Reviews
Information about men's health issues for Indigenous Aboriginal and Torres Strait Islander peoples is reviewed here.
Summary of Indigenous men's health
Indigenous males have a lower life expectancy, poorer health and higher incarceration rates than other Australian males [1]. They are exposed to many health risk factors and stressors across their life span. Many Indigenous men experience barriers in accessing health services, particularly in remote areas. There is a need for improving culturally appropriate service provision and training more Indigenous male health workers [2]. Awareness of health issues, including those specific to men (for example, prostate and testicular cancers), needs to be increased among Indigenous men. A holistic approach is required for addressing Indigenous men's health - encompassing social, environmental, emotional and spiritual factors, philosophies, histories and community contexts of culture [3, 4]. A focus on social and emotional wellbeing includes providing supportive and healthy environments and addressing identity and land issues.
It is important to consider Indigenous men's health within an historical context. Before colonisation, Indigenous men had meaningful, active roles, with authority and status within the family and community [5]. The kinship system ensured that members of a community knew where they stood with each other and their responsibilities and obligations were clearly defined. Male Elders were responsible for the management and maintenance of traditional obligations, sacred objects, spiritual matters and the performance of ritual. They provided leadership, including resolving disputes, educating the young and advising on marriage partners. Elders were entrusted with custodianship of the law and an overriding duty to maintain it and pass it down to the next generation [6].
In traditional Aboriginal and Torres Strait Islander societies, young men had a clear passage to manhood [6]. During initiation processes, boys were taught the rights and obligations of adult males, and some of the secrets of the sacred law. Initiation was a test of worthiness and courage designed to instill qualities of discipline, self-reliance, obedience, and cooperativeness. A young man gained status by participating in further tests and ceremonies during subsequent years. A man became entrusted with more secrets about the sacred law and grew in power and influence.
The process of colonisation was demoralising to Aboriginal and Torres Strait Islander people [4]. Men were forced to adopt a lifestyle alien to their traditional roles within communities and family structures [4]. The introduction of colonial law, segregation and assimilation policies, and the institutionalisation of Indigenous people in effect prevented (or severely limited) them from practising or participating in traditional rituals and customs. This resulted in long-term physical and psychological effects on Aboriginal and Torres Strait Islander people.
The imposition of a non-traditional existence had damaging impacts on the health of Aboriginal people, particularly men, with negative economic, cultural and social effects [7]. Psychological effects include feelings of hate, anger, frustration, grief, depression and alienation [3]. Denial of their traditional culture has been a commonplace technique used by Indigenous men in order to survive within the dominant, non-Indigenous society. Feelings of grief and loss, demoralisation, trauma and mental distress are often associated with substance misuse, violence and destructive behaviours, but the mental health issues of Indigenous men are poorly researched and understood [4]. In considering the health and wellbeing of Indigenous men, it is important also to take into account the construction of 'masculinity', the relationships between Indigenous males and females, and concepts of health which may differ from Anglo-European ways of thinking [8].
Historical and socioeconomic factors have been linked to socio-somatic illness among Indigenous Australians: that is, 'those physical ailments, bodily disorders and psychological or mental conditions that impair the health of Aboriginal people and the wellbeing of Aboriginal communities, and which result either directly or indirectly from sociological disadvantage; economic deprivation; racism; assimilationist legislation, policies and practices; unemployment; lack of housing; dispossession, alienation from land, and forced separation from parents, children, families and communities; and other traumas, which impinge upon Aboriginal people and have done so since dispossession' [4].
There are recent positive signs, however, that may contribute to improvements in the health of Indigenous men [8]. These include: an increasing focus on Indigenous men's health; the provision of men's health clinics; the formation of men's health groups; conferences; promotion of role models; and increasing Indigenous leadership. For Indigenous males, the need to gain control over the conditions that affect their health and wellbeing is paramount. Underlying the health issues are the political, economic and cultural dispossession and disempowerment of Aboriginal and Torres Strait Islander males. Indigenous men's health needs to be specifically targeted with culturally appropriate services - and the need is urgent.
Health status of the male Indigenous population
Population
Based on figures from the 2001 Australian Census of Housing and Population, the Australia-wide population of Indigenous males was projected to be 255,543 at 31 December 2007 [9]. About 37% of Indigenous males were less than 15 years old, compared with 19% of non-Indigenous males (based on the non-Indigenous male population at 30 June 2004).
