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Australian Indigenous HealthBulletin
 
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spacing1Summary of the health of Indigenous people in Western Australia, 2013

This Summary of Indigenous health in Western Australia provides brief information in plain language about health problems and common risk and protective factors in the Aboriginal and Torres Strait Islander population in Western Australia (WA).

Suggested citation: Australian Indigenous HealthInfoNet (2014) Summary of Indigenous health in Western Australia, 2013. Retrieved [access date] from http://www.healthinfonet.ecu.edu.au/wa_summary

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For more comprehensive information about Indigenous health status, please access the HealthInfoNet's Overview of the health of Indigenous people in Western Australia (http://www.healthinfonet.ecu.edu.au/states-territories-home/wa/reviews/our-review).

Summary of Indigenous health in Western Australia, 2013

Introduction

This summary includes the following information about Aboriginal and Torres Strait Islander peoples in WA:

It uses information from the most up-to-date sources to help create a picture of the health of WA’s Indigenous people including:

Data for these reports are collected through health surveys, by hospitals, and by doctors across Australia.

It is important that health data are accurate; if some details are missing the information may not be accurate. For example, to understand data about the health of Indigenous people, states and territories need to collect information about their patients, including whether a person is Indigenous. Some states and territories (including WA, and also SA and the NT) reliably collect this data, but others (like the ACT and Tas) do not. This means that most information about the health of Indigenous people is fairly accurate for WA, but not for Australia as a whole. The information about the Indigenous population is getting better, but there are still limitations.

To create a complete picture of Indigenous health, all the information in this report should be looked at in the context of the 'social determinants of health'. The ‘social determinants of health’ is a term used to talk about factors that affect people's health [1][2][3], including if a person:

Social determinants that are particularly important to many Indigenous people are:

If a person feels safe, has a job that earns enough money, and feels connected to their family and friends, they will generally be healthier. Indigenous people are generally worse off than non-Indigenous people when it comes to the social determinants of health [1].

A lot of health services are not as accessible and user-friendly for Indigenous people as they are for non-Indigenous people, adding to higher levels of disadvantage. Sometimes this is because more Indigenous people than non-Indigenous live in remote locations and not all health services are offered outside of cities. Sometimes health services are not culturally appropriate (do not consider Indigenous culture and the specific needs of Indigenous people). Also, some Indigenous people may not be able to use some services because they are too expensive.

What makes health services more accessible for Indigenous people?:

More detailed information about the health of Indigenous peoples, social issues, and risk and protective factors, is available from the HealthInfoNet’s web resource (www.healthinfonet.ecu.edu.au).

What do we know about WA’s Indigenous population?

According to the most recent Census, it was estimated that there were 88,277 Indigenous people living in WA in 2011 [4]. Indigenous people made up almost 4% of WA’s population. Around one-in-three of WA’s Indigenous people lived in Perth, and one-in-six lived in the South-West. The table below provides more details about where Indigenous people in WA lived (Table 1).

Table 1: Indigenous population in WA, 30 June 2011
RegionNumber of Indigenous people% of Indigenous people in WA
Notes:
  1. The regions are the ‘Indigenous regions’ used by the ABS for population estimates
  2. The table presents 2011 Census ‘count’ numbers which have not been adjusted; these numbers are likely to underestimates the numbers of Indigenous people
  3. There were high proportions of the region’s populations where Indigenous status was not known, ranging from 18% in the South Hedland region to around 5% in Perth and the South-Western region
Source: Derived from ABS, 2013 [5]
Perth 25,531 37
South-Western WA 10,552 15
South Hedland 7,260 10
Geraldton 6,330 9
Kalgoorlie 5,618 8
Kununurra 5,504 8
Broome 4,372 6
West Kimberley 4,041 6
Total 69,670 100

The number of Indigenous people counted in the 2011 Census was much higher than the number counted in the 2006 Census [6]. This could be explained by a number of factors:

In 2011, 96% of Indigenous people in WA identified as Aboriginal, 2% identified as Torres Strait Islanders, and 2% identified as both Aboriginal and Torres Strait Islander [7].

The Indigenous population is younger than the non-Indigenous population in WA [4]. In 2011, more than one-third of Indigenous people were less than 15 years old (compared with one-in-five for non-Indigenous people). About 3% of Indigenous people were 65 years or over (compared with 12% of non-Indigenous people). Figure 1 shows a comparison of the age profiles of the Indigenous and non-Indigenous populations in WA.

Figure 1. Population pyramid of Indigenous and non-Indigenous populations in WA, 2011

Population pyramid of Indigenous and non-Indigenous populations in WA, 2011

Source: ABS, 2013 [4]
What is a 'rate'?

One way of looking at how common a disease is in a population is by calculating a ‘rate’. You can calculate a rate by dividing the number of cases of a disease by the population, for a specific amount of time. By calculating rates, you can compare how common a disease is in different populations (like Indigenous and non-Indigenous people) or between sexes (men and women). You can also calculate rates for deaths, which lets you compare the number of deaths in two different populations.

There is a special calculation for ‘infant mortality rates’. To calculate this rate, the number of infants (children under one year of age) who died in one calendar year is divided by the number of live births in the same year.

What do we know about Indigenous births in WA?

In 2011, there were 2,506 births registered in WA where one or both parents were Indigenous (eight out of every 100 births) [8]. Indigenous women had more children and had them at younger ages than did non-Indigenous women.

Indigenous women in WA had, on average, three births in their lifetime (compared with two births in their lifetime for all women in WA) [8]. Around four-in-five Indigenous mothers were younger than 30 years when they had their babies, compared with less than one-half of non-Indigenous mothers. Indigenous women were five times more likely to give birth when they were teenagers than were non-Indigenous women.

In 2010, the average weight for babies born to Indigenous women in WA was 3,139 grams, more than 200 grams less than the average of babies born to all Western Australian mothers [9]. Babies born to Indigenous women were more than twice as likely to be of low birthweight (less than 2,500 grams) than were those born to non-Indigenous women. Low birthweight can increase the risk of a child developing health problems.

What do we know about Indigenous deaths in WA?

