Aboriginal and Torres Strait Islander Health Performance Framework - 2010
Why is it important?:Social and emotional wellbeing is a holistic concept related to individual, family and community experience. For Aboriginal and Torres Strait Islander peoples, health is not just the physical wellbeing of the individual but the ‘social, emotional and cultural wellbeing of the whole community’ (Social Health Reference Group 2004, p. 3). The Guidelines for Effective Approaches to Aboriginal and Torres Strait Islander Public Health point out the impact of colonisation on Aboriginal and Torres Strait Islander peoples, including past policies and practices: ‘This includes: loss of land, which was the economic and spiritual base for Aboriginal and Torres Strait Islander communities; loss of large numbers of people through wars, massacres, and epidemics; immense damage to traditional social and political structures, traditional languages, and belief systems; the ongoing impact of the relocation of peoples to missions and reserves; removal of children from their families; continued racism and exclusion; and immense socio-economic deprivation’ (NPHP 2006, p. 21). Social, historical and economic disadvantage is interconnected with grief, loss and trauma, high rates of physical and mental health problems, adult mortality, suicide, child removals, incarceration rates and intergenerational trauma. Experience of discrimination also leads to psychological distress and has a negative impact on health (Paradies & Cunningham 2008).
Aboriginal and Torres Strait Islander peoples have higher levels of acute morbidity and mortality from mental illness, assault, self-harm and suicide than other Australians, higher levels of alcohol and other drug use, and more frequent contact with the criminal justice system. Levels of child abuse and neglect are higher for Indigenous than for non-Indigenous Australian children. Education, employment and income are lower for Indigenous Australians. These and many other measures indicate there is a significant gap between the overall level of social and emotional wellbeing for Aboriginal and Torres Strait Islander peoples and other Australians.
Findings:The NATSISS collects information on a range of social issues relevant to the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples.
Aboriginal and Torres Strait Islander peoples retain strong links to their traditional culture. In 2008, 62% of Aboriginal and Torres Strait Islander people aged 15 years and over reported they identified with a clan group, 25% currently lived in traditional lands, and 63% had attended cultural events in the last 12 months. Family and community attachments are important factors in the lives of Aboriginal and Torres Strait Islander peoples (see measure 1.14). Eighty nine per cent reported that, in a time of crisis, they could get support from outside the household. Approximately 89% also reported that they had been involved in social activities in the last 3 months.
In 2008, approximately 38% of Indigenous people aged 15 years and over reported that they and/or a relative had been removed from their natural family.
Psychological DistressIn 2008, 32% of Indigenous Australians aged 18 years and over reported high levels of psychological distress. After adjusting for age, this was 2.5 times the rate for non-Indigenous adults. Rates are higher for Aboriginal and Torres Strait Islander adults across all age groups. Indigenous women (35%) were significantly more likely than Indigenous men (28%) to report high/very high levels of psychological distress and to have seen a health professional about their feelings. Psychological distress did not differ significantly by age group or remoteness.
Those who reported excellent/very good health in 2008 were less likely than those who reported fair/poor health to also report high levels of psychological distress (20% and 52% respectively).
High/very high psychological distress levels were associated with lower income (37% in the lowest income quintile reported distress compared with 21% in the highest), housing tenure (35% for renters compared with 24% for home owners), educational attainment (37% of those for whom Year 9 or below was the highest year of schooling completed compared with 26% for Year 12 education) and employment status (25% for employed people compared with 46% for unemployed, and 38% for those not in the labour force).
Life StressorsIn 2008, Aboriginal and Torres Strait Islander peoples reported high levels of stressors in their lives, with 79% of people aged 18 years and over reporting that they, their family or close friends had experienced at least one stressor in the last 12 months. The most common stressors reported were the death of a family member or close friend (40%), serious illness or disability (33%), inability to get a job (23%), alcohol-related problems (21%), or mental illness (17%). People living in major cities tended to experience a greater number of stressors on average than those living in regional or remote areas. Stressors that were more common for this group compared with those living in regional and remote areas included serious illness or disability, drug related problems, witness to violence, discrimination/racism, abuse or violent crime and involuntary loss of job. Those living in remote/very remote areas tended to report death of a family member or close friend and overcrowding at home as stressors more often than those living in major cities and regional areas.
Research has shown that parental stress such as employment and financial status is associated with the wellbeing of children, through decreased health service utilisation for the child’s needs and emotional or behavioural difficulties (Ou et al. 2010; Strazdins et al. 2010).
