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Health risk factors

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Factors contributing to Indigenous health

Selected health risk and protective factors

As noted under 'The context of Indigenous health', 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].

Information about some of these determinants is available (see ‘Indicators of Indigenous social disadvantage’), but attention tends to be focused on the so-called '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 Indigenous people is influenced by 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 Indigenous people aged 15 years or older reported eating an adequate amount of fruit (43%) each day, and only one-in-twenty people ate enough vegetables (5%) each day [8]. Females were more likely than males to have eaten an adequate amount of fruit (44% and 41% respectively) and vegetables (7% and 3% respectively) each day. Levels of fruit and vegetable consumption were different for Indigenous people living in remote and non-remote areas; 49% of Indigenous people aged 15 years or older living in remote areas consumed the recommended number of servings of fruit each day compared with 41% of people in non-remote areas. Conversely, Indigenous people aged 15 years or older living in non-remote areas were more likely than those in remote areas to consume adequate amounts of vegetables (5% compared with 3%) each day. 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 0.9) 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, but the 2004-2005 NATSIHS found that more than three-quarters (76%) of Indigenous people aged 12 years or older living in non-remote areas reported that they usually drank whole milk (including full-cream powdered milk), with only 19% drinking reduced fat and/or skim milk [9]. The consumption of reduced fat and/or skim milk was very low (6%) among Indigenous people aged 12 years or older living in remote areas, and 87% reported that they drank whole milk. Around 83% of Indigenous people aged 12 years or older living in remote areas reported 'sometimes' or 'usually' adding salt after cooking, compared with two-thirds (66%) of those living in non-remote areas.

The 2004-2005 NATSIHS addressed the issue of food security by asking respondents aged 15 years or older whether they had run out of food in the previous 12 months [10]. ‘Running out of food but able to get food by other means’ was reported by 28% of Indigenous people aged 15 years or older living in remote areas (seven times more common than among non-Indigenous people) and by 12% of those living in non-remote areas (four times more common than among non-Indigenous people) [11]. ‘Going without food when they could not afford to buy more’ was reported by approximately 8% of Indigenous people aged 15 years or older living in non-remote areas (four times more common than among non-Indigenous people), and by approximately 7% of those living in remote areas (seven times more common than among non-Indigenous people).

The 2004-2005 NATSIHS examined associations between dietary behaviour and income, educational attainment, and self-reported health [11]. Indigenous people who reported no usual daily intake of fruit or vegetables were more likely to be in the lowest quintile of income. Low fruit and vegetable intakes were also associated with tobacco use and risky/high risk alcohol consumption.

The Footprints in time: longitudinal study of Indigenous children reported that levels of relative isolation affected the diet of children aged 2-7 years in 2010 [12]. Cereals, protein, and fruit and vegetables were the types of food eaten by most children across all locations, but 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. Around 78% of all the children drank water and 7% ate bush tucker.

In attempting to address the issue of food security in the NT, the Australian Government established a licensing regime for community stores as part of the NTER in 2007 [13]. An evaluation of the Community stores licensing program concluded that licensing had positively impacted food security, particularly with regard to the quality, quantity, and range of healthy foods available in the remote stores involved in the project. The licensing program was extended in 2012 to operate throughout the NT, except in major centres [14].

Physical activity

Australia’s physical activity and sedentary behaviour guidelines recommends moderate physical activity on most, preferably all, days of the week to improve health and reduce the risk of chronic disease and other conditions [15]. At least 60 minutes of activity is recommended for children, and at least 30 minutes for adults; these amounts can be in blocks of activity or accumulated throughout the day in short bursts. Low levels of physical activity have been shown to be a risk factor for CVD, type 2 diabetes, certain cancers, depression and other social and emotional wellbeing conditions, overweight and obesity, and a weakened musculoskeletal system.

According to the 2012-2013 AATSIHS, 46% of Indigenous 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); after age-adjustment, this level was 0.9 times that of their non-Indigenous counterparts [8]. Two-fifths (40%) of Indigenous adults had exercised for at least 150 minutes over five sessions in the previous week; after age-adjustment, 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; after age-adjustment these levels of physical activity were 0.9 and 0.6 times those of their non-Indigenous counterparts, respectively.

Of Indigenous 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%) [8]. 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. Of Indigenous 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; after age-adjustment, this level of physical inactivity was 1.1 times that of their non-Indigenous counterparts. A higher proportion of Indigenous women than Indigenous men were physically inactive (68% compared with 55%); this pattern was evident for all age-groups.