Indigenous people are much more likely than non-Indigenous people to die before they are old [10][11]. The most recent estimates show that an Indigenous boy born in WA in 2005-2007 could be expected to live to 65 years, 14 years less than a non-Indigenous boy (Figure 2) [10]. An Indigenous girl born in 2005-2007 could be expected to live to 70.4 years, 12.5 years less than a non-Indigenous girl. (In 2010, the ABS changed the way it calculates Indigenous life expectancy, so recent estimates cannot be compared with older estimates.)

Figure 2. Expectations of life at birth for Indigenous and non-Indigenous males and females in WA, 2005-2007

Expectations of life at birth for Indigenous and non-Indigenous males and females in WA, 2005-2007

Source: ABS, 2009 [10]

In 2011, there were 454 Indigenous deaths registered in WA [12]. Many Indigenous deaths are incorrectly counted as non-Indigenous because the person or family are not identified as Indigenous – the actual number of Indigenous deaths is not known, but would be higher than the number registered.

The leading causes of death in 2006-2010 for Indigenous people in WA were:

Babies born to Indigenous women are more likely to die in their first year than those born to non-Indigenous women [12]. In 2009-2011, the infant mortality rate (see boxed information, What is a rate?, for details) for Indigenous babies in WA was more than twice as high as that for non-Indigenous babies. The rate for Indigenous male babies was higher than that for Indigenous female babies.

Specific health conditions

What do we know about heart health in WA’s Indigenous population?

Many Indigenous people are affected by cardiovascular disease (CVD), a group of diseases affecting the heart and circulatory system [14]. The most common types of CVD are coronary heart disease (including heart attack), stroke, heart failure, and high blood pressure. Risk factors (a behaviour or characteristic that makes it more likely for a person to get a disease) for CVD include: smoking tobacco, not eating well, and having diabetes.

In the 2004-2005 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS), one-in-ten Indigenous people in WA reported having a heart and circulatory problem [15]. Heart and related conditions were more common for Indigenous women than for non-Indigenous women, but the same for Indigenous and non-Indigenous men. High blood pressure (the most commonly reported condition nationally) was reported more often by Indigenous people than by non-Indigenous people.

CVD was the most common cause of death for Indigenous people in WA in 2006-2010 [15]. One-quarter of Indigenous deaths were from CVD. Deaths from CVD happened more than twice as often for Indigenous people as for non-Indigenous people.

What do we know about cancer in WA’s Indigenous population?

Cancer is a disease of the body's cells (the basic building blocks of the body) [16]. Cancer can occur almost anywhere in the body. Normally cells multiply and grow in an ordered way, but sometimes the DNA (genetic blueprint) of cells is damaged resulting in uncontrolled growth. If cancer cells spread into surrounding areas, or to different parts of the body (metastasise), they are known as ‘malignant’; malignant cancers can cause illness and death.

In 2004-2005, 1% of Indigenous people in WA reported having cancer, which is about half as many as non-Indigenous people [17].

In 2007-2011, the rate of new cases (incidence rate) of cancer was the same for Indigenous and non-Indigenous people in WA [18]. Incidence rates varied depending on the type of cancer. Indigenous people had higher incidence rates than did non-Indigenous people for:

The rate of new cases of cervical cancer was two times higher for Indigenous women than for non-Indigenous women in WA in 2004-2008 [15].

In 2007-2011, Indigenous people had lower incidence rates than did non-Indigenous people in WA for:

Death rates from cancer tend to be higher for Indigenous people than for non-Indigenous people. In 2006-2010, cancer was the third most common cause of death for Indigenous people in WA [13]. The types of cancer that caused the most deaths among Indigenous people were cancer of digestive organs and lung cancer [15]. The chance of getting lung cancer increases when people smoke tobacco.

The fact that Indigenous people are more likely than non-Indigenous people to die from cancer could be because:

What do we know about diabetes in WA’s Indigenous population?

Diabetes is a condition where the body cannot properly process glucose (a type of sugar) [20]. Normally the body can convert glucose into energy with the help of a hormone called insulin. If someone has diabetes, their body doesn’t produce insulin properly. Without enough insulin the body cannot turn glucose into energy, and it stays in the blood. The treatment of diabetes depends on the type of diabetes – if someone has type 1 diabetes they will need insulin injections; if someone has type 2 diabetes they may be able to manage it by living a healthy lifestyle or taking some medicines. It is possible for a person to have type 2 diabetes without knowing it.

Diabetes is a major health problem for Indigenous people, but it is hard to know just how many Indigenous people have the disease. Diabetes or high sugar levels was reported by 9% of Indigenous people in WA in the 2004-2005 NATSIHS [17], but it is believed that only around one-half of Indigenous people with diabetes actually know they have it; it has been estimated that between 10% and 30% of Indigenous people Australia-wide may have the condition [21][22]. Diabetes was almost four times more common for Indigenous people than for non-Indigenous people in WA (Figure 3).

In 2006-2010, diabetes caused almost one-in-ten Indigenous deaths in WA [13]. Deaths from diabetes were nine times more common for Indigenous people than for non-Indigenous people.

Figure 3. Proportions (%) of Indigenous and non-Indigenous people in WA reporting diabetes as a long-term health condition, by age-group, 2004-2005

Proportions (%) of Indigenous and non-Indigenous people in WA reporting diabetes as a long-term health condition, by age-group, 2004-2005

Source: AIHW, 2013 [15]

What do we know about the social and emotional wellbeing of WA’s Indigenous people?

Social and emotional wellbeing is a term used to talk about a person’s overall social, emotional, psychological (mental), spiritual, and cultural wellbeing. Factors that are important to social and emotional wellbeing include a person’s:

Social and emotional wellbeing is often confused with mental health, but it is much broader: social and emotional wellbeing is concerned with the overall wellbeing of the person. On the other hand, mental health describes how a person thinks and feels, and how they cope with and take part in everyday life. It is often seen, incorrectly, as simply the absence of a mental illness.

Many things can influence a person’s social and emotional wellbeing, including:

Measuring social and emotional wellbeing is difficult, but it usually relies on self-reported feelings (like happiness or calmness) or ‘stressors’ (stressful events in a person’s life).

