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The health of individuals and populations is influenced and determined by many factors acting in various combinations . The dominant view is that health is ‘multicausal’ with healthiness, disease, disability and death the result of the interaction of human biology (genetics), lifestyle and environmental (including social) 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’ . These ‘determinants’, which are complex and interrelated, include income, education, employment, stress, social networks and support, social exclusion, working and living conditions, gender and behavioural aspects. Related to these are cultural factors, such as traditions, attitudes, beliefs, and customs. Together, these social and cultural factors also have a major influence on a person’s behaviour. Indicators of the social disadvantage experienced by Indigenous people should be borne in mind in the interpretation of information about a number of specific health determinants.
The 2002 NATSISS collected information about stressors experienced by Indigenous people in the previous 12 months (stressors included: death of a family member or friend; serious illness or disability; not able to get a job; and alcohol or drug-related problem) . The 2004-2005 NATSIHS included separate information for WA on stressors experienced by Indigenous people in the previous 12 months (information about such stressors is potentially very important, but their usefulness is limited in that they were published in relative isolation and without appropriate comparison with non-Indigenous people). Over three quarters (78%) of Indigenous people 18 years and over reported experiencing more than one personal stressor with only 21% reporting no experienced stressors . The stressors reported most frequently by Indigenous people were: death of a family member or close friend (51%); alcohol and drug problems (29%); member of family sent to jail/currently in jail (24%) and trouble with the police (20%). Other stressors reported included being witness to violence (14%); overcrowding at home (14%); not being able to get a job, discrimination, abuse or violent crime (13%); gambling problem (11%); divorce or separation (10%); serious accident (9%); and involuntary loss of job (5%).
The nutritional status of Indigenous people is influenced by socio-economic disadvantage, and geographical, environmental and social factors . Poor nutrition is a common risk factor for overweight and obesity, malnutrition, cardiovascular disease, type 2 diabetes, certain cancers, osteoporosis, and tooth decay .
Fruit and vegetable consumption is strongly linked to the prevention of chronic disease and to better health therefore the nutritional status of Australian populations is usually determined by assessment of the amount of fruit and vegetables consumed on a daily basis . The National Health and Medical Research Council (NHMRC) recommend a daily intake for adults of at least two serves of fruit and five of vegetables. Other recommendations are to limit saturated fats and moderate total fat intake, and to choose foods low in salt. In 2003, insufficient fruit and vegetable consumption contributed to 3.5% of the total burden of disease in Indigenous Australians and 5.7% of deaths .
According to the 2004-2005 NATSIHS, 94% of Indigenous people aged 12 years and older in WA consumed vegetables daily with 28% consuming one serve or less, 56% having two-four serves, 15% having five or more serves (recommended minimum consumption; NHMRC) . Consumption of vegetables was similar for non-Indigenous people with 16% consuming one serve or more, 66% consuming two-four serves and 19% having the recommended five or more serves. The reported figures for daily consumption of fruit revealed that 52% consumed only one serve or less (slightly more than their non-Indigenous counterparts (44%)), while 48% reported having two or more serves daily, almost 10% less than non-Indigenous people (56%) . Detailed information about the consumption of fruit and vegetables was not collected for respondents in the 2004-2005 NATSIHS by remoteness, but the proportions of people who did not consume these dietary items daily was substantially higher for Indigenous people aged 12 years or older living in remote areas than for those living in non-remote areas – 12% and 0.7% respectively for vegetable consumption, and 24% and 7.6% respectively for fruit consumption .
The 2004-2005 NATSIHS also provided data on the consumption of salt and milk for Indigenous people by remoteness. For Indigenous people aged 12 years or older in WA living in remote areas, 86% reported ‘sometimes’ or ‘usually’ adding salt after cooking compared with 71% of those living in non-remote areas . (Data on the consumption of salt by non-Indigenous people was not available.) Over three-quarters of Indigenous people aged 12 years or older in WA reported drinking whole milk (including full-cream powdered milk) as their usual choice, with those living in remote areas reporting higher levels of consumption than those in non-remote areas (87% and 70% respectively). The level of whole milk consumption for non-Indigenous people living in WA was slightly more than one-half the level of consumption for Indigenous people. Less than one-quarter of Indigenous people reported consuming low/reduced fat milk with those living in remote areas consuming more than those in non-remote areas (25% compared with 7.1%). This rate was lower than their non-Indigenous counterparts with 39% of non-Indigenous people reported drinking reduced fat/skim milk. Overall, 3.8% of Indigenous people reported not drinking milk at all, which was less than their non-Indigenous counterparts (5.4%) .
