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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', probably more appropriately called ‘ecologic’ , are complex and interrelated; they 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 . 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 .
Limited information about some of these ecologic factors is available (see 'The context of Indigenous health'), but attention still 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 ecologic factors (‘determinants’ of health).
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, CVD, 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, low fruit and vegetable consumption contributed to 3.5% of the total burden of disease, and 5.7% of deaths, among Indigenous people .
According to the 2004-2005 NATSIHS, 94% of Indigenous people aged 12 years and older living in WA consumed vegetables daily, with 28% consuming one serve or less, 56% having two-four serves, and 15% having five or more serves (NHMRC’s recommended minimum consumption) . 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 85% of Indigenous people in WA consumed fruit daily, with 52% consuming one serve or less (slightly more than their non-Indigenous counterparts (44%)), and 48% 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 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.
In 2008, 42% of Indigenous children aged 4-14 years living in non-remote areas of WA reported consuming the recommended daily intake of vegetables, and 79% reported consuming the recommended daily amount of fruit .
The 2004-2005 NATSIHS also provided data on the consumption of salt and milk among Indigenous people by remoteness. Among Indigenous people aged 12 years or older in WA living in remote areas, 86% reported ‘sometimes’ or ‘usually’ adding salt after cooking compared with 70% 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. Around 17% of Indigenous people in WA reported consuming low/reduced fat/skim milk, with those living in non-remote areas consuming more than those in remote areas (25% compared with 7.1%). This proportion was lower than that for their non-Indigenous counterparts, with 39% of non-Indigenous people drinking reduced fat/skim milk. Overall, 4.1% 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 reported having no access to fresh food, fruit and vegetables . This was 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 49km; the majority of communities (62%) were within 30km of fresh food supplies, while 15% of communities were more than 100km 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 CVD 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 as they can every day. Insufficient levels of physical activity have shown to be a risk factor for CVD, type 2 diabetes, certain cancers, depression, and overweight and obesity .
According to the 2008 NATSISS, 29% of Indigenous people aged 15 years and older living in WA took part in sport or other physical activities in the 12 months prior to the survey (Derived from ). Participation in sport or other physical activities was slightly higher for Indigenous males than for Indigenous females in WA (32% compared with 27%). Around two-thirds (66%) of WA Indigenous children aged 4-14 years took part in physical activity in the 12 months prior to the survey.
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 . 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 proportions of physical activity among WA Indigenous people by level were: high level (5%); moderate level (24%), low level (25%), and sedentary level (46%) . 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%) .
The standard measure for classifying a person's weight for height is body mass index (BMI – weight in kilograms divided by height in metres squared) . Being overweight (BMI 25.0 to 29.9) or obese (BMI of 30.0 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, either alone or in combination, such as poor nutrition, physical inactivity, socioeconomic disadvantage, genetic predisposition, increased age, and alcohol use. Being underweight (BMI less than 18.5) can also have adverse health consequences, including decreased immunity (leading to increased susceptibility to some infectious diseases) and osteoporosis (bone loss). The 2013 NHMRC dietary guidelines for adults recommend that adults prevent weight gain by being physically active and eating according to their energy needs.
Overweight and obesity were responsible for 11% of the total burden of disease among Indigenous people in Australia in 2003, second only to tobacco . It is possible, however, that this may be an under-estimate because it has been suggested that BMI cut-offs may be uncertain for the Indigenous population (due to differences in body shape and other physiological factors) . It has been suggested that a BMI of 22 might be more appropriate than 25 as a measure of acceptable weight for Indigenous people. There is also evidence that measuring the waist to hip ratio (WHR) in Indigenous people is more sensitive and easier to measure than BMI .
According to the 2004-2005 NATSIHS, Indigenous people aged 15 years or older living in WA were 1.3 times more likely than their non-Indigenous counterparts to be overweight/obese . No significant difference was reported according to remoteness of residence: 58% of Indigenous people living in remote areas of WA were obese/overweight compared with 59% of Indigenous people living in non-remote areas.
In 2004-2005, a higher proportion of Indigenous adults in WA were overweight/obese than non-Indigenous adults in every age-group (Table 24) . The highest proportion was among Indigenous people aged 45-54 years. Proportions were similar for Indigenous people in WA and Australia-wide. The disparity between Indigenous and non-Indigenous people was greater for females than for males in each age-group in WA in 2004-2005 .
|Indigenous||Non-Indigenous||Rate ratio||Indigenous||Non-Indigenous||Rate ratio|
|Source: AIHW, 2013 |
After age-adjustment, 4.5% of Indigenous people in WA were underweight 31% were normal weight, 30% were overweight and 35% obese (Figure 2) .