The 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) collected information on positive wellbeing and asked people to report on feelings of happiness, calmness and peacefulness, fullness of life, and energy levels. The survey found that most (nine-out-of-ten) Indigenous people in WA felt happy some, most, or all of the time [15]. Around four-out-of-five Indigenous people reported feeling calm and peaceful, full of life, and that they had a lot of energy some, most, or all of the time.

Similar information has not been collected from non-Indigenous people, so there is no way to compare Indigenous and non-Indigenous people's positive wellbeing. It is likely, however, that Indigenous people would report lower levels of social and emotional wellbeing overall because they experience higher levels of psychological distress and more stressors when compared with non-Indigenous people [25][26].

The 2008 NATSISS and the 2007-2008 National Health Survey (NHS) found that Indigenous adults in WA were almost three times more likely to feel high or very high levels of psychological distress than were non-Indigenous adults [15]. The 2008 NATSISS found that, nationally, almost eight-out-of-ten Indigenous people experienced one or more significant stressors in the year before the survey interview [25]; this compared with six-out-of-ten for the general Australian population [26].

Compared with the stressors reported by the general Australian population in the 2010 General Social Survey (GSS), many more Indigenous people Australia-wide reported stressors like: the death of a family member or friend; alcohol related problems; and trouble with the police (Figure 4) [25]. Almost one-in-eight Indigenous people also reported that either they, a family member, or friend had been sent to jail in the previous 12 months, but this stressor was not reported by the general population.

Figure 4. Proportion (%) of Indigenous and non-Indigenous people who experienced stressor(s), by type of stressor, 2008 and 2010, Australia

Proportion (%) of Indigenous and non-Indigenous people who experienced stressor(s), by type of stressor, 2008 and 2010, Australia

Source: AIHW, 2011 [25], ABS, 2011 [26]

In 2008-10, Indigenous men in WA were three times more likely, and Indigenous women two times more likely, to be hospitalised for mental health-related conditions than were non-Indigenous men and women. The most common mental-health related conditions that Indigenous people in WA required hospitalisation for included ‘mental and behavioural disorders due to psychoactive substance use’ and ‘schizophrenia, schizotypical, and delusional disorders’ [15].

In 2005-2009, the death rate from ‘mental and behavioural disorders’ was more than three times higher for Indigenous people than non-Indigenous people in WA (‘mental and behavioural disorders’ occur when a person becomes unwell in the mind and experiences changes in their thinking, feelings, and/or behaviour that affects their day-to-day life) [27].

Deaths from ‘mental and behavioural disorders’ do not include deaths from ‘intentional self-harm’ (suicide). In 2011, intentional self-harm was the third leading cause of death for Indigenous people in WA [28]. In 2005-2009, deaths from intentional self-harm were three times higher for Indigenous people than for non-Indigenous people [27].

The most detailed information on the social and emotional wellbeing of Indigenous children comes from the Western Australian Aboriginal Child Health Survey (WAACHS). This survey found that almost one-quarter of Indigenous children and young people were rated by their carer (parent or guardian) as being at high risk of ‘clinically significant emotional or behavioural difficulties’ (emotional or behavioural problems that affect a person's day-to-day life); this compares with one-in-seven children for the general WA population [29].

Indigenous children whose carers had been forcibly separated (taken away) from their families were at high risk of having ‘clinically significant emotional or behavioural difficulties’, more than twice the risk of children whose carer had not been forcibly separated [29]. These children also had twice the rates of alcohol and other drug use.

The WAACHS also found that seven-in-ten Indigenous children were living in families that had experienced three or more major life stress events (like a death in the family, serious illness, family breakdown, financial problems, or arrest) in the year before the survey, and one-in-five had experienced seven or more major stress events [29].

What do we know about kidney health in WA’s Indigenous population?

Healthy kidneys help the body by removing waste and extra water, and keeping the blood clean and chemically balanced [30]. When the kidneys stop working properly – as is the case when someone has kidney disease – ‘waste’ can build up in the blood and damage the body. Chronic kidney disease (CKD) is when the kidneys gradually stop working [31]. End-stage kidney disease (ESKD) is when the kidneys have totally or almost totally stopped working. People with ESKD must either have regular dialysis (be hooked up to a machine that filters the blood) or have a kidney transplant to stay alive.

Kidney disease is a serious health problem for many Indigenous people in WA. In 2008-2010, 132 Indigenous patients were newly diagnosed with ESKD [15]. ESKD was 12 times more common for Indigenous people than for non-Indigenous people in WA.

ESKD affects Indigenous people when they are much younger than it does for non-Indigenous people. In 2008-2010, Indigenous people in WA aged 25-44 years were 15 times more likely to be diagnosed with ESKD than non-Indigenous people (Figure 5) [15].

Figure 5. Notification rates of end-stage kidney disease for Indigenous and non-Indigenous people in WA, by age-group, 2008-2010

Notification rates of end-stage kidney disease for Indigenous and non-Indigenous people in WA, by age-group, 2008-2010

Note:
  1. Rates are per 100,000 population. These rates show how many Indigenous and non-Indigenous people in WA had ESKD per 100,000. This means, for example, that for every 100,000 Indigenous people in WA aged 55-64 years, around 340 had ESKD in 2008-2010
Source: AIHW, 2013 [15]

Across Australia, dialysis was the most common reason for Indigenous people to be admitted to hospital in 2010-11 [32]. Almost one-half of all Indigenous hospital admissions were for dialysis. Indigenous people were admitted to hospital for dialysis 11 times more often than were other Australians.

Some people need to have dialysis every day. People can have dialysis at hospitals, special out-of-hospital satellite units, or in the home (which requires special equipment and training for the patient and their carer(s), and is very costly) [33]. Accessing dialysis can sometimes be difficult for Indigenous people who live in rural or remote locations because they may have to travel to receive treatment.

In 2006-2010, Indigenous people in WA were more than five times more likely to die from kidney disease than were non-Indigenous people [13].

What do we know about injury in WA’s Indigenous population?

Injury generally refers to physical harm to a person's body [34] including:

Cultural and everyday life situations for Indigenous people can affect the types of injuries they experience and how often injuries occur. Some factors that can increase the risk of injury include:

It is hard to know exactly how many Indigenous people in WA suffered injuries, but in 2004-2005 Indigenous people across Australia reported injuries around one-and-a-half times more often than did non-Indigenous people [37].

