, and the reporting of any environmental concerns to relevant government bodies. They frequently undertake a range of specific activities, such as rubbish disposal and dog and pest control [12]. Keeping records of environmental health conditions within the community; reporting to the community council; and providing education to community members regarding healthy living practices are also among their tasks [2].

Promoting and creating sustained environmental health improvements in remote Indigenous communities requires a dedicated and well trained health workforce, but across Australia vocational training and education for Indigenous environmental health workers lacks uniformity, and wages, conditions, and support vary [11].

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National Indigenous Environmental Health Forum

In May 1999, the enHealth Council established the National Indigenous Environmental Health Forum (NIEHF). The NIEHF, a sub-committee of the enHealth Council, is comprised of Indigenous environmental health practitioners from each state and territory [16]. Facilitating the development of an appropriately supported and trained Indigenous environmental health workforce is central to NIEHF objectives. The NIEHF advises the enHealth Council and makes recommendations for Indigenous environmental health [15, 18]. Its aims are to [19]:

  • provide a mechanism for environmental health workers to participate in decision-making and information-sharing;
  • be a reference group for the enHealth Council to comment on issues and information referred by the enHealth Council, or identified by the NIEHF, that impact on the work of Indigenous environmental health;
  • facilitate community representation and consultation; and
  • convene biennial national Indigenous environmental health conferences.

In 2004, the enHealth Council released a discussion paper reviewing the work undertaken by Indigenous environmental health workers, and outlining existing training and classification systems across jurisdictions. The discussion paper arose from a NIEHF workshop convened in 2003. Its primary objective is to develop an action plan to improve Indigenous environmental health by ensuring a sustained role for Indigenous environmental health workers in its management [16].

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Conferences

National Indigenous environmental health workshops and conferences have been held since 1988 to [15]:

  • provide a forum for the discussion of Indigenous environmental health issues;
  • raise the profile of relevant issues; and
  • give Indigenous environmental health practitioners a voice.

The aim of these forums is to help identify the concerns and issues facing environmental health workers and their communities by providing an opportunity to: share information; present papers on successful projects and innovative techniques; establish networks with environmental health workers in other States and Territories; and highlight common issues that would benefit from attention nationally [19].

Indigenous environmental health workforce development has been a recurring theme at conferences and workshops. The development needs, work impediments and ways forward for Indigenous environmental health workers have been the subject of discussion and various issues have been identified, including: training; career paths; support and representation; award wages linked to qualifications; and working in partnerships [16].

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Summary

The physical environment has a strong influence on the health of many Indigenous people, particularly those living in remote or very remote parts of Australia.

Indigenous households are significantly larger in size than other Australian households. Overcrowding is common for many Indigenous households, and may increase risks to health. Indigenous people are more likely than other Australians to live in rented houses, resulting in relatively higher accommodation costs. Dwellings in many Indigenous communities are more likely to require repairs or replacements than are dwellings occupied by non-Indigenous people. Many Indigenous communities experience disruptions to their electricity and water supplies, mainly due to equipment failure. Rubbish disposal is organised widely, but inadequacies (such as a lack of fencing around the tips) increase risks to health. Flooding and ponding occur in a large number of Indigenous communities.

The provision of high quality housing and related infrastructure (to the standards experienced by other Australians) is essential to ensure more equitable health outcomes for Indigenous people, but this alone does not guarantee sustained health benefits. National policy initiatives, including: the establishment of the NIEHF; the conduct of national conferences; and efforts to support the development of a well-trained Indigenous environmental health workforce are also integral to current endeavours to develop a healthy environment for Indigenous communities.

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References

1. Australian Department of Family and Community Services (2003) National Indigenous housing guide: improving the living environment for safety, health and sustainability. 2nd ed. Canberra: Australian Department of Family and Community Services
View full report (PDF - 553KB)
2. Territory Health Services (2002) The public health bush book. 2nd ed. Darwin: Territory Health Services
View contents
3. Bailie RS, Runcie MJ (2001) Household infrastructure in Aboriginal communities and the implications for health improvement. Medical Journal of Australia;175:363-366
View full paper
4. Bailie R, Siciliano F, Dane G, Bevan L, Paradies Y, Carson B (2002) Atlas of health-related infrastructure in discrete Indigenous communities. Melbourne: Aboriginal and Torres Strait Islander Commission
View HealthInfoNet abstract
5. Thomson N, ed. (2003) The health of Indigenous Australians. South Melbourne: Oxford University Press
View HealthInfoNet abstract
View abstract
6. Pholeros P, Rainow S, Torzillo P (1993) Housing for health: towards a healthy living environment for Aboriginal Australia. Newport Beach NSW: HealthHabitat
7. Australian Bureau of Statistics, Australian Institute of Health and Welfare (2003) The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples 2003. Canberra: Australian Institute of Health and Welfare and the Australian Bureau of Statistics
View HealthInfoNet abstract
View full report
8. Taylor V (2001) Health hardware for housing for rural and remote Indigenous communities. In: Canyon D, Speare R, eds. Rural and remote environmental health 1. Brisbane: The Australasian College of Tropical Medicine:42-49
View contents
9. Office of the Deputy Prime Minister (2004) The impact of overcrowding on health and education: a review of the literature. London: Office of the Deputy Prime Minister
View summary
10. Harris G, ed. (2000) Environmental health handbook: a practical manual for remote communities. Darwin: Menzies School of Health Research
View full report (PDF - 2.08MB - large file warning!)
11. Wayte K, Bailie R, Gray N, Henderson G (2004) Framework for research on Aboriginal health and the physical environment: final report. Darwin: Cooperative Research Centre for Aboriginal Health
12. Australian Bureau of Statistics (2002) Housing and infrastructure in Aboriginal and Torres Strait Islander communities, Australia 2001. Canberra: Australian Bureau of Statistics
View HealthInfoNet abstract
View summary
13. Australian Bureau of Statistics (2001) Australian housing survey - Aboriginal and Torres Strait Islander results. Canberra: Australian Bureau of Statistics
View summary
14. Australian Bureau of Statistics (2000) Housing and infrastructure in Aboriginal and Torres Strait Islander communities, Australia 1999. Canberra: Australian Bureau of Statistics
View summary
15. enHealth Council (2000) Indigenous environmental health: report of the Second National Workshop, 20-21 May 1999, Broome, Western Australia. Canberra: Commonwealth Department of Health and Aged Care
View HealthInfoNet abstract
View full report (PDF - 607MB)
16. enHealth Council (2004) National review of Indigenous environmental health workers: discussion paper. Canberra: enHealth Council, Department of Health and Ageing
17. Queensland Health (2004) Indigenous environmental health, information for health professionals. Retrieved 28 October 2004 from http://www.health.qld.gov.au/HealthyLiving/Indigenous_Environmental_Health_HP.htm
18. Urbis Keys Young (2002) Accountability in Indigenous Environmental Health Services, Australia 2002, Indigenous environmental health mapping project. Canberra: Commonwealth Department of Health and Ageing
View full report (PDF - 614KB)
19. enHealth Council (2001) Indigenous environmental health: report of the third national conference, 14-16 November 2000, Alice Springs, Northern Territory. Canberra: Commonwealth Department of Health and Aged Care
View full report (PDF - 621KB)

Last updated: 1 May 2008