Social and emotional wellbeing of childrenThe Western Australia Aboriginal Child Health Survey (WAACHS) collected information on the social and emotional wellbeing of Aboriginal children during 2001 and 2002 (only a small number of Torres Strait Islander children participated in the survey). This survey found that a variety of health conditions, social circumstances and behaviours experienced by individuals, their carers and families are associated with the social and emotional wellbeing of Indigenous children (Zubrick et al. 2005). Using a well established method to measure emotional and behavioural difficulties in children (the Strengths and Difficulties Questionnaire), 24% of Aboriginal children aged 4–17 years surveyed were assessed as being at high risk of clinically significant emotional or behavioural difficulties compared with 15% of all children. Aboriginal boys were twice as likely as Aboriginal girls to be at high risk of clinically significant emotional or behavioural difficulties. Those children living in areas of extreme isolation were less at risk than those living in urban areas.
Factors associated with high risk of clinically significant emotional or behavioural difficulties in Aboriginal children included the number of stressful events experienced by the family in the 12 months before the survey (such as illness, hospitalisation, death of a close family member, family break-up, arrests, job loss, financial difficulties), quality of parenting, family functioning and family care arrangements. Residential mobility, the physical health of the child (speech, hearing and vision problems), the physical health of the carer, and carer’s use of mental health services were also associated with an increased risk of clinically significant emotional or behavioural difficulties in children.
Around one-fifth of children were living in families that functioned poorly (families with poor communication and decision making, poor emotional support, limited time spent together, and poor family cooperation). These children were over twice as likely to be at high risk of emotional and behavioural difficulties as children living in families with very good quality of parenting or very good family functioning. Those who had been subject to racism in the past 6 months were more than twice as likely to be at high risk of emotional and behavioural difficulties than those who had not experienced racism.
Suicidal behaviour of teenagersIn 2001-2002, an additional survey was administered to young people aged 12–17 years in Western Australia to measure rates of suicidal thoughts and suicide attempts. Suicidal thoughts were reported by around 1 in 6 (16%) of these young people in the 12 months prior to the survey. A higher proportion of Aboriginal girls reported they had seriously thought about ending their own life than Aboriginal boys (20% compared with 12%). Of those who had suicidal thoughts in the 12 months prior to the survey, 39% reported they had attempted suicide in the same period. The proportion of Aboriginal children who reported suicidal thoughts was significantly higher among those who smoked regularly, used cannabis, drank to excess in the 6 months prior to survey, were exposed to some form of family violence, or who had a friend who had attempted suicide.
Hospitalisation for mental health issuesIn the period July 2006 to June 2008, mental health- related conditions were the principal reason for 4.2% of hospital admissions for Aboriginal and Torres Strait Islander peoples in the jurisdictions with adequate data quality (NSW, Vic, Qld, WA, SA and NT). Indigenous men were hospitalised for mental health-related conditions at rates that were 2.2 times the rate of other Australian men, and Indigenous women at rates that were 1.5 times the rate for other Australian women. There has been a very slight increase in the gap between Indigenous and other Australian people for hospitalisation for these conditions over time.
The most common reasons for mental health-related hospitalisation were mental and behavioural disorders due to psychoactive substance use (37% of episodes); schizophrenia (26%); mood disorders (14%); and neurotic, stress-related disorders (14%). Indigenous hospitalisation rates for mental health-related issues vary between jurisdictions. The highest rates were for South Australia (44 per 1,000). In the Northern Territory, mental health-related hospitalisation rates were very low for both Aboriginal and Torres Strait Islander peoples and other Australians (13 and 6 respectively).
Other ServicesDuring the period 2004–05 to 2008–09, 10% of encounters between GPs for Indigenous patients were for mental health-related problems. This was almost 2% higher than for other patients. Depression was the most frequently reported mental health-related problem managed by GPs for Aboriginal and Torres Strait Islander people, followed by drug misuse (licit or illicit), anxiety and sleep disturbance. Depression was also the most common mental health-related problem managed for other Australians followed by anxiety.