In WA, injury was the second most common reason that Indigenous people were admitted to hospital (after dialysis) in 2008-2010 [13]. Indigenous people were admitted to hospital for injuries around three times more often than were non-Indigenous people. The main causes of Indigenous injury-related hospital admissions were assault and falls.

In 2006-2010, injury was the second most common cause of death for Indigenous people in WA [13]. Indigenous people were more than three times as likely as non-Indigenous people to die from injuries.

What do we know about respiratory health in WA’s Indigenous population?

The respiratory system includes all the parts of the body involved with breathing, including the nose, throat, larynx (voice box), trachea (windpipe), and lungs [38]. Respiratory disease occurs if any of these parts of the body is damaged or diseased and breathing is affected. Common types of respiratory disease include colds and similar viral infections, asthma and pneumonia.

Risk factors for respiratory disease include: infections, smoking (including passive smoking, breathing in another person's tobacco smoke, which is particularly bad for children), poor environmental conditions (especially areas that are dusty or have lots of pollen or pollution), poor living conditions, and other diseases (like diabetes, heart and kidney disease) [38].

In WA, Indigenous and non-Indigenous people had similar levels of respiratory disease in 2004-2005 [17]. Asthma (the most common respiratory condition for Indigenous people) was reported by 14% of Indigenous people in WA.

In 2008-10, Indigenous people in WA were admitted to hospital because of a respiratory condition four times more often than non-Indigenous people [13].

Indigenous people in WA were three times more likely to die from a respiratory disease than were non-Indigenous people in 2006-2010 [15].

What do we know about eye health in WA’s Indigenous population?

Having healthy eyes is important for everyday life; they are needed to read and study, play sports, drive, and work [39]. There are a number of problems that can affect the health of the eye [40]. The most common conditions are:

Eye problems are associated with: getting older, smoking, injuries, exposure to ultra-violet (UV) light from the sun, and not eating enough healthy food [40]. Eye health problems can result in low vision (not being able to see properly) and sometimes result in impaired eyesight and blindness. This can be corrected with glasses, contact lenses or eye surgery.

Many Indigenous people do not have access to specialised eye health services, including optometrists and ophthalmologists (specialist eye doctors) [41]. As a result, Indigenous people are more likely than non-Indigenous people to have eye health problems that are preventable. In the 2004-2005 NATSIHS, eye and/or sight problems were reported by almost one-third of Indigenous people in WA [37].

The 2008 National Indigenous Eye Health Survey (NIEHS) found that, in WA, 12% of Indigenous adults and 2% of Indigenous children had low vision. The main causes of low vision and blindness for Indigenous adults were refractive error, cataracts, diabetic retinopathy, and trachoma [42][43].

Diabetes, a major problem for Indigenous people, can cause eye disease and loss of vision. The 2008 NIEHS found that 12% of Indigenous people with diabetes in WA had sight problems, and only 16% had an eye examination in the last year [42].

The 2008 NIEHS reported that the prevalence of vision loss due to cataract was 5% in WA - higher than in any other state or territory [43].

In 2012, 4% of Indigenous children aged 1-14 years who were screened in WA had active trachoma [44]. The prevalence was highest (10%) among screened children in the Goldfields region, followed by 4% in the Mid-West region, and 2% in the Pilbara and Kimberley regions.

The 2008 NIEHS found Indigenous children had better vision than other children in Australia, especially in remote areas [43]. There were similar findings for Indigenous children in the WAACHS [45].

What do we know about ear health in WA’s Indigenous population?

Ear health is very important for hearing, learning and balance [46]. If ears get damaged, people might:

There are a number of ear diseases, but the most common is called otitis media (OM) which can cause hearing loss [46]. OM is an ear disease where the middle ear is affected by infection from bacteria or viruses and it can be very painful. Fluid may build up in the middle ear and sometimes the ear drum is damaged; fluid may also leak from the ear.

Ear disease is associated with people living in crowded homes (particularly with people who smoke), living in poor conditions, or having poor hygiene. Children who go to day-care centres are often more likely than others to get ear infections.

The 2008 NATSISS found that 9% of Indigenous children in WA had ear or hearing problems [47]. Of these children, 5% had OM and 2% had partial or total hearing loss. The 2004-2005 NATSIHS found that 4% of Indigenous children in WA had OM [15], a level more than twice as high as that for non-Indigenous children [48]. Around 5% of Indigenous children were completely or partially deaf, which was twice as common as for non-Indigenous children.

The WAACHS found that almost one-in-five Indigenous children had recurring ear infections (ear infections that keep coming back) [45]. Young children (0-11 years) were more likely to have recurring ear infections than were older children (12-17 years). Carers reported hearing that wasn’t normal for 7% of Indigenous children. There is a strong link between recurring ear infections and abnormal hearing: 28% of children who had recurring ear infections with discharge (runny ears) also had abnormal hearing, compared with 1% of those without ear infections.

What do we know about oral health in WA’s Indigenous population?

Oral health is a term used for the health of a person's teeth and gums [49]. If people have unhealthy teeth and gums they will probably have some pain; they may not be able to eat a variety of healthy foods or talk to other people comfortably. Two common oral health problems are caries and gum diseases. Caries is caused by bacteria that decay (break down) the enamel (hard outer part of the tooth); if caries is not treated the tooth will continue to decay and will eventually have to be removed. Caries is caused by poor oral hygiene and eating a lot of sticky and sweet foods that let bacteria grow and multiply. Gum disease (also known as periodontal disease) is caused by bacteria that attack the gums causing them to swell and bleed. If gum disease is not treated, the gums start to break down and the teeth will become loose because the gums won’t be strong enough to hold them in place. Gum disease is caused by poor oral hygiene (poor care of the teeth and gums) and linked with not going to the dentist regularly, being older, tobacco use, low education, low income, and some medical conditions including diabetes and osteoporosis [50][51][52].

The 2004-2005 NATSIHS found that three-in-four Indigenous adults in WA had lost less than five adult teeth in their lifetime [17]. Indigenous people lost more teeth as they got older. The NATSIHS also found that one-in-six Indigenous adults in WA had never seen a dentist or other health professional about their teeth.