According to the 2008 NATSISS, almost two-thirds (64%) of Indigenous children aged 4-14 years had taken part in some form of physical activity or sport in the 12 months prior to the survey (Derived from [16]). Of all Indigenous children aged 4-14 years who participated in some form of physical activity or sport, males had slightly higher levels of participation (66%) than did females (63%) (Derived from [16]). Among Indigenous children, the highest level of participation in physical activity was for children living in major cities (68%), followed by those living in inner/outer regional areas (65%), and in remote/very remote areas (58%). Of children participating in physical activity, the highest proportions were in Tas and the ACT (both 74%) and the lowest in the NT (50%).

Among adults, almost one-third (30%) of Indigenous people aged 15 years and over had taken part in some type of physical activity or sport in the previous 12 months (Derived from [16]). Participation levels were higher among Indigenous males (38%) than among Indigenous females (23%); levels decreased with age for both sexes – from around 44% for the 15-24 years age-group to around 10% for the 55 years and over age-group. For both sexes, participation levels were highest for Indigenous people living in major cities (33%), followed by those living in inner/outer regional areas (29%) and remote/very remote areas (28%). The jurisdictions with the highest participation levels were the ACT (46%), followed by Vic (34%); the lowest level was reported for SA (27%). Differences in proportions for Indigenous males and females were greatest in the NT, where Indigenous males participated more than twice as much as Indigenous females (42% compared with 20%).

Bodyweight

The standard measure for classifying a person’s weight status is body mass index (BMI: weight in kilograms divided by height in metres squared) [17]. 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 [18][7][19]. 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 an indicator of increased risk for the development of some chronic diseases, such as heart disease, hypertensive disease and type 2 diabetes [20]. Abdominal obesity can be measured by waist circumference alone (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 [21]. 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 [22][23][24]. 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 [23][24].

Based on BMI information collected as a part of the 2012-2013 AATSIHS, 66% of Indigenous people aged 15 years or older were classified as overweight (29%) or obese (37%) [8]. Combined overweight/obesity levels were significantly higher for people living in non-remote areas (67%) than for those living in remote areas (61%). A higher proportion of Indigenous females were overweight or obese (67%) than were males (64%), mainly due to higher obesity levels for females. After age-adjustment, the combined overweight/obesity levels were slightly higher for Indigenous people aged 15 years or older than those for their non-Indigenous counterparts (prevalence ratio 1.1), but Indigenous people were 1.5 times as likely as non-Indigenous people to be obese (rate ratio 1.4 for males and 1.7 for females). According to their BMI, almost 30% of Indigenous children aged 2-14 years were overweight (20%) or obese (10%), 62% were in the normal weight range, and 8% were underweight.

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 (60%) 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, 80% of males and 73% of females aged 18 years or older were at increased risk of developing chronic diseases. Based on both waist circumference and WHR, the proportions of Indigenous men and women who were at increased risk of developing chronic diseases were higher in older age-groups.

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 [9]:

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 [25]. Indigenous adults were also more likely to be underweight if:

A 2012 study of Indigenous children aged 5 to17 years in the Torres Strait found that 46% were overweight or obese and 35% had central obesity [26]. Females had higher levels of central obesity (50%) than did 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) [27]. In comparison, the National Health Survey 2007-2008 reported 17% of all Australian children aged 5 to 17 years were overweight and 8% obese [28].

Immunisation

Vaccination has been very successful in contributing to improvements in Indigenous health and child survival in recent decades, but some vaccine-preventable diseases are still experienced at higher rates among Indigenous people than among non-Indigenous people [29]. In recognition of these higher rates, there are some additional recommendations for vaccination for Indigenous people.

From 2005, the National immunisation program for children included vaccines for hepatitis B, diphtheria-tetanus-pertussis (DTP), Haemophilus influenzae type B (Hib), measles, mumps, rubella (MMR) and polio. In more recent years vaccines have been included for pneumococcal disease, meningococcal C, Varicella (chickenpox), rotavirus, HPV, and influenza [30].

Childhood vaccination

According to the Australian Childhood Immunisation Register (ACIR), Indigenous children had slightly lower coverage for all vaccines at 1 year of age than other children at 31 December 2011 (85% of Indigenous children fully immunised compared with 92% of other children); coverage for Indigenous and other children was similar at 2 years of age (92% and 93% respectively), and 5 years of age (87% and 90% respectively) [30].