Figure 2. Weight status of adults, by Indigenous status and weight classification, WA, 2004-2005
Source: AIHW, 2013 
In response to the greater burden of communicable diseases among Indigenous people, the latest version of the Australian immunisation handbook, endorsed by the NHMRC, includes a special section devoted to vaccination for Aboriginal and Torres Strait Islander people .
According to the Australian Childhood Immunisation Register, 82% of 1 year-old Indigenous children in WA and 91% of their non-Indigenous counterparts were fully vaccinated against hepatitis B, diphtheria and tetanus (DTP), polio, and Haemophilus influenza type B (Hib) in 2011 . The level of vaccination of 1 year-old Indigenous children Australia-wide was 85%, slightly higher than in WA.
For Indigenous children aged 2 years, 88% were fully vaccinated (with the additional immunisation against measles, mumps and rubella (MMR)) in 2011, compared with 91% of non-Indigenous children . The level of vaccination of 2 year-old Indigenous children Australia-wide was 92%.
In WA in 2011, 80% of Indigenous children aged 5 years and 87% of their non-Indigenous counterparts were fully vaccinated . The level of vaccination of 5 year-old Indigenous children Australia-wide was 87%, higher than in WA.
In 2004-2005, nearly two-thirds (60%) of Indigenous people in WA aged 50 years or older had been vaccinated against influenza in the previous 12 months and 35% had been vaccinated against pneumonia in the previous five years . WA and Australia-wide vaccination levels were similar for Indigenous people. Vaccination levels were higher for Indigenous people living in remote areas of WA than for those living in non-remote areas: 73% of Indigenous people living in remote areas were vaccinated for influenza (compared with 48% for those living in non-remote areas); 48% of Indigenous people living in remote areas were vaccinated for pneumonia (compared with 24% in those living in non-remote areas) . Australia-wide, vaccination levels for both influenza and pneumonia were higher among Indigenous people aged 50 years and older than among their non-Indigenous counterparts .
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 lower the risk of obesity and protect against a range of chronic illnesses that can develop in adulthood, including type 2 diabetes, heart disease, atherosclerosis, and high blood pressure . Preliminary results 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. The NHMRC recommends exclusive breastfeeding of infants aged 0-6 months, to be continued after the introduction of solid foods until the age of 12 months and older .
Surveys indicate that a majority of Indigenous women in WA breastfeed their babies. The WAACHS reported that Western Australian mothers of Indigenous children, particularly those living in more isolated areas, were more likely than mothers in the general population to initiate breastfeeding and breastfeed for longer . According to the 2004-2005 NATSIHS, 81% of Indigenous babies aged 0-3 years living in non-remote areas of WA had been breastfed or were being breastfed at the time of the survey, compared with 90% of non-Indigenous babies . In 2008, 85% of Indigenous babies aged 0-3 years in WA had been breastfed, a higher proportion than that for Indigenous children Australia-wide (77%) . Around 22% of Indigenous babies aged 1-3 years in WA were being breastfed at the time of survey, compared with 11% Australia-wide. The median age at which Indigenous babies in WA stopped breastfeeding entirely was 22 weeks, compared with 17 weeks for Indigenous babies Australia-wide.
The introduction of solid food to Indigenous infants in WA in 2008 occurred most frequently among those aged 3-6 months (41%), followed by those aged 6-9 months (38%) . Around 2.0% were given solid foods at less than 3 months-of-age. These figures compare favourably with Indigenous infants Australia-wide (43%, 30% and 4.7%, respectively).
Tobacco use increases the risk of chronic disease, including CVD, certain cancers, and lung diseases, as well as a variety of other health conditions . 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 sudden infant death syndrome (SIDS).
In 2003, tobacco use was the leading cause of burden of disease and injury among Indigenous people in Australia, responsible for 12% of the total burden of disease . Tobacco use accounted for one-in-five deaths in the Indigenous population.
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 2004-2005 NATSIHS17 , but there has been a slight decrease from the level reported in 2002 (48%) . After age-adjustment, the 2004-2005 NATSIHS found that daily smoking among Indigenous people aged 18 years and older in WA was 2.0 times more common than among their non-Indigenous counterparts .