The 2008 NATSISS found that almost one-third of Indigenous children in WA had problems with their teeth and gums [13]. The WAACHS found that one-in-five Indigenous children in WA had holes in their teeth; two-in-five had tooth decay, teeth removed, or fillings [45].

A study in five remote communities in WA found that tooth decay was more common and more severe for Indigenous children than for non-Indigenous children [53]. The study also found that Indigenous children had more toothaches than did non-Indigenous children; only half of the Indigenous children in the study brushed their teeth every day, and one-third never brushed their teeth.

What do we know about disability in WA’s Indigenous population?

Disability may affect how a person moves around and looks after themselves, how they learn, or how they communicate [54][55]. There are a lot of different kinds of disability:

A disability where a person ‘needs assistance with core activities’ is one that is severe and affects how a person is able to live their life [13].

In 2008, one-half of Indigenous adults in WA had some form of disability or long term health condition [15]. Around one-in-twelve Indigenous adults needed assistance with core activities because of a disability.

Disability becomes more common as people get older [7]. In 2011, Indigenous adults in WA were more likely to need assistance with core activities than non-Indigenous adults in every age-group (Figure 6), and a higher proportion of Indigenous adults needed assistance with a core activities from a younger age [7][56]. Overall, Indigenous people were more than twice as likely as non-Indigenous adults to need assistance with core activities.

Figure 6. Proportions (%) of Indigenous and non-Indigenous adults needing assistance with core activities, by age-group, WA (non-remote areas), 2011

Proportions (%) of Indigenous and non-Indigenous adults needing assistance with core activities, by age-group, WA (non-remote areas), 2011

Source: Derived from ABS, 2013 [7] and ABS, 2001 [56]

What do we know about communicable diseases in WA’s Indigenous population?

Communicable diseases are diseases that are passed from person to person either by direct contact with an infected person or indirectly, such as through contaminated (dirty/unclean) food or water. Another example of indirect transmission is when the disease is spread through the air, such as when an infected person coughs or sneezes and another person breathes in the air that contains the germs. Communicable diseases can be caused by:

Improvements to personal and environmental cleanliness, and the introduction of new immunisations (vaccines), have greatly reduced the number of people who catch some communicable diseases [58].

If a person contracts (catches/develops) certain communicable diseases (like tuberculosis), the disease must be ‘notified’; this means that the information is collected by health authorities. Unfortunately, Indigenous status is often not reported in notifications. Only WA, SA, and the NT reliably identify Indigenous status in the notification of communicable diseases [59].

Recent information about communicable diseases in WA includes:

Hepatitis: an inflammation of the liver caused by viral infections, alcohol or other drugs, toxins, or an attack by the body’s immune system on itself [60].

Invasive pneumococcal disease (IPD): caused by a bacterium and can lead to several major health conditions, such as pneumonia and meningitis [62].

Sexually transmissible infections (STIs): caused by bacteria and viruses and can lead, if left untreated, to a range of health conditions, such as pelvic inflammatory disease (which can cause blocked fallopian tubes) in women [64][65].

HIV (human immunodeficiency virus): an infection that destroys cells in the body’s immune system [66].

What do we know about factors contributing to Indigenous health in WA?

Nutrition

If a person eats healthy food they are more likely to be healthy [67]. A healthy diet includes:

Having access to healthy foods can be a challenge for some Indigenous people who live in remote locations because food that has to be shipped over long distances is not always available, or because fresh foods may be expensive [67].

The 2004-2005 NATSIHS found that most Indigenous people in WA ate fruit (85%) and vegetables (94%) every day [17]. More Indigenous people living in non-remote areas ate fruits and vegetables daily than did those living in remote areas. This may be because fruit and vegetables are more available and less expensive in non-remote areas than in remote areas.

The 2008 NATSISS found that, for Indigenous children in WA, four-in-ten ate the recommended daily serve of vegetables, and eight-in-ten ate the recommended amount of fruit [15].

The 2004-2005 NATSIHS found that most Indigenous people in WA drank whole milk, and only around one-in-six Indigenous people drank reduced fat or skim milk [17]. Most Indigenous people added salt to their food after it was cooked.

Physical activity

Keeping physically active is important for staying healthy. Physical exercise is good for a person’s social and emotional wellbeing and reduces the risks of heart problems, diabetes, and some cancers [68].

The 2008 NATSISS found that one-third of Indigenous adults, and two-thirds of Indigenous children, in WA took part in sport in the year before survey [Derived from [69]].

The 2005-2005 NATSIHS found that, among Indigenous adults in WA, almost one-half were sedentary (very little or no exercise) (Figure 7). Around one-third of Indigenous people undertook moderate or high levels of physical activity.

Figure 7. Proportions (%) of Indigenous adults by levels of physical activity, WA, 2004-2005

Proportions (%) of Indigenous adults by levels of physical activity, WA, 2004-2005

Note:
  1. Indigenous adults are those people aged 15 years and older
Source: AIHW, 2011 [25]

Tobacco use

Smoking tobacco is a major cause of:

Passive smoking also contributes to poor health, particularly for children [70].

The 2008 NATSISS found that two-in-five Indigenous people in WA were current smokers [71]. This level is the same as that in the 2004-2005 NATSIHS [17], but a decrease from the level in 2002 [72]. In 2004-2005, smoking was twice as common for Indigenous adults as for non-Indigenous adults in WA [17].

In 2009, half of Indigenous mothers in WA smoked when they were pregnant, a level four times higher than that for non-Indigenous mothers [13].

In 2008, seven-in-ten Indigenous children lived with someone who was a daily smoker, and two-in-ten lived with someone who usually smoked inside the house on a daily basis [13].

Alcohol use

Drinking too much alcohol is related to:

If a woman drinks alcohol when she is pregnant, the unborn child may be affected by fetal alcohol spectrum disorder (FASD), the term used to describe the physical, behavioural, and learning problems caused by alcohol damage to the brain and other parts of the body of the unborn baby [74]. The 2008 NATSISS found that most (79%) mothers of Indigenous children in WA did not drink during pregnancy, and 16% drank less alcohol during pregnancy [75]. Only 5% drank the same amount or more alcohol during pregnancy.

