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Discussion Paper for the Development of the National Aboriginal and Torres Strait Islander Health Plan

Key considerations and opportunities to improve health and wellbeing

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This section of the Discussion Paper suggests a number of issues that could be tackled in the Health Plan. These include aspects of the health system, determinants of health such as education and employment, and building on the strengths and resilience of Aboriginal and Torres Strait Islander peoples to actively manage their health. Your thoughts on these issues and any other issues you would like to see addressed would be appreciated.

Determinants of health

The origins of health behaviours are located in a complex range of environmental, social, economic, family and community factors. Avoidable health inequalities arise because of the circumstances in which people grow, live, work and age, as well as the systems put in place to deal with illness. Between one third and one half of the health gap may be explained by differences in the social determinants of health.⁶These factors include education, employment, income, housing, environment and community functioning. They affect the health of people and can also influence how a person interacts with health and other services.

For example, we know that Indigenous adults are less likely to smoke if they have completed Year 12, if they are employed and if they have higher incomes. We also know that social and family factors play important roles in a person’s health and wellbeing. People who have been removed from their family or have received little or no support in a time of crisis are more likely to be smokers.⁷

We also acknowledge that realising necessary improvements in education and employment outcomes will require integrated approaches to improving health outcomes. For example, chronic ear disease negatively affects the education attainment of Indigenous school children, and poor health explains almost 43% of the known gap in labour force participation for Indigenous males, and around 14% of the gap for Indigenous females (in non-remote locations).⁸

The following snapshots of the most important social determinants of the health of Indigenous Australians are provided to help guide your responses to the questions in the sections below.

Culture, family and community functioning

The rich cultural practices, knowledge systems and cultural expressions of Aboriginal and Torres Strait Islander peoples are a source of great strength, resilience and pride. Strong cultural identity is fundamental to Aboriginal and Torres Strait Islander health and social and emotional wellbeing.⁹

We know that Aboriginal and Torres Strait Islander people draw strength from a range of factors such as connectedness to family, culture and identity. For Aboriginal and Torres Strait Islander peoples, health is not just about the physical wellbeing of the individual, but also the social, emotional and cultural wellbeing of the whole community.¹⁰

Strong family connections, kinship arrangements and support are the foundation of good social and emotional wellbeing among Aboriginal young people. We also know that family centred approaches to health care, including family involvement in decision making, are important for the successful prevention and management of chronic diseases. Therefore, engaging with Aboriginal and Torres Strait Islander people and their families in a respectful and culturally competent way is important for preventative health and effective service delivery.¹¹
Evidence shows that Indigenous Australians who have strong cultural attachment are more likely to report better health and wellbeing.¹² This links with connectedness to family, as close contact with extended family is needed for developing a strong sense of identity. Instilling a strong sense of self and identity increases an individual’s resilience and ability to grow and contribute to the community in which they choose to live and work.

Aboriginal and Torres Strait Islander peoples have identified a number of elements of community life that are needed for high levels of functioning. These include connectedness to country, land, and culture, resilience, strong leadership, and feeling safe. This is supported by national and international evidence about the role that communities play in enabling individuals and families to thrive.

A well-functioning community optimises health and wellbeing by creating an environment that is safe and supports both individuals and families to fulfil their potential. For example, there is evidence to show that environment is a factor in influencing a child’s early development. A community in which there are strong social and familial links, which supports parents to provide children with safe places to play and interact, will help develop the child’s cognitive, social and emotional skills, and contribute to their outcomes over the life course. Environments that do not provide children with early emotional and social development put children at an early disadvantage, and are linked to poorer outcomes at school and later life.¹³People who were able to have a frequent say on community issues were more likely to report feeling happy all/most of the time than those who with little or no input and suffered less psychological distress.¹⁴

While acknowledging the legacy of dispossession and disempowerment of Aboriginal and Torres Strait Islander peoples, it is important to recognise the vital role of each individual, family and community in building the social norms that are the foundation of lasting change. Asserting responsibility in such processes is a means of empowerment that will lead to better health outcomes and greater and improved life opportunities.

If there is to be an improvement in health outcomes for Aboriginal and Torres Strait Islander peoples, to achieve the closing the gap targets, then there must be genuine collaboration with Aboriginal and Torres Strait Islander peoples. Governments and health system action alone, without this engagement, will not be successful.

In this context, accepting the responsibility for the promotion of positive norms and social behaviours within families and communities is vital to creating lasting change. The Australian Government is supporting this through a range of measures and will continue to partner with Aboriginal and Torres Strait Islander individuals, communities and groups to build responsibility.¹⁵Top of page

Early Childhood and Education

Early childhood is a critical time in human development. Research shows that experiences children have in the early years of life set neurological and biological pathways that can have life-long impacts on health, learning and behaviour.¹⁶ The Council of Australian Governments has made a commitment to universal access to early childhood education for all children in the year before full time schooling as well as ensuring all Indigenous four year olds in remote communities have access to early childhood education within five years (by 2013).