For the 1 year age-group, the greatest difference in overall vaccination coverage was in SA, where coverage for Indigenous children was significantly lower (15% lower) than for non-Indigenous children (ratio 0.8) [30]. In terms of specific vaccines, the greatest difference in coverage nationally, was for Hib, which was 8.7% lower among Indigenous children than that among non-Indigenous children (ratio 0.9). For the 2 years age-group, ACT had the greatest difference in vaccination: coverage for Indigenous children was 8.1% lower than that for non-Indigenous children (ratio 0.9). In terms of specific vaccines, there was little difference in coverage nationally between Indigenous and non-Indigenous children. For the 5 years age-group, the greatest difference in overall vaccination was in SA, where coverage was 8.8% lower for Indigenous children than that for non-Indigenous children, (ratio 0.9). In terms of specific vaccines, the greatest differences in vaccine coverage nationally were for DTP and polio, both with coverage 3.7% lower for Indigenous children than that for non-Indigenous children (ratio 1.0).

Immunisation coverage for Indigenous children has varied over the years [30]. Combined data for NSW, Vic, WA, SA and the NT for 2001-2011 reveal that the difference in coverage for the 1 year age-group was at its lowest difference in 2004 (6.3% lower for Indigenous children than for non-Indigenous children) and highest difference (10.2% lower) in 2008. Coverage was 7.0% lower for Indigenous children than for non-Indigenous children in 2011. For the 2 years age-group, the coverage difference was 6.1% (lower among Indigenous children than among non-Indigenous children) in 2009, but was only 0.3% in both 2010 and 2011. For the 5 years age-group, information is available only for 2008-201132: coverage difference has been around 3-4% (lower for Indigenous children than for non-Indigenous children).

Adult vaccination

Three-fifths (60%) of Indigenous people aged 50 years or older reported to the 2004-2005 NATSIHS that they had been vaccinated against influenza in the previous 12 months, with vaccination levels higher for people living in remote areas (80%) than for those living in non-remote areas (52%) [9]. Indigenous males had slightly lower vaccination coverage (58%) than did Indigenous females (61%). These levels were higher than those for non-Indigenous males and females (49% and 54%, respectively).

Similarly, vaccination levels for pneumonia in the previous five years were higher for Indigenous adults aged 50 years or older (all: 34%; males: 31%, females: 37%) than those for their non-Indigenous counterparts (all: 20%, males: 18%, females: 23%) [9]. Vaccination levels were lower in non-remote areas (26%) than remote areas (56%).

According to the 2004-2005 NATSIHS, Indigenous people aged 65 years or older had higher levels of coverage for influenza in the previous 12 months (84%) than did non-Indigenous people of the same age-group (73%) [30]. Reported coverage of pneumonia vaccination was also slightly higher among Indigenous people 65 years or older (48%) than among their non-Indigenous counterparts (43%).

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 [31]. 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 [31]. 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 [32]. 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 [9]. 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 [9]. 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 [33].

The Footprints in time – the longitudinal study of Aboriginal children collected data from 11 sites (rural, remote and urban) around Australia in 2008-2009 [34]. Data on breastfeeding from this study showed that 80% of Indigenous children in the study 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, certain cancers, and lung diseases, as well as a variety of other health conditions [35]. 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 notable concern to health, with children particularly susceptible to 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 [21]. Tobacco use accounted for one-in-five deaths in the Indigenous population.

The 2012-2013 AATSIHS found that 43% of Indigenous people aged 15 years and over reported that they were current smokers [36]. This represents a significant reduction from levels reported in the NATSISS 2008 (47%), and 2002 (51%) [37][38]. 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 [39].

In 2012-2013, the proportion of Indigenous men who were current smokers (45%) was similar to the proportion of Indigenous women (41%) [36]. After age-adjustment, Indigenous people were 2.4 times more likely to smoke than non-Indigenous people (42% compared with 17%, respectively).

The overall proportion of current smokers in remote areas in 2012-2013 (52%) has not changed significantly since 2002 (56%) [40]. In 2012-2013, Indigenous people living in remote areas reported a higher proportion of current smokers (52%) than those living in non-remote areas (40%). The age-group with the highest proportion of current smokers in remote areas was the 25-34 years age-group (63%).

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: 50% less people are smoking among 15-17 year olds (16% down from 32%); and around 30% less people are smoking among 18-24 year olds (40% down from 56%) [40]. 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 30% in 2002.