Indigenous people are much more likely to not drink alcohol (abstain) than non-Indigenous people [76]. The 2008 NATSISS found that more than one-third of Indigenous adults in WA did not drink alcohol [77]. However, Indigenous people who drink alcohol are more likely to drink at high-risk levels than non-Indigenous people. The 2008 NATSISS found that one-in-five Indigenous adults in WA were drinking at medium or high-risk levels [17].

In 2005-2009, the alcohol-related death rate was 11 times higher for Indigenous people than that for non-Indigenous people in WA [27].

Concluding comments

Overall Indigenous people in WA are not as healthy as non-Indigenous people, but there have been a number of improvements in WA and across Australia recently, including:

The reasons why the health of Indigenous people is worse than that of non-Indigenous people are complex, but represent a combination of general factors (like education, employment, income, and socioeconomic status) and factors having to do with the health sector (like not having access to culturally appropriate services or support).

Within the health sector, there is a need for:

Improvements to the health of Indigenous people in Australia need an ongoing commitment by all Australian governments, through the Council of Australian Governments (COAG), to ‘close the gap’ in health and other disadvantages between Indigenous and other Australians.

In addressing the COAG ‘closing the gap’ commitments, the Australian and state and territory governments gave $4.6 billion in 2008 over four years to address early childhood development, health, housing, economic participation, and remote service delivery. COAG also arranged a number of supportive commitments in the corporate and community sectors.

Each state and territory had to develop plans explaining how they would help in ‘closing the gap’. The WA State Government agreed to a process that involved genuine engagement and partnership with the Western Australian Aboriginal community [84][85].

In April 2013, the Australian Government announced $777 million to fund its share of a renewed National partnership agreement on closing the gap in Indigenous health outcomes for another three years (to 30 June 2016) [86]. The state and territory governments were asked to continue their investment to renew the National partnership agreement. In June 2013, the WA State Government announced new funding of $31 million to continue services to improve the health and wellbeing of Aboriginal West Australians [86].

The COAG commitments to date are encouraging, but ‘closing the gaps’ in health and other disadvantages will not be easy and will take a long time. Improvements in the health and wellbeing of Indigenous people will depend on a long-term commitment by all Australian governments and the involvement of Indigenous communities. This commitment will need to include strategies that address health services and the social and other factors that affect the health disadvantages faced by Indigenous people.