People living in rural and remote areas of Australia are often limited in their food choices because of transport, distance, cost, and geographical or climatic conditions creating barriers for adequate and accessible food supply . The Environmental health needs survey, conducted in 2007-2008 (the third in a series surveying housing, services, utilities, community infrastructure and the immediate living environment in discrete Indigenous communities in WA), found that 10% of Indigenous communities in WA report having no access to fresh food, fruit and vegetables . This is a reduction from the 17% of communities surveyed in 2004 that had no access to fresh food, fruit and vegetables. The same survey found that the average distance travelled by community members for fresh food supplies was 49 kilometres-the majority of communities (62%) are within 30kms of fresh food supplies, whilst 15% of communities are more than 100kms from the nearest fresh food supplies.
The National physical activity guidelines for Australians recommend at least 30 minutes of moderate activity on at least five days of the week to reduce the risk of cardiovascular disease and other chronic conditions . The recommended daily activity can be a combination of shorter activities such as two lots of 15 minute activities. The guidelines also suggest that adults think of all body movement as a benefit and incorporate as much active body movement they can every day. Insufficient levels of physical activity have shown to be a risk factor for cardiovascular disease, type 2 diabetes, certain cancers, depression, and overweight and obesity .
Self-reported data from the 2008 NATSISS revealed that of all Indigenous adults who took part in sport or physical activities in the 12 months prior to the survey, 13.1% were living in WA . Of all Indigenous females who took part in sport or physical activities, 15.4% were living in WA compared with 11.5% of Indigenous males. For Indigenous children aged 4-14 who took part in sport or physical activities, 13.6% were living in WA.
The 2004-2005 NATSIHS collected information relating to the frequency, intensity and duration of exercise undertaken by Indigenous people living in non-remote areas across Australia [29, 44]. In non-remote areas of WA, 71% of Indigenous people aged 15 years or older reported being sedentary (less than 100 minutes or no exercise) or practicing low levels of exercise (100 minutes to less than 1,600 minutes). The proportion of Indigenous people in non-remote areas across Australia who were sedentary or engaged in low level exercise in the two weeks prior to interview was higher in 2004-2005 (75%) than in 2001 (68%) .
Body mass index (BMI) - weight in kilograms divided by the square of height in metres - is the internationally recognised measure for classifying overweight and obesity in adults. Being overweight (BMI between 25 to 29.9) or obese (BMI >= 30) increases a person’s risk for cardiovascular disease, type 2 diabetes, respiratory diseases, renal disease, certain cancers, osteoarthritis, pregnancy complications, and psychosocial problems . A high BMI can be the result of poor nutrition, physical inactivity, socioeconomic disadvantage, genetic predisposition, increased age, and alcohol and tobacco use . A BMI in the range of 18.5-24.99 is classified as acceptable, conferring an ‘average’ risk of co-morbidity.
Current information using 2003 data on the contribution of risk factors to Indigenous disease burden (ill health, disability and premature death) revealed that high body mass (overweight/obesity) was responsible for 11.4% of the total Indigenous Australian burden of disease, making it the second leading cause among 11 risk factors examined . This data may actually under-represent the total numbers of Indigenous Australians who are at risk of the health problems associated with being overweight or obese. This is because optimal BMI cut-offs are still unknown in Indigenous Australian populations due to differences in body shape and other physiological factors between different population groups. Research indicates that an appropriate BMI for acceptable weight in Indigenous Australian populations might be between 17 and 22kg/m2 . There is also evidence that measuring the waist to hip ratio (WHR) in Indigenous peoples is more sensitive and easier to measure than body mass index . Research has shown that WHR is the most accurate predictor of cardio-metabolic risks is Indigenous populations, with BMI being the least accurate .
According to the 2004-2005 NATSIHS, Indigenous people aged 15 years or older living in non-remote areas in WA were 1.2 times more likely than their non-Indigenous counterparts to be overweight/obese (59% compared with 50%, after adjusting for differences in the age structures of the two populations) . No significant difference was reported according to remoteness of residence, but in each age group the disparity between Indigenous and non-Indigenous people was greater for females than for males (58% of Indigenous females reported being overweight/obese compared with 41% of non-Indigenous females; 59% of Indigenous males reported being overweight/obese compared with 60% of non-Indigenous males) . After adjusting for non-response, the proportion of Indigenous people in non-remote areas Australia-wide who were overweight or obese increased from 48% in 1995 to 56% in 2004-2005 .
Data for the underweight and normal weight categories were not separated for WA, but 41% of Indigenous people and 50% of non-Indigenous people aged 15 years or older in WA were recorded as being in the combined category underweight/normal weight range (Derived from ). Over one-third of Indigenous males, females and non-Indigenous males were reported as being in this range but the level was higher for non-Indigenous women (59%).