Mortality and life expectancy
Experimental life expectancy for Indigenous males at birth for 1996-2001 is estimated to be around 60 years - around 17 years less than for males in the total Australian population (77 years) [10].
For residents of Queensland, Western Australia, South Australia, and the Northern Territory - the jurisdictions with reasonable identification of Indigenous status - there were 909 deaths identified as Indigenous males in 2006. In those jurisdictions, 73% of Indigenous males died before the age of 65 years [10]. In comparison, only 25% of deaths of non-Indigenous males occurred before 65 years. The median age at death ranged from 45 to 59 years for Indigenous males, and from 65 to 78 years for non-Indigenous males.
Age-specific death rates for Indigenous males were at least double those experienced by the total population, except for those aged 75 years or older [10]. The greatest differences between Indigenous and total population males occurred in the 35-44 and 45-54 years age groups, with rates up to six times greater than those recorded for the total population.
Causes of death
The most recent detailed information about causes of death for Indigenous males are for 1999-2003 and relate only to Queensland, Western Australia, South Australia and the Northern Territory [11].
For those jurisdictions in that time period, cardiovascular disease was responsible for 27% of Indigenous male deaths. The ratio of the number of Indigenous male deaths to the number expected from rates for the non-Indigenous male population – known as the standardised mortality ratio (SMR) – was 2.9 for deaths from cardiovascular disease.
Death rates from cardiovascular disease were higher for Indigenous males than for non-Indigenous males for every age group [11]. The greatest differences in age-specific death rates for males was in the age groups 25-34 and 35-44 years, with rates for Indigenous males 8 to 9 times higher than those for non-Indigenous males . For deaths attributed to cardiovascular disease, ischaemic heart disease (heart attack, angina) was responsible for 63% of Indigenous male deaths, and cerebrovascular disease (stroke) for 15% of deaths.
The next most common causes of death for Indigenous males living in Queensland, WA, SA and the NT in 1999-2003 were those resulting from external causes (such as accidents, intentional self harm/suicide and assault), which accounted for 16% of all Indigenous deaths [11]. The Indigenous: non-Indigenous SMR for external causes was 2.7. The most common external causes were suicide (34%), transport-related injuries (27%) and assault (11%). Among males under 34 years, the Indigenous suicide rate was three times higher than that for non-Indigenous males. For deaths caused by assault, the rates for Indigenous males in the 10-year age groups between 25 to 54 years were 10 to 18 times those of non-Indigenous males.
Of the major death groupings, the highest Indigenous: non-Indigenous SMR for males - 7.5 - was for ‘endocrine diseases and metabolic diseases’ [11]. These deaths were predominantly due to diabetes mellitus. In 1999-2003, diabetes was recorded as the underlying cause of death for 8% of Indigenous people, compared with 2% of non-Indigenous Australians. The differences in death rates from diabetes were greatest in the 35-44 and 45-54 years age groups, for which groups the rates for Indigenous males were 23-25 times those for males in the total population.
Other important causes of death for Indigenous males living in Queensland, WA, SA and the NT in 1999-2003 were:
- neoplasms (cancers) – responsible for 14% of total Indigenous deaths, with an Indigenous:non-Indigenous SMR of 1.5.
- respiratory disease – responsible for almost 9% of total Indigenous deaths, with an Indigenous:non-Indigenous SMR of 4.0.
- chronic kidney disease – responsible for 3% of Indigenous male deaths, with an Indigenous:non-Indigenous SMR of 7 [11]
Multiple causes of death include all causes and conditions reported on the medical certificate of death incorporating the underlying, immediate and other associated causes of death [11]. Multiple causes of death were more common among Indigenous people, numbering 84% of total Indigenous male deaths compared with 77% of non-Indigenous male deaths
Hospitalisation
Almost 6% of hospital separations for males living in Queensland, WA, SA and the NT in 2005-06 were identified as Indigenous [12]. Indigenous males, after adjusting for age, were about two times more likely to be hospitalised than were non-Indigenous males. Detailed information about these separations is not available, however. The following information relates to separations in 2003-04 for all Australian jurisdictions, even though only the data for WA, SA and the NT were deemed ‘acceptable’ in relation to the level of completeness of Indigenous identification [11].