References

  1. Carson B, Dunbar T, Chenhall RD, Bailie R, eds. (2007) Social determinants of Indigenous health. Crows Nest, NSW: Allen and Unwin
  2. Wilkinson R, Marmot M (2003) Social determinants of health: the solid facts. Denmark: World Health Organization
  3. Marmot M (2004) The status syndrome: how social standing affects our health and longevity. New York: Holt Paperbacks
  4. Australian Bureau of Statistics (2013) Australian demographic statistics, September quarter 2012. Canberra: Australian Bureau of Statistics
  5. Australian Bureau of Statistics (2013) TableBuilder. Retrieved 2013 from http://www.abs.gov.au/websitedbs/censushome.nsf/home/tablebuilder?opendocument&navpos=240
  6. Biddle N (2012) CAEPR Indigenous population project 2011 census papers: population and age structure. Canberra: Centre for Aboriginal Economic Policy Research
  7. Australian Bureau of Statistics (2013) Community profiles. Retrieved 2013 from http://www.abs.gov.au/websitedbs/censushome.nsf/home/communityprofiles?opendocument&navpos=230
  8. Australian Bureau of Statistics (2012) Births, Australia, 2011. Canberra: Australian Bureau of Statistics
  9. Li Z, Zeki R, Hilder L, Sullivan EA (2012) Australia's mothers and babies 2010. Canberra: Australian Institute of Health and Welfare
  10. Australian Bureau of Statistics (2009) Experimental life tables for Aboriginal and Torres Strait Islander Australians: 2005-2007. Canberra: Australian Bureau of Statistics
  11. Australian Bureau of Statistics (2013) Deaths, Australia, 2012. Canberra: Australian Bureau of Statistics
  12. Australian Bureau of Statistics (2012) Deaths, Australia, 2011. Canberra: Australian Bureau of Statistics
  13. Australian Institute of Health and Welfare (2013) Aboriginal and Torres Strait Islander health performance framework 2012 report: Western Australia. Canberra: Australian Institute of Health and Welfare
  14. Penm E (2008) Cardiovascular disease and its associated risk factors in Aboriginal and Torres Strait Islander peoples 2004-05. Canberra: Australian Institute of Health and Welfare
  15. Australian Institute of Health and Welfare (2013) Aboriginal and Torres Strait Islander health performance framework 2012 report: Western Australia supplementary tables. Canberra: Australian Institute of Health and Welfare
  16. Australian Institute of Health and Welfare (2010) Cancer in Australia 2010: an overview. Canberra: Australian Institute of Health and Welfare
  17. Australian Bureau of Statistics (2006) National Aboriginal and Torres Strait Islander health survey: Western Australia, 2004-05. Retrieved 30 May 2006 from http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4715.5.55.0052004-05?OpenDocument
  18. Cancer incidence in WA, 2007-2011 (2013) Western Australian Cancer Registry
  19. Cunningham J, Rumbold AR, Zhang X, Condon JR (2008) Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia. Lancet Oncology; 9(6): 585-595
  20. Diabetes Australia (2011) Understanding diabetes. Retrieved 23 September 2011 from http://www.diabetesaustralia.com.au/en/Understanding-Diabetes/
  21. De Courten M, Hodge A, Dowse G, King I, Vickery J, Zimmet P (1998) Review of the epidemiology, aetiology, pathogenesis and preventability of diabetes in Aboriginal and Torres Strait Islander populations. Canberra: Commonwealth Department of Health and Family Services
  22. Australian Institute of Health and Welfare (2011) Key indicators of progress for chronic disease and associated determinants: data report. Canberra: Australian Institute of Health and Welfare
  23. Garvey D (2008) Review of the social and emotional wellbeing of Indigenous Australian peoples. Retrieved 2008 from http://www.healthinfonet.ecu.edu.au/other-health-conditions/mental-health/reviews/our-review
  24. Swan P, Raphael B (1995) "Ways forward": national Aboriginal and Torres Strait Islander mental health policy national consultancy report. Canberra: Department of Health and Ageing, Australia
  25. Australian Institute of Health and Welfare (2011) Aboriginal and Torres Strait Islander health performance framework 2010: detailed analyses. Canberra: Australian Institute of Health and Welfare
  26. Australian Bureau of Statistics (2011) General social survey: summary results, Australia, 2010 : Personal stressors [data cube]. Retrieved 30 September 2011 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&4159do011_gss2010.xls&4159.0&Data%20Cubes&0EEA50189835C2CCCA25791A00146784&0&2010&30.09.2011&Latest
  27. Steering Committee for the Review of Government Service Provision (2011) Overcoming Indigenous disadvantage: key indicators 2011. Canberra: Productivity Commission, Australia
  28. Australian Bureau of Statistics (2013) Causes of Death, Australia, 2011. Canberra: Australian Bureau of Statistics
  29. Zubrick SR, Silburn SR, Lawrence DM, Mitrou FG, Dalby RB, Blair EM, Griffin J, Milroy H, De Maio JA, Cox A, Li J (2005) The social and emotional wellbeing of Aboriginal children and young people: vol 2. Perth: Telethon Institute for Child Health Research and Curtin University of Technology
  30. National Kidney and Urologic Diseases Information Clearinghouse (2014) The kidneys and how they work. Retrieved 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/yourkidneys/
  31. Chronic kidney disease (CKD) management in general practice (2009) Kidney Health Australia
  32. Australian Institute of Health and Welfare (2012) Australian hospital statistics 2010-11 supplementary tables. Canberra: Australian Institute of Health and Welfare
  33. Australian Institute of Health and Welfare (2011) Chronic kidney disease in Aboriginal and Torres Strait Islander people 2011. Canberra: Australian Institute of Health and Welfare
  34. National Public Health Partnership (2005) The national injury prevention and safety promotion plan: 2004-2014. Canberra: National Public Health Partnership
  35. National Public Health Partnership (2005) The national Aboriginal and Torres Strait Islander safety promotion strategy. Canberra: National Public Health Partnership
  36. Clapham K, O’Dea K, Chenhall R (2007) Interventions and sustainable programs. In: Carson B, Dunbar T, Chenhall RD, Bailie R, eds. Social determinants of Indigenous health. Crows Nest, NSW: Allen and Unwin: 271-295
  37. Australian Bureau of Statistics (2006) National Aboriginal and Torres Strait Islander Health Survey: Australia, 2004-05. Canberra: Australian Bureau of Statistics
  38. Australian Institute of Health and Welfare (2010) Asthma, chronic obstructive pulmonary disease and other respiratory diseases in Australia. Canberra: Australian Institute of Health and Welfare
  39. Eye health education resource kit: I see for culture (2009) International Centre for Eyecare Education
  40. Burns J, Thomson N (2003) Eye health. In: Thomson N, ed. The health of Indigenous Australians. South Melbourne: Oxford University Press: 273-289
  41. Taylor HR, Boudville A, Anjou M, McNeil R (2011) The roadmap to close the gap for vision: summary report. Melbourne: Indigenous Eye Health Unit, the University of Melbourne
  42. Taylor HR, National Indigenous Eye Health Survey Team (2009) National Indigenous eye health survey: minum barreng (tracking eyes): summary report. Melbourne: Indigenous Eye Health Unit, The University of Melbourne
  43. Taylor HR, National Indigenous Eye Health Survey Team (2009) National Indigenous eye health survey: minum barreng (tracking eyes): full report. Melbourne: Indigenous Eye Health Unit, The University of Melbourne
  44. The Kirby Institute (2013) Australian trachoma surveillance report 2012. Sydney: The Kirby Institute, University of New South Wales
  45. Zubrick SR, Lawrence DM, Silburn SR, Blair E, Milroy H, Wilkes T, Eades S, D'Antoine H, Read AW, Ishiguchi P, Doyle S (2004) The health of Aboriginal children and young people [volumes 1-4]. Perth: Telethon Institute for Child Health Research
  46. Burrow S, Thomson N (2003) Ear disease and hearing loss. In: Thomson N, ed. The health of Indigenous Australians. South Melbourne: Oxford University Press: 247-272