In response to the greater burden of communicable diseases among Indigenous people, the NHMRC endorsed a series of special guidelines and schedules for immunisation of vaccine-preventable diseases, which include some extra vaccinations . The latest recommendations are available from the Department of Health and Ageing website.
According to the Australian Childhood Immunisation Register, the proportion of Indigenous children in WA aged five years who were fully immunised in 2010 was 80%, slightly lower than that recorded for other Australians (87%) . More detailed data specific to WA are not available, but according to the 2004-2005 NATSIHS 88% of Indigenous children aged 0-6 years living in non-remote areas across Australia were fully immunised against the vaccine-preventable diseases included in the relevant NHMRC vaccination schedule . Based on actual immunisation records, the level fully immunised would appear to be somewhat lower, as the proportions for the separate vaccines were: diphtheria and tetanus (79%), whooping cough (74%), hepatitis B (83%), poliomyelitis (79%), Hib (73%), and MMR (measles, mumps, and rubella) (85%).
In 2004-05, nearly two-thirds (60%) of Indigenous people across Australia aged 50 years or older reported to the NATSIHS that they had been vaccinated against influenza in the previous 12 months; with vaccination levels reported as higher for people living in remote areas (80%) than for those living in non-remote areas (52%); with all levels higher than those for non-Indigenous people (46%) . Similarly, vaccination levels for pneumonia in the previous five years were higher for Indigenous adults aged 50 years or older (remote: 56%; non-remote: 26%; all: 34%) than that for their non-Indigenous counterparts (20%). Further findings from the NATSIHS reported that in WA, 30% of Indigenous Australians aged 50 years and over were fully vaccinated against influenza and pneumococcal disease, with this proportion similar to figures for Indigenous people Australia wide at 31%, and rates of screening for cervical cancer for Indigenous women aged 20-69 years at 42.6%18 .
Breast milk, which is the natural and optimum food for babies, contains proteins, fats and carbohydrates at levels that are appropriate for an infant’s metabolic capacities and growth requirements . Breast milk also has anti-infective properties and contains immunoglobulins which provide some immunity against early childhood diseases . Subsequently, breastfeeding is considered as having many positive effects on the survival, growth and development of infants . Evidence suggests that breastfeeding may also lower the risk of obesity and protect against a range of chronic illnesses which can develop in adulthood, including type 2 diabetes, heart disease, atherosclerosis, and high blood pressure . Preliminary results by Australian researchers from the Australian Institute for Economic Research on Health, suggest that between 11% and 28% of the chronic disease burden in Australia could be attributed to a lack of breastfeeding during infancy .
Surveys indicate that a majority of Indigenous women breastfeed their babies. The WAACHS reported that mothers of Indigenous children were more likely to initiate breastfeeding and breastfeed for longer than mothers in the general population, particularly those living in more isolated areas . According to the 2004-2005 NATSIHS, in non-remote areas of WA, 81% of Indigenous babies aged 0-3 years had been breastfed or were currently being breastfed compared with 90% of non-Indigenous babies . Similar figures were reported Australia wide with 79% of Indigenous babies aged 0-3 years reported as having been breastfed or were currently being breastfed compared with 88% of non-Indigenous babies . Data collected in 2008 from the Footprints in time survey (a longitudinal study of Indigenous children undertaken by the Australian Government Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA)), also revealed similar results with 80% of Indigenous children Australia-wide reported as having been breastfed .
Tobacco smoking is the most preventable cause of ill health and death in Australia . In 2003, tobacco contributed to 7.8% of the burden of disease; lung cancer (35%), chronic obstructive pulmonary disease (COPD) (27%) and ischaemic heart disease (coronary heart disease) (15%) accounted for more than three quarters of this burden . In 2003, tobacco was attributed to 20% of the burden of cancer disease and nearly 10% of the burden of cardiovascular disease . For the same period, tobacco contributed to 12% of the burden of disease among the Indigenous population; the highest level of disease burden attributable to tobacco was for cancer (35%) and cardiovascular disease (33%) . Smoking tobacco also increases the risk of stroke, asthma, rheumatoid arthritis and osteoporosis . Passive smoking is also of concern to health, with children particularly susceptible.