Mortality for mental health issuesDeaths due to self-harm (suicide) accounted for 4% of Indigenous deaths between 2004 and 2008 in the jurisdictions with adequate data quality (NSW, Qld, WA, SA and the NT). After adjusting for age differences this was twice the rate for non-Indigenous Australians. Mental health-related conditions were responsible for 2.5% of Aboriginal and Torres Strait Islander Australian deaths in 2004–08, one and a half times the rate for non-Indigenous Australians. The highest rate ratio was in the 15–24 year age group for men and 35–44 year group for women (7 and 11 times the non-Indigenous rate respectively).
Implications:Data on this issue are incomplete, including for children. The collection of additional national data is important. The policy response to social and emotional wellbeing problems needs to be multidimensional, and focus not only on mental health services. It needs to involve a wide range of stakeholders including Indigenous communities, the health sector, housing, education, employment and economic development, family services, crime prevention and justice. It needs to support culturally valid understandings of health, build on the strengths, resilience and endurance within Aboriginal and Torres Strait Islander communities and recognise the important historical and cultural diversity within communities (Social Health Reference Group 2004).
The Australian Government has commited to supporting the social and emotional wellbeing of the Stolen Generations, their families and communities through the Bringing Them Home Counsellors and Link Up Services programs.
In 2006, COAG agreed to several mental health measures including the Improving the capacity of workers in Aboriginal and Torres Strait Islander communities initiative to support health practitioners to identify mental illness and make referrals. Projects implemented under this initiative include Aboriginal Mental Health First Aid training, a mental health literacy training course and funding of 10 mental health worker positions nationally. Cultural competence training for non-Indigenous mental health practitioners has just been completed through the Australian Indigenous Psychologists Association. The Indigenous Mental Health Book Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice will help prepare students and health practitioners to meet Indigenous mental health needs when working in mainstream and Aboriginal Medical Services.
The Fourth National Mental Health Plan: An agenda for collaborative government action in mental health 2009–2014 includes 34 actions aimed at improving outcomes for people with mental disorders. The plan takes a whole of government approach, acknowledging that many of the determinants of good mental health and of mental illness are influenced by factors beyond the health system. One of the actions is ‘the development of coordinated actions to implement a renewed Aboriginal and Torres Strait Islander social and emotional well-being framework’. AHMAC is considering a year-by-year approach to how these actions will be implemented.
The Mental Health: taking action to tackle suicide package includes $22.6 million for community-led activities for high risk groups including Indigenous Australians. National Health Reform is also an important foundation for taking mental health forward.
Figure 43 – Proportion of people who reported high or very high levels of psychological distress, by Indigenous status and age group, persons aged 18 years & over, 2008
Source: AIHW analysis of the 2008 NATSISS and 2007–08 NHS
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Figure 44 – Mental health-related mortality rates per 1000, by Indigenous status, age group and sex, NSW, Qld, WA, SA and NT, 2004–2008
Source: AIHW and ABS analysis of National Mortality Database
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Figure 45 – Proportion of people reporting selected stressors, by remoteness area, Indigenous persons aged 18 years and over, 2008
Source: AIHW analysis of the 2008 NATSISS
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Table 24 – Proportion of people who reported psychological distress, by level of psychological distress, by selected population characteristics, Indigenous persons aged 18 years and over, 2008
Level of psychological distress:
Self-assessed health status
Highest year of school completed:
|Year 9 or below|
|1st quintile (lowest)|
|5th quintile (highest)|
|Not in labour force|
Figure 46 – Hospitalisation rates from mental health-related conditions by Indigenous status, Qld, WA, SA and NT, age-standardised, 2001–02 to 2007–08; NSW, Vic. Qld, WA, SA, NT 2004–05 to 2007–08
Source: AIHW analysis of National Hospital Morbidity Database
Text description of figure 46 (TXT 1KB)
Figure 47 – Age-specific hospitalisation rates for a principal diagnosis of mental health-related conditions, by Indigenous status, NSW, Vic., Qld, WA, SA and NT, July 2006 to June 2008
Source: AIHW analysis of National Hospital Morbidity Database
Text description of figure 47 (TXT 1KB)
Table 25 – Age-standardised hospitalisations of Indigenous persons for principal diagnosis of mental health-related conditions, by type of condition and sex, NSW, Vic., Qld, WA, SA and NT, July 2006 to June 2008
Rate per 1,000
Rate per 1,000
Rate per 1,000
|Mental & behavioural disorders due to psychoactive substance use|
|Schizophrenia, schizotypal and delusional disorders|
|Neurotic, stress-related disorders|
|Total mental health related conditions 1|
Source: AIHW analysis of National Hospital Morbidity Database