There were more than 90,000 separations of Indigenous males from hospital across Australia in 2003-04, with a separation rate more than twice that of non-Indigenous males [derived from 13].
More than 38% of all separations of Indigenous males were for care involving renal dialysis for chronic kidney disease – at a rate almost 9 times that of non-Indigenous males [11]. Of course, a large proportion of these separations involved very frequent hospitalisation of the same men – even 2-3 times per week – so these data are not really comparable with those summarised below for other conditions.
The ICD group ‘injury and poisoning’ was responsible for the next highest number of separations of Indigenous males, more than 9,600 [11]. More than 7,600 of these – 10.3% of all separations of Indigenous male – were for injury of some kind, at a rate 1.6 times that of non-Indigenous males. The main specific forms of injury were:
- assault –2.1% of all separations of Indigenous males at a rate 6.7 times that of non-Indigenous males;
- accidental falls – 1.8% of all separations of Indigenous males at a rate 1.3 times that of non-Indigenous males
- transport injuries – 1.1% of all separations of Indigenous males at a rate 1.1 times that of non-Indigenous males; and
- self-inflicted injury – 0.5% of all separations of Indigenous males at a rate 2.4 times that of non-Indigenous males.
Other important causes of hospitalisation for Indigenous males were:
- respiratory disease – responsible for 8.6% of all separations of Indigenous males at a rate 2.0 times that of non-Indigenous males. More than one-quarter of Indigenous separations for respiratory disease was attributed to influenza and/or pneumonia;
- mental and behavioural disorders – responsible for 5.3% of all separations of Indigenous males at a rate 2.1 times that of non-Indigenous males. Almost one-half of Indigenous separations for mental and behavioural disorders was attributed to substance use;
- cardiovascular disease – responsible for 4.1% of all separations of Indigenous males at a rate 1.8 times that of non-Indigenous males; and
- infectious and parasitic conditions – responsible for 2.8% of all separations of Indigenous males at a rate 1.9 times that of non-Indigenous males [11].
Factors contributing to the health of Indigenous men
The factors contributing to the poor health status of Indigenous men should be seen within the broad context of the ‘social determinants of health’ [14, 15]. These ‘determinants’, which are complex and interrelated, include income, education, employment, stress, social networks and support, social exclusion, working and living conditions and behavioural aspects. Related to these are cultural factors, such as traditions, attitudes, beliefs, and customs. Together, the social and cultural factors have a major influence on a person’s behaviour [14-16].
The access or otherwise to health services is another factor that can modify the influence on these underlying factors on the health of individuals [16].
Social and economic factors
Education: In the 2001 Census it was reported that Indigenous males were less likely than non-Indigenous males to have completed year 12 or equivalent and were also less likely to have completed year 12 than Indigenous females (19% and 16% respectively) [17]. Approximately 19% of Indigenous males reported a non-school qualification compared with approximately 46% of males in the non-Indigenous population.
Employment: The 2001 Census recorded a lower labour force participation rate for Indigenous males (61%) compared with non-Indigenous males (71%) [17]. There was a higher proportion of Indigenous males (47%) than females (36%) in employment. The Community Development Employment Project (CDEP) aims to create local employment opportunities in remote Indigenous communities where the labour market might not provide employment opportunities. CDEP accounts for 20% of Indigenous male employment. The rate of unemployment for Indigenous males was 22% compared with 8% for non-Indigenous males.
Income: In 2001 the average (mean) equivalised income gross household income for Indigenous persons was $364 per week which is 62% of the corresponding income for non-Indigenous persons at $585 per week [17]. Indigenous households tend to be larger than non-Indigenous households.
Incarceration: In June 2004 there were 5,048 Indigenous prisoners in Australia representing 21% of the prisoner population (only 2% of the total adult male Australian population is Indigenous) [11]. After adjusting for age, Indigenous Australians were 11 times more likely than non-Indigenous Australians to be imprisoned, with 92% being male. Over the decade 1992-2004, the proportion of Indigenous prisoners increased from 14% to 21% [11]. For Indigenous men, it has been asserted that mental ill health is a key contributor to higher incarceration rates, violence and deaths in custody, and may often be attributable to low socioeconomic status and/or historical factors [4].
Health risk factors
Indigenous men are vulnerable to the effects of a range of risk factors, as reported in the 2004-05 National Health Survey [18]:
- Indigenous males 18 years and over were twice as likely as non-Indigenous males to report that they were current smokers [18].