The 2008 NATSISS, found that 44% of the Indigenous population in WA aged 15 years and over were current smokers . This figure has not changed from the prevalence reported in the 2004-05 NATSIHS. According to the 2004-2005 NATSIHS, 44% of Indigenous people aged 18 years or older in WA reported that they were current smokers; the level was slightly higher for people living in remote areas (46%) than for those living in non-remote areas (42%). After adjusting for differences in the age structures of the two populations, daily smoking was 2.0 times more common among Indigenous people aged 18 years or older (39%) than among their non-Indigenous counterparts (20%) . The proportion of Indigenous men who smoked daily (45%) was lower than the proportion of Indigenous women (51%), but more Indigenous males in remote areas were current daily smokers (53%) than their non-remote counterparts (35%). Proportions for Indigenous women living in remote and non-remote areas were similar (50% and 52% respectively). AIHW analysis of the National Perinatal Statistics Unit (NPSU) National perinatal data collection found that Indigenous women in WA smoked during pregnancy at 3.6 times the rate of their non-Indigenous counterparts (54% compared with 15%) .
Excessive alcohol use has been found to contribute to a wide range of diseases including stroke, coronary heart disease, high blood pressure, some cancers, and pancreatitis . It also contributes to a wide range of injuries including motor vehicle accidents, drownings, homicides, and falls.
Abstinence from drinking alcohol is advised for women when pregnant or breastfeeding . Consumption of alcohol in pregnancy can affect the unborn child leading to Foetal alcohol spectrum disorder (FASD); an umbrella term that describes a range of diagnoses (comprising abnormalities such as growth retardation, characteristic facial features, and central nervous system anomalies - including intellectual impairment). These disorders are incurable and wholly preventable .
In 2003, alcohol contributed to 2.3% of the burden of disease in Australia . Among Indigenous Australians alcohol accounted for 5.4% of the burden of disease; the highest levels of disease burden attributable to alcohol were for injury (22%), mental disorders (16%), and cancers (6%) .
Surveys have consistently shown that Indigenous people are less likely to drink alcohol than non-Indigenous people19 , but those who do drink are more likely to consume it at hazardous levels . The 2008 NATSISS, found that 35% of Indigenous people aged 15 years and over had never consumed alcohol or had not done so in the last 12 months compared with 17% of the total Australian population aged 14 years or older . NATSISS data is not directly comparable to the 2004-05 NATSIHS due to conceptual and methodology differences, however both surveys report similar results for those drinking at risky/high risk levels; the 2008 NATSISS found that 17% of the Indigenous population aged 15 years or older reported drinking at medium/high risk levels, while the 2004-05 NATSIHS found that 16% of the Indigenous population aged 18 years and over reported drinking at risky/high risk levels . After adjusting for the age differences between the Indigenous and non-Indigenous populations, the NATSIHS found that the proportion of Indigenous adults who reported drinking at risky/high risk levels was similar to that of the non-Indigenous population (15% and 14% respectively) .
The 2008 NATSISS found that 34% of the Indigenous population in WA aged 15 years or older abstained from alcohol in the last 12 months . Analysis by the ABS and AIHW of the 2004-05 NATSIHS found that 26% of the Indigenous population in WA aged 18 years or over had abstained from alcohol in the last 12 months . Further analysis by the ABS and AIHW of the 2004-05 NATSIHS and the 2004-05 NHS found that 30% of the Indigenous population in WA abstained from alcohol in the previous 12 months compared with 14% of the Western Australian non-Indigenous population .
The 2008 NATSISS also found that 19% of Indigenous people in WA aged 15 years or older drank at me-dium/high risk levels . While not directly comparable, this is similar to the 2004-05 NATSIHS which found that 19% of Indigenous people in WA aged 18 years and older drank at risky/high risk levels . Analysis by the ABS and AIHW of the 2004-05 NATSIHS and the 2004-05 NHS found that those who drank at long-term risky/high risk levels were similar for the Western Australian Indigenous and non-Indigenous population (16% and 15% respectively), but the proportion of the Indigenous population who drank at short-term risky/high risk levels was more than twice that of the non-Indigenous population (18% and 8% respectively) .
In the six jurisdictions of NSW, Vic, Qld, WA, SA and the NT combined, over the period July 2004 to June 2006, approximately 1.4% of all hospitalisations of Indigenous Australians were for a principle diagnosis related to alcohol use; Indigenous males were hospitalised at five times the rate of non-Indigenous males per 1,000 population (12.5 compared with 2.5 respectively), and Indigenous females were hospitalised at three times the rate of non-Indigenous females per 1,000 population (6.0 compared with 1.8 respectively) . Around 80% of all Indigenous hospitalisations related to alcohol use had a principal diagnosis of mental and behavioural disorder due to alcohol use; the most common type of disorder was acute intoxication. Indigenous Australians were hospitalised at eight times the rate of their non-Indigenous counterparts for acute intoxication (3.4 compared with 0.4 per 1,000 respectively); at 10 times the rate for mental and behavioural disorders due to withdrawal (1.3 compared with 0.1 per 1,000 respectively); and at 23 times the rate for psychotic disorder (0.3 compared with 0.0 per 1,000 respectively). Indigenous hospitalisation for liver disease and for accidental poisoning by alcohol occurred at five times the rate of non-Indigenous Australians (1.2 and 0.2 per 1,000 compared with 0.2 and 0.1 per 1,000 respectively).