In WA, a higher proportion of Indigenous people living in remote or very remote areas in 2008 were current smokers (52%) compared with those living in inner/outer regional areas (43%) or major cities (36%) . The age-groups with the highest proportion of Indigenous smokers were the 25-34 years and 35-44 years age-groups (56% and 55% respectively).
The proportion of Indigenous men who were currently smokers (49%) was higher than the proportion of Indigenous women (46%) in 2008 . Indigenous males and females living in remote areas were more likely to report being a current smoker (53% and 52%, respectively) than Indigenous males and females living in non-remote areas (45% and 42%, respectively).
More than half (51%) of Indigenous mothers in WA smoked during pregnancy in 2009 . After age-adjustment, this level was more than four times higher than the level among non-Indigenous mothers.
In 2008, 67% of Indigenous children aged 0-14 years in WA lived with someone who was a daily smoker, a level almost twice as high as that for non-Indigenous children . Around 18% of Indigenous children aged 0-14 years lived in households where someone smoked inside the house on a daily basis. A higher portion of Indigenous children in remote areas lived with a current smoker than among those living in non-remote areas.
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, drowning, homicides, and falls. Consumption of alcohol in pregnancy can also affect the unborn child, and abstinence from drinking alcohol is advised for women when pregnant or breastfeeding . Consumption of alcohol during pregnancy may lead to fetal alcohol spectrum disorder (FASD), an umbrella term that describes a range of disorders (comprising abnormalities such as growth retardation, characteristic facial features, and central nervous system anomalies - including intellectual impairment) . These disorders are wholly preventable, but incurable.
In 2003, the burden of disease attributable to alcohol use among Indigenous people was almost twice that among other Australians (5.4% compared with 3.2%) . Of 11 selected risk factors, alcohol use was the fifth leading cause of the burden of disease among Indigenous people . The highest levels of disease burden attributable to alcohol use among Indigenous people were for injury (22%), mental disorders (16%), and cancers (6.3%).
Surveys have consistently shown that Indigenous people are less likely to drink alcohol than non-Indigenous people18 , but those who do drink are more likely to consume it at harmful levels .
The 2010 National drug household survey (NDSHS) found that Indigenous people aged 14 years or older were 1.4 times more likely than their non-Indigenous counterparts to abstain from drinking alcohol, and 1.5 times more likely to drink alcohol at risky levels for both single occasion and lifetime harm .
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 previous 12 months, compared with 17% of the total Australian population aged 14 years or older . NATSISS data are not directly comparable with the 2004-2005 NATSIHS (due to conceptual and methodology differences), but the 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, and the 2004-2005 NATSIHS found that 16% of the Indigenous population aged 18 years and over reported drinking at risky/high risk levels . After age-adjustment, 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) in 2004-2005 .
The 2008 NATSISS found that 34% of the Indigenous population in WA aged 15 years or older had never consumed alcohol or had not done so in previous 12 months . Analysis of the 2004-2005 NATSIHS found that 26% of the Indigenous population aged 18 years or over in WA had abstained from alcohol in the last 12 months . Further analysis of the 2004-2005 NATSIHS and the 2004-2005 NHS found that 30% of the Indigenous population abstained from alcohol in the previous 12 months compared with 14% of the non-Indigenous population in WA.
The 2008 NATSISS also found that 19% of Indigenous people in WA aged 15 years or older drank alcohol at medium/high risk levels . While not directly comparable, this is similar to the 2004-2005 NATSIHS which found that 19% of Indigenous people in WA aged 18 years and older drank at risky/high risk levels . Analysis of the 2004-2005 NATSIHS and the 2004-2005 NHS found similar levels of long-term risky/high risk levels for Indigenous and non-Indigenous people in WA (16% and 15% respectively), but the proportion of the Indigenous population who drank at short-term risky/high risk levels on a weekly basis was more than twice that of the non-Indigenous population (18% and 8% respectively) .