Studies show that education is a key factor in improving health and wellbeing. For example, higher levels of education are linked to a better understanding of healthy lifestyles and the health care system. They also show higher mortality rates for those with fewer years of education, particularly for smoking-related diseases.¹⁷ Those who stay on at school tend to smoke less, be more active and drink less alcohol, all of which reduces the risk of chronic disease in adults.

Currently many more Aboriginal and Torres Strait Islander children do not meet national minimum standards for reading, writing and numeracy. Fewer Aboriginal and Torres Strait Islander students complete Year 12 than students from other backgrounds. The Council of Australian Governments has set targets to halve the gap in reading, writing and numeracy by 2018 and halve the gap in Year 12 or equivalent attainment rates by 2020.

Having good outcomes at school supports further education and employment prospects. Harnessing strong networks both at home and through involvement with the education system is key to improving school attendance and educational outcomes. The Council of Australian Governments has agreed to several reforms in education to improve positive outcomes for Aboriginal and Torres Strait Islander children and reduce inequalities. These include the Aboriginal and Torres Strait Islander Education Action Plan and the National Partnership Agreement on Indigenous Early Childhood Development as well as a range of reforms to improve the quality of early childhood services and schools and promote better outcomes from training providers and universities.

Health Literacy

Health literacy is fundamental if people are to successfully manage their own health. A person’s ability to make informed health-related choices is determined by their ability to understand health information, such as understanding instructions on prescription drug bottles, medical appointment slips, medical education brochures, doctor’s directions and consent forms and the ability to negotiate complex health care systems.

Aboriginal and Torres Strait Islander peoples overall have lower school retention and literacy rates, with the literacy score for Indigenous Australians in 2006 lower than for non-Indigenous Australians. Lower literacy levels are likely to be a barrier to health promotion activities based around health education.¹⁸ This is also likely to have an impact on compliance with health treatment, including taking medications as and when prescribed.

Employment and Income

Having a job and an income has been generally shown to have a positive effect on an individual’s health and wellbeing. Long periods of unemployment, not being in the labour force and frequent changes in employment status have been found to have negative effects on an individual’s health over and above the effects of poverty and prior ill health. However, the impact of labour force participation on the health of Aboriginal and Torres Strait Islander people is complex and likely to be affected by different factors than those that influence non-Indigenous people.¹⁹

The type of employment and how employment is experienced by Aboriginal and Torres Strait Islander people may also impact the health benefits they gain through employment.²⁰ Short-term, low-skilled, low paid jobs where employees have little control over what they do and/or experience racism and discrimination in the workplace have been shown to diminish the positive health effects of employment. Evidence indicates that Aboriginal and Torres Strait Islander employment is largely characterised by these factors.

Conversely, the poor health profile of the Aboriginal and Torres Strait Islander population also acts as a barrier to increasing participation rates. Studies have shown that the poor health of a family member was a common reason for lower labour force participation rates amongst women, while men indicated that their own poor health limited their participation.²¹ In 2008, 54% of Indigenous Australians were employed compared to 76% of non-Indigenous Australians.

The Council of Australian Governments has set a target to halve the gap in employment within a decade. Around 100,000 additional Indigenous Australians will need to be in jobs by 2018 to achieve this target.

There is strong evidence from Australian and international studies that low socioeconomic status is associated with poor health.²² Low income is associated with a wide range of disadvantage including poor health, shorter life expectancy, poor education, substance misuse, reduced social participation, crime and violence. In 2008, half of all Aboriginal and Torres Strait Islander peoples were in the bottom 20% of average household incomes. Cost has been identified as a barrier to accessing health care by Aboriginal and Torres Strait Islander peoples. Having a low income combined with high food costs, especially in remote areas, means that people may choose low-cost options which are generally less healthy than fresh fruit and vegetables and lean meats, which tend to cost more.Top of page

Housing

Factors relating to housing such as overcrowding, homelessness, housing tenure, and infrastructure such as clean water, sewerage and a reliable power supply, have significant impacts on health. These housing factors are associated with infectious diseases such as meningitis, acute rheumatic fever, tuberculosis, and skin and respiratory infections.²³ The latest national data on overcrowding show that in 2008 approximately 25% of Indigenous Australians lived in overcrowded households. Overcrowding rates were higher in remote areas. Living in a crowded house also makes it hard for children to find a quiet place to do their homework. A healthy home is a fundamental pre-condition of a healthy population. Australian Governments have committed to improvements in housing through a number of National Partnership Agreements including the National Partnership Agreement on Remote Indigenous Housing, the National Partnership on Homelessness and various Housing for Health programs.

Location

Where people live influences their ability to access health and other services. Having access to transport, be it a family car or reliable public transport and safe roads, also impacts on access to services. Twice as many Indigenous Australians experience difficulties with transport than non-Indigenous Australians and this is higher in remote areas (18%) than non-remote areas (8%). Where a person lives also has a bearing on their diet and nutrition. Evidence shows that 21% of