For the years 2005–06, both Indigenous males and females in WA experienced significantly higher rates of alcohol-related attendance at hospital emergency departments than their non-Indigenous counterparts (8.9 and 4.5 per 100,000 population respectively) . In 2005, admissions and beddays from the harmful use of alcohol that were wholly attributable to alcohol were also higher among Indigenous males compared with their non-Indigenous counterparts (37% for admissions and 38% for beddays compared with 30% and 26% respectively) and Indigenous females compared with their non-Indigenous counterparts (31% for admissions and 27% for beddays compared with 23% and 18% respectively). For the total population, the Kimberley and Pilbara had the highest hospitalisation rates due to alcohol consumption among the nine health regions compared with the State rate. For the Indigenous population, the Goldfields, Great Southern, Kimberley, Midwest, Pilbara and Wheatbelt had significantly higher rates compared with the State rate.
In the six jurisdictions of NSW, Vic, Qld, WA, SA and the NT combined, over the period July 2004 to June 2006, 4% of deaths were related to alcohol use; the majority were for alcoholic liver disease . Death from alcoholic liver disease occurred at eight times the rate of non-Indigenous Australians (24.1 per 100,000 compared with 3.2 per 100,000); death from mental and behavioural disorders due to alcohol use occurred at ten times the rate (10.2 per 100,000 compared with 1.0 per 100,000); and death from poisoning by alcohol occurred at nine times the rate (0.9 per 100,000 compared with 0.1 per 100,000). Overall, Indigenous males died from alcohol-related causes at seven times the rate of non-Indigenous males (48.4 per 100,000 compared with 6.8 per 100,000), and Indigenous females died from alcohol-related causes at twelve times the rate of non-Indigenous females (23.8 per 100,000 compared with 1.9 per 100,000).
In WA, for the years 1997-2005, Person years of life (PYL) (a measure of the level of premature death resulting from alcohol use) per 1,000 population was almost four times higher for Indigenous males compared with their non-Indigenous counterparts (21.7 compared with 5.5 respectively) and over seven times higher for Indigenous females compared with their non-Indigenous counterparts (9.5 compared with 1.3 respectively) . For the years 1997-2005, the proportion of alcohol deaths wholly attributable to alcohol was twice as great for Indigenous males compared with their non-Indigenous counterparts (43% and 20% respectively), and over three times as great for Indigenous females compared with their non-Indigenous counterparts (55% and 16% respectively).
Illicit drug use describes the use of those drugs which are illegal (for example, cannabis, heroin, ecstasy and cocaine), the use of volatile substances (for example, petrol, glue and solvents) and the non-medical use of prescribed drugs . Illicit drug use is a risk factor for ill-health including conditions such as HIV/AIDS, hepatitis, poisoning and self-inflicted injury and can cause death. In 2003, illicit drug use accounted for 2% of the burden of disease and was attributed to 8% of the mental health burden of disease, and 4% of the injury burden of disease Australia wide . For the same year, illicit drug use contributed to 3.4% of the burden of disease among the Indigenous population; the highest level of disease burden attributable to illicit drugs was for mental health (13%) and injury (4%) .
The 2008 NATSISS found that 20% of Indigenous Australians aged 15 years and over had used an illicit substance in the last 12 months prior to interview, a rate one and a half times the level of that reported in the 2007 National drug strategy household survey (NDSHS) for the Australian population aged 14 years or over (13%), but less than that reported in the 2004-05 NATSIHS for the Indigenous population aged 18 years and over (28%) .
According to the 2004-2005 NATSIHS, 31% of Indigenous people in WA aged 18 years or older reported having used illicit drugs in the past 12 months (including amphetamines, marijuana and/or pain killers/tranquilisers/sleeping pills). The proportions were higher for Indigenous males than females in WA (37% compared with 27%), and Australia wide (32% compared with 24%) . The 2004-05 NATSIHS also revealed that the proportion of Indigenous people aged 18 years and older in WA who have used an illicit drug in the past 12 months prior to interview (31%) was twice the level of that reported in the 2007 NDSHS for the Western Australian population (16%) .