In 2008-09, Indigenous people living in WA were hospitalised for ICD ‘Mental and behavioural disorders’ relating to alcohol use at 6.8 times the rate of non-Indigenous people (Table 25) . The most common type of ‘Mental and behavioural disorder’ was acute intoxication, for which Indigenous people were hospitalised at more than 14 times the rate of non-Indigenous people. The hospitalisation rate for alcoholic liver disease was 9.3 times higher for Indigenous people than that for non-Indigenous people.
|Source: Steering Committee for the Review of Government Service Provision, 2011 |
|Alcoholic liver disease||2.7||0.3||0.9||0.1||1.8||0.2||9.3|
|Other inflammatory liver disease||n.p.||0.1||n.p.||0.1||0.2||0.1||3.2|
|Toxic effect of alcohol||0.2||0.0||0.1||0.0||0.1||0.0||5.2|
|Intentional self-poisoning by and exposure to alcohol||0.3||0.2||0.5||0.3||0.4||0.3||1.5|
|Poisoning by and exposure to alcohol, undetermined intent||n.p.||0.0||0.2||0.0||0.1||0.0||5.0|
In 2005–06, Indigenous males and females living in WA experienced significantly higher rates of alcohol-related attendance at hospital emergency departments than did their non-Indigenous counterparts . In 2005, admissions and bed-days 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 bed-days compared with 30% and 26% respectively) and Indigenous females compared with their non-Indigenous counterparts (31% for admissions and 27% for bed-days compared with 23% and 18% respectively). For the total population, the Kimberley and Pilbara had the highest hospitalisation rates from alcohol consumption among the nine health regions compared with the State rate. For the Indigenous population, the Goldfields, Great Southern, Kimberley, Midwest, and Pilbara had significantly higher rates compared with the State rate.
In 2005-2009, the age-standardised death rate for alcohol-related deaths was 11 times higher for Indigenous people than that for non-Indigenous people in WA . The rate for Indigenous males (62 per 100,000) was higher than that for Indigenous females (36 per 100,000). The Indigenous:non-Indigenous rate ratio was higher for females (17) than for males (9.5).
In 2006-2010, alcohol-related diseases accounted for 5.8% of avoidable deaths among Indigenous people aged 0-74 years in WA . After age-adjustment, the Indigenous death rate for avoidable deaths was 10 times higher than the rate for non-Indigenous people in WA.
In WA, for the years 1997-2005, person years of life lost (PYLL) (a measure of the level of premature death resulting from alcohol use) was almost four times higher for Indigenous males than for their non-Indigenous counterparts (22 compared with 5.5 per 1,000 population) and over seven times higher for Indigenous females than for non-Indigenous females (9.5 compared with 1.3 per 1,000 population) . The proportion of alcohol-related deaths in 1997-2005 wholly attributable to alcohol was twice as high for Indigenous males as those for their non-Indigenous counterparts (43% compared with 20%), and over three times as high for Indigenous females than for non-Indigenous females (55% compared with 16%).
Illicit drug use describes the use of those drugs which 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 (e.g. analgesics) . Illicit drug use is a risk factor for ill-health including conditions such as HIV/AIDS, hepatitis, chronic conditions (such as CVD and social and emotional wellbeing), poisoning and self-inflicted injury, and can cause death.
In 2003, illicit drug use accounted for 2.0% of the burden of disease in Australia and was responsible for 8.0% of the mental health burden of disease, and 3.6% of the injury burden of disease . 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%) .
Australia-wide, the 2008 NATSISS found that 23% of Indigenous people aged 15 years and over had used an illicit substance in the 12 months prior to the survey . This level was 1.6 times that reported for the non-Indigenous population aged 14 years or over (14%) in the 2010 NDSHS, but less than that reported in the 2004-2005 NATSIHS for the Indigenous population aged 18 years and over (28%) .
According to the 2008 NATSISS, 45% of Indigenous people in WA aged 18 years and older reported ever having used an illicit substance, and 25% reported having used one in the previous 12 months . These proportions were slightly lower than those reported in the 2004-2005 NATSIHS, in which 54% of Indigenous people in WA reported ever using a substance and 31% having used a substance in the previous 12 months . Comparison of the 2008 NATSISS and the 2010 NDSHS found that a higher proportion of Indigenous people (25%) than of the total population (19%) had used an illicit substance in the previous 12 months in WA . 19
Among Indigenous people in WA in 2008, the most commonly used illicit substances were marijuana, hashish or cannabis resin (used by 21% of Indigenous people in WA in the previous 12 months), followed by amphetamines/speed (4.1%), and ecstasy/designer drugs (2.4%) .
Indigenous males had a higher proportion of use of illicit substances than did Indigenous females in WA in 2008: 54% of Indigenous males reported ever having used an illicit substance compared with 37% of Indigenous females; 31% of Indigenous males reported use within the previous 12 months, compared with 20% of Indigenous females . The proportions for use in the previous 12 months were slightly higher for Indigenous males and females in WA than the national proportions for Indigenous people.