- Indigenous males were more likely to be classified as obese than were non-Indigenous males. In the 55 years and over age group this was as high as 30% for Indigenous males compared with 18% for non-Indigenous males [18].
- Indigenous adults were more likely than non-Indigenous adults to have consumed alcohol in the past week [18]. For Indigenous males, hazardous levels peaked in the 35-44 years age group with 17% reporting high risk levels of alcohol consumption. The proportion of Indigenous males who consumed alcohol at risky or high risk levels was generally higher than that for females, with variations across the age groups.
- Around 22% of Indigenous people reported illicit substance use at least once in their lifetime [18]. 56% of males had used substances compared with 46% of females. The most commonly used substances by males were marijuana (29%) followed by amphetamines (10%).
- 5% of Indigenous Australians do not eat vegetables daily, and 14% do not eat fruit daily. 4% do not drink milk and 46% usually add salt after cooking [18].
Access to health services
Access to health services can be affected by a range of physical, economic, cultural and personal factors, availability of transport, distance to and availability of services, possession of private health insurance, and proficiency in English [11]. Also of importance is the extent of involvement of Indigenous people in the provision of services, and community control of services. It is important that health services are culturally appropriate and that there is access to a health professional of the same sex [2]
A number of Indigenous health services provide men's health clinics, including: Anyinginyi Congress Aboriginal Medical Service ( Tennant Creek, NT), Bega Garnbirringu ( Kalgoorlie , WA) and WuChopperen Health Service ( Cairns, Qld).
Towards a national framework for the health of Indigenous men
At the Rural Health Conference 2003, Mick Adams outlined the first proposed National Framework for Improving the Health and Wellbeing of Aboriginal and Torres Strait Islander Males, and the history of its development [3]. The following sections summarise his presentation.
Framework outline
The Framework is based on a comprehensive health care approach to improving the health status of Aboriginal and Torres Strait Islander males and addressing their high burden of disease and greater prevalence of risk factors [3]. It is intended to complement and support existing health strategies and policies with broader population initiatives (at national and local levels), which could include targeted health issues. Improvements have been achieved in isolated cases such as at the Gapuwiyak Men's Clinic, where significant and sustained increases in attendance have been reported since 1997 [19]. The general approach is based on the need for interventions across the continuum of care, underpinned by a high quality workforce and appropriate research.
The aim of the Framework is to address Indigenous men's issues incorporating the 'grass roots' movement of men who want to claim back their right to decent standards of health and wellbeing [3].
History
The first National Aboriginal and Torres Strait Islander Male Health Convention was held at Ross River in October 1999. A reference group emerged from this gathering comprising a collection of like-minded men who were charged by the conference to highlight, promote and address issues associated with Aboriginal and Torres Strait Islander male health and well-being [3].
In 2000 the National Aboriginal and Torres Strait Islander Male Health Policy Forum was held and a working party was formed to provide advice to the Office for Aboriginal and Torres Strait Islander Health (OATSIH), who had been given the task of coordinating the development of the Framework [3]. The Framework is the result of substantial negotiation across jurisdictions.
In 2001 the Guiding Principles which underpin the Framework were noted and accepted by the National Aboriginal and Torres Strait Islander Health Council. They call for: reconstructing male empowerment and self-determination; a holistic approach, continuum of care; shared intersectoral responsibilities; a partnership approach; strategy and policy development; access and support; and workforce initiatives.
Key areas of focus
Seven key areas of focus have been identified, which were informed by the Aboriginal and Torres Strait Islander Male Health Forum report (August 2000). They reflect concerns raised by men's forums and various levels of discussion and provide a point of reference for stakeholder consideration and action. They include:
- partnerships and collaboration
- integrating Aboriginal and Torres Strait Islander male health in targeted health strategies and services
- improving access to appropriate health care
- workforce, education and training
- health promotion and prevention
- building the evidence base
- a healthier generation.