  47. Australian Bureau of Statistics (2009) National Aboriginal and Torres Strait Islander social survey, 2008. Retrieved 11 April 2011 from http://www.abs.gov.au/ausstats/abs@.nsf/mf/4714.0?OpenDocument
  48. Australian Bureau of Statistics (2006) National Health Survey: summary of results, Australia, 2004-05. Canberra: Australian Bureau of Statistics
  49. Harford J, Spencer J, Roberts-Thomson K (2003) Oral health. In: Thomson N, ed. The health of Indigenous Australians. South Melbourne: Oxford University Press: 313-338
  50. Australian Institute of Health and Welfare (2002) Chronic diseases and associated risk factors in Australia, 2001. Canberra: Australian Institute of Health and Welfare
  51. Genco RJ (1996) Current view of risk factors for periodontal diseases. Journal of Periodontology; 67(10): 1041-1049
  52. Jeffcoat MK, Chestnut C (1993) Systemic osteoporosis and oral bone loss: evidence shows increased risk factors. Journal of the American Dental Association; 124(11): 49-56
  53. Dogar F, Kruger E, Dyson K, Tennant M (2011) Oral health of pre-school children in rural and remote Western Australia. Rural and Remote Health; 11: 1869 Retrieved 4 December 2011 from http://www.rrh.org.au/publishedarticles/article_print_1869.pdf
  54. World Health Organization (2002) Towards a common language for functioning, disability and health: ICF, the international classification of functioning, disability and health. Geneva: World Health Organization
  55. Australian Bureau of Statistics (2010) Disability, ageing and carers, Australia: summary of findings, 2009. Canberra: Australian Bureau of Statistics
  56. Australian Bureau of Statistics (2001) Australian demographic statistics: June quarter 2001. Canberra: Australian Bureau of Statistics
  57. Australian Institute of Health and Welfare (2004) Australia's health 2004: the ninth biennial health report of the Australian Institute of Health and Welfare. Canberra: Australian Institute of Health and Welfare
  58. Australian Institute of Health and Welfare (2010) Australia's health 2010: the twelfth biennial report of the Australian Institute of Health and Welfare. Canberra: Australian Institute of Health and Welfare
  59. Australian Bureau of Statistics, Australian Institute of Health and Welfare (2008) The health and welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008. Canberra: Australian Bureau of Statistics and Australian Institute of Health and Welfare
  60. Hepatitis Australia (2010) About hepatitis. Retrieved 18 November 2011 from http://www.hepatitisaustralia.com/about-hepatitis
  61. The Kirby Institute (2012) HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2012. Sydney: University of New South Wales
  62. Chiu C, Dey A, Wang H, Menzies R, Deeks S, Mahajan D, Macartney K, Brotherton J, Jardine A, Quinn H, Jelfs J, Booy R, Lawrence G, Jayasinghe S, Roberts A, Senanayake S, Wood N, McIntyre P (2010) Vaccine preventable diseases in Australia, 2005 to 2007. Canberra: Australian Department of Health and Ageing
  63. Lehmann D, Willis J, Moore HC, Giele C, Murphy D, Keil AD, Harrison C, Bayley K, Watson M, Richmond P (2010) The changing epidemiology of invasive pneumococcal disease in Aboriginal and non-Aboriginal Western Australians from 1997 through 2007 and emergence of nonvaccine serotypes. Clinical Infectious Diseases; 50(11): 1477-1486
  64. Gonorrhoea (2006) Family Planning Association of WA
  65. Bowden FJ, Tabrizi SN, Garland SM, Fairley CK (2002) Sexually transmitted infections: new diagnostic approaches and treatments. Medical Journal of Australia; 176(11): 551-557
  66. HIV & AIDS (2012) Western Australia Communicable Disease Control
  67. National Health and Medical Research Council (2000) Nutrition in Aboriginal and Torres Strait Islander peoples: an information paper. Canberra: National Health and Medical Research Council
  68. Department of Health and Ageing (2010) Physical activity guidelines. Retrieved 1 October 2010 from http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines
  69. National Aboriginal and Torres Strait Islander Social Survey, 2008: Tables 1 and 2: whether participated in sporting, social or community activities in last 12 months [unpublished] (2011) Australian Bureau of Statistics
  70. Australian Health Ministers’ Advisory Council (2011) Aboriginal and Torres Strait Islander health performance framework: 2010 report. Canberra: Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing
  71. Australian Bureau of Statistics (2009) National Aboriginal and Torres Strait Islander social survey, 2008: Table 03. Indigenous persons aged 15 years and over, by State or territory of usual residence [data cube]. Retrieved from http://www.abs.gov.au/AUSSTATS/SUBSCRIBER.NSF/log?openagent&47140do003_2008.xls&4714.0&Data%20Cubes&6363A5295689F400CA25765E001532CB&0&2008&30.10.2009&Previous
  72. Australian Bureau of Statistics (2009) National Aboriginal and Torres Strait Islander social survey, 2008: Western Australia. Retrieved from http://www.abs.gov.au/AUSSTATS/SUBSCRIBER.NSF/log?openagent&4714.0_wa_2008.xls&4714.0&Data%20Cubes&B22632E05CE9508ECA25770B00170626&0&2008&21.04.2010&Previous
  73. National Health and Medical Research Council (2009) Australian guidelines to reduce health risks from drinking alcohol. Canberra: National Health and Medical Research Council
  74. Mattson SN, Vaurio L (2009) Fetal alcohol spectrum disorders. In: Yeates KO, Ris MD, Taylor HG, Pennington BF, eds. Pediatric neuropsychology : research, theory and practice. 2nd ed. New York: Guilford Press: 265-296
  75. Australian Institute of Health and Welfare (2013) Aboriginal and Torres Strait Islander health performance framework 2012: detailed analyses. Canberra: Australian Institute of Health and Welfare
  76. Wilson M, Stearne A, Gray D, Saggers S (2010) Review of the harmful use of alcohol amongst Indigenous Australians. Perth, WA: Australian Indigenous HealthInfoNet
  77. Australian Bureau of Statistics (2009) National Aboriginal and Torres Strait Islander social survey, 2008: Table 01. Indigenous persons aged 15 years and over, by Aboriginal or Torres Strait Islander origin [data cube]. Retrieved from http://abs.gov.au/AUSSTATS/SUBSCRIBER.NSF/log?openagent&47140do001_2008.xls&4714.0&Data%20Cubes&54C4C4C9B713B0C9CA25765E00152DF5&0&2008&30.10.2009&Previous
  78. Adams K, Burgess J, Dharmage S (2010) Trachoma surveillance report 2009. Melbourne: National Trachoma Surveillance and Reporting Unit
  79. Barry C, Krause VL, Cook HM, Menzies RI (2012) Invasive pneumococcal disease in Australia 2007 and 2008. Communicable Diseases Intelligence; 36(2): E151-E165
  80. Jacups SP, Cheng A (2011) The epidemiology of community acquired bacteremic pneumonia, due to streptococcus pneumoniae, in the top end of the Northern Territory, Australia - over 22 years. Vaccine; 29(33): 5386-5392
  81. Mak DB (2004) Invasive pneumococcal disease in the Kimberley, 1995-2001. Australian Journal of Rural Health; 12(6): 237-240
  82. Menzies R, Turnour C, Chiu C, McIntyre P (2008) Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia, 2003 to 2006. Canberra: Department of Health and Ageing
  83. Thomas DP (2012) Changes in smoking intensity among Aboriginal and Torres Strait Islander people, 1994–2008. Medical Journal of Australia; 197(9): 503-506
  84. Western Australian Department of Health (2011) Our footprints : a traveller's guide to the COAG implementation process in Western Australia. Perth: Government of Western Australia
  85. Western Australian Department of Indigenous Affairs (2010) Closing the gap in Indigenous life outcomes, Western Australia. Perth, WA: Department of Indigenous Affairs, Western Australia
  86. Government of Western Australia (2013) Closing the Gap funding continues. Retrieved 19 June 2013 from http://www.mediastatements.wa.gov.au/Pages/StatementDetails.aspx?listName=StatementsBarnett&StatId=7496

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