High rates of smoking have been reported for Indigenous mothers [41]. 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 [42][43]. For Indigenous people aged 15 years and older the proportion was 26% [39].

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 [44]. 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 conditions (comprising abnormalities such as growth retardation, characteristic facial features, and central nervous system anomalies (including intellectual impairment)) [45]. These disorders are incurable, but 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%) [46][47]. Of 11 selected risk factors, alcohol was the fifth leading cause of the burden of disease among Indigenous people [46]. The highest levels of disease burden attributable to alcohol use among Indigenous people were for injury (22%), mental disorders (16%), and cancers (6.3%).

Box 6: Assessing risks from use of alcohol

In 2009, the NHMRC introduced revised guidelines that depart from specifying 'risky' and 'high risk' levels of drinking [44]. 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, and 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 breast feeding women is not to drink alcohol.

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 [30][8][30].

In the 2012-2013 AATSIHS, 23% of Indigenous people aged 18 years or older had never consumed alcohol or had not done so for more than 12 months [48]. 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 [48]. 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 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).

The 2012-2013 AATSIHS reported that 22% of the Indigenous 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) [48]. Females were almost twice as likely as men not to exceed the 2009 guidelines (24% compared with 13%, respectively). After age-adjustment, Indigenous people were half as likely as non-Indigenous people to drink at low risk (according to the 2001 guidelines (24% compared with 43%)) and to not exceed the 2009 guidelines (20% compared with 37%).

Levels of short term/single occasion drinking risk and long term/lifetime drinking risk were similar for both the Indigenous and non-Indigenous populations (according to the 2009 guidelines). Among Indigenous people aged 18 years and over, 57% reported drinking in excess for short-term/single occasion risk (binge drinking; no more than four standard drinks in a single day) [48]. Indigenous males were 1.5 times more likely than Indigenous females to exceed the guidelines (68% compared with 46%, respectively). After age-adjustment, drinking at risk on a single occasion was similar for both the Indigenous and non-Indigenous populations (52% compared with 45%, respectively; ratio 1.1).

Among Indigenous drinkers aged 18 years and over in 2012-2013, 20% drank at levels exceeding the 2009 guidelines for long-term/lifetime drinking risk (based on drinking no more than two standard drinks on any single day for males and females) [49]. Indigenous males were 2.7 times more likely than Indigenous females to exceed the guidelines (29% compared with 11%, respectively). After age-adjustment, lifetime drinking risk was similar for both the Indigenous and non-Indigenous populations (ratio 1.0).

The findings above do not reflect the levels of drinking risk for short term/single occasion use revealed by the number of drinks consumed above four standard drinks. This is shown by using the measures in the 2001 drinking guidelines for short term risky/high risk drinking [48].

While similar levels of short-term risky drinking (more than six and four standard drinks on a single occasion for males and females, respectively) were reported for both Indigenous males and females (around 11%), Indigenous males were nearly 1.4 times as likely to drink at short-term high risk (more than 11 standards drinks on a single occasion) than Indigenous females (more than seven standard drinks) (50% compared with 35%, respectively) [48]. Similar levels of gender parity in short-term risky drinking levels and gender differences in short-term high risk drinking were found in the non-Indigenous population. After age-adjustment, Indigenous people were 1.4 times as likely to drink at high risk of short-term harm as non-Indigenous people.

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 [30]. 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) [30]. 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 ICD ‘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) [30].

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 [30]. 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 those for non-Indigenous people.

Illicit drug use

Illicit drug 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 [18]. Illicit drug use is a risk factor for ill-health, including conditions such as infection with bloodborne viruses, mental illness, poisoning and self-inflicted injury, and can cause death.

Illicit drug 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 [47]. For the same year, illicit drug use was responsible for 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 (3.6%) [46].

Extent of illicit drug use among Indigenous people

The 2012-2013 AATSIHS found that 22% of Indigenous people aged 15 years and over had used an illicit substance in the last 12 months prior to interview [8]. This is a slight decrease from that reported in the 2008 NATSISS (23%) [30]. These levels are approximately 1.5 times that reported in the 2010 National Drug Strategy Household Survey (NDSHS) for the Australian population aged 14 years or over (15%) [50], but less than that reported by Indigenous people aged 18 years or over (28%) in the 2004-2005 NATSIHS [9]. The 2012-2013 AATSIHS found that illicit drug use in the previous 12 months was highest among younger age-groups: 15-24 years (27%), 25-34 years (26%), 35-44 years (23%), and 45-54 (19%) [51].

The 2012-2013 AATSIHS found that the illicit substance most commonly used by Indigenous people aged 15 years and over in the last 12 months was cannabis (18%) [51]. The proportion of users was similar to that reported in the 2008 NATSISS (17%) [30]. Use of pain killers and sedatives (3.8%), amphetamines (2.3%) had decreased compared with the 2008 NATSISS (4.5% and 4%, respectively) [30].

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 2.7% [51].

In 2012-2013, males were at least 1.5 times more likely than females to have used an illicit drug in the previous 12 months; this was the case across all drug types except pain killers where proportions were similar (4% compared with 3.5%). Overall, around twice as many males as females had used cannabis (23% compared with 14%), amphetamines (2.8% compared with 1.8%), and ‘other drugs’ (3.6% compared with 1.8%).

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%); greater use was the case for all drug types [51]. These proportions are similar to those reported in the 2008 NATSISS (24% and 17%, respectively) [30]. Similarly, in 2012-2013, the proportion of Indigenous people who had ever used illicit substances was higher for those living in non-remote areas (46%) than in remote areas (35%) [51]. These proportions are similar to those reported in the 2008 NATSISS (47% and 31% respectively) [30].

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%) and risky/high-risk drinkers (8.1%) compared with those who had 'never used an illicit substance' (35% were current smokers and 3.2% were risky/high-risk drinkers) [30].

Higher proportions of Indigenous people who had experienced stressors in the last 12 months were more likely to be 'recent substance users' than 'never used illicit substances'. Of those who had experienced violence, around 12% were 'recent substance users' compared with 4.6% who 'never used illicit substances'.

Hospitalisation

Between July 2008 and June 2010, there were 4,537 hospital separations related to substance use among Indigenous people in NSW, Vic, Qld, WA, SA and the NT [30]. Hospitalisation for conditions relating to substance use for Indigenous people occurred at around twice the rate of those for non-Indigenous people. The leading cause of substance use-related hospitalisations was ICD 'Mental/behavioural disorders related to cannabinoids', which was responsible for 17% of drug related hospitalisations. Indigenous people were hospitalised at 5.3 times the rate of non-Indigenous people due to cannabis use. The second leading cause of hospitalisation was from use of opioids (9.5%) followed by multiple drug and psychoactive substances (8.9%). Indigenous people were hospitalised for opioid and multiple drug use at two and three times the rate, respectively, of non-Indigenous people. Poisoning resulting from 'Use of antiepileptic, sedative-hypnotic and anti-Parkinson's drugs', and 'Psychotropic drugs (including antidepressants)' were the second and third most common causes of drug-related hospitalisation, accounting for 14% and 15% of all of these hospitalisations.

In relation to remoteness of residence, Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in the period June 2008 to June 2010 were hospitalised with a principal diagnosis related to drug use at 3.0 times the rate of non-Indigenous people in major cities, 2.5 times the rate in inner regional areas, 2.2 times the rate in outer regional areas, 2.8 times the rate in remote areas, and 1.4 times the rate in very remote areas [30].

According to the 2008 NATSISS, 95% of mothers of Indigenous children aged 0-3 years did not use illicit drugs during pregnancy [30]. Around 4% of mothers of Indigenous children in NSW, Qld, Tas/ACT and the NT used illicit drugs during pregnancy. The proportion of mothers of Indigenous children who did use drugs during pregnancy was highest in Vic (9.3%), followed by WA (8.5%), and SA (6.1%).

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 in 2005-2009 than that for their non-Indigenous counterparts (7.8 compared with 5.3 per 100,000) (Table 35) [52]. Rates were higher for Indigenous people than for non-Indigenous people in NSW, WA and SA, but similar in Qld. Rates for Indigenous males (9.5 per 100,000) were higher than those for Indigenous females (6.1 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, 2005-2009
JurisdictionIndigenous rateNon-Indigenous rateRate ratio
Source: SCRGSP, 2011 [52]
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 11.5 5.5 2.1
Qld 4.0 4.3 0.9
WA 9.3 5.4 1.7
SA 17.8 6.3 2.8
NSW, Qld, WA, SA and the NT 7.8 5.3 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 [53]. 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.

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Endnotes

  1. From 2008, fully vaccinated status for 5 year-olds is reported in place of that for 6 year-olds due to changes to reporting practices.
 
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