It is recognised that improvements in Aboriginal and Torres Strait Islander male health and well-being may not be easily measured in the short term and that a long term strategy is therefore needed. It is suggested that that the framework will be in place initially for a period of 3 years with importance placed on information exchange in the following key areas:
- improvements in Aboriginal and Torres Strait Islander male health and well-being
- the acceptance, commitment and support of the Framework key stakeholders
- progress and achievements in the key areas of focus
- the ongoing effectiveness and sustainability of the Framework and the commitment and sustainability of partnerships
The Working Party is seeking the endorsement of the Framework by SCATSIH and have asked that the SCATSIH refer the Framework to Australian Health Minister's Advisory Council (AHMAC) for its consideration and endorsement. As a general position the Working Party would like to see:
- all Aboriginal Health Forums consider prioritising male health issues within existing and future planning processes
- all national strategies consider their impact on Aboriginal and Torres Strait Islander male health.
Launch
In October 2005, a lack of national funding for the 4th National Aboriginal and Torres Strait Islander Male Health Convention led to its incorporation with the 6th National Men’s Health Conference. During this conference Indigenous men launched the National Framework for Improving the Health and Wellbeing of Aboriginal and Torres Strait Islander Males, but it has yet to be implemented [20, 21].
References
1 National Aboriginal and Torres Strait Islander Health Council (2003) National strategic framework for Aboriginal and Torres Strait Islander health: framework for action by governments. Canberra: National Aboriginal and Torres Strait Islander Health Council
2 Briscoe A (2000) Indigenous men's health access strategy. Aboriginal and Islander Health Worker Journal;24(1):7-11
3 Adams M (2003) The national framework for improving the health and wellbeing of Aboriginal and Torres Strait Islander males. Paper presented at the National Rural Health Conference 1-4 March 2003, Hobart, Tasmania
4 NSW Department of Health (2003) Aboriginal men's health implementation plan. Sydney: NSW Department of Health
5 Adams MJ (2001) How Aboriginal and Torres Strait Islander men care for their health: an ethnographic study. Unpublished Master of Arts thesis, Curtin University of Technology, Perth, Western Australia
6 Warburton J, Chambers B (2007) Older Indigenous Australians: their integral role in culture and community. Australasian Journal on Ageing;26(1):3-7
7 Bellear S (1996) Men's business. Paper presented at the National Men's Conference, 10-11 August 1995 Canberra
8 Lowe H, Spry F (2002) Living male: journeys of Aboriginal and Torres Strait Islander males towards better health and well-being. Casuarina: Northern Territory Male Health Reference Committee
9 Australian Bureau of Statistics (2004) Experimental estimates and projections, Aboriginal and Torres Strait Islander Australians. Canberra: Australian Bureau of Statistics
10 Australian Bureau of Statistics (2007) Deaths Australia, 2006. (ABS catalogue no. 3302.0) Canberra: Australian Bureau of Statistics
11 Australian Bureau of Statistics, Australian Institute of Health and Welfare (2005) The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples 2005. (ABS catalogue no. 4704.0) Canberra: Australian Institute of Health and Welfare and the Australian Bureau of Statistics
12 Australian Institute of Health and Welfare (2007) Australian hospital statistics 2005-06. (AIHW catalogue no. HSE 50) Canberra: Australian Institute of Health and Welfare
13 Australian Institute of Health and Welfare (2005) Australian hospital statistics 2003-04. (AIHW catalogue no. HSE 37) Canberra: Australian Institute of Health and Welfare
14 Marmot M, Wilkinson R, eds.(1999) Social determinants of health. Oxford: Oxford University Press
15 Wilkinson R, Marmot M, eds.(2003) Social determinants of health: the solid facts. Second ed. ed. Copenhagen, Denmark: World Health Organization
16 Public Health Agency of Canada (2003) Determinants of health: what makes Canadians healthy or unhealthy? Retrieved 12 July 2005 from http://www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php
17 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. (ABS catalogue no. 4704.0) Canberra: Australian Institute of Health and Welfare and the Australian Bureau of Statistics
18 Australian Bureau of Statistics (2006) National Aboriginal and Torres Strait Islander Health Survey: Australia, 2004-05. (ABS catalogue no. 4715.0) Canberra: Australian Bureau of Statistics
19 Bryce S (1999) Men's health program at Gapuwiyak. Northern Territory Disease Control Bulletin;6(3):10-13
20 Macdonald JJ, Millan G, Adams M (2006) Men's health: Indigenous and non-Indigenous men getting together [conference report]. Medical Journal of Australia;185(8):416-417
21 Wenitong M (2006) Aboriginal and Torres Strait Islander male health, wellbeing and leadership. Medical Journal of Australia;185(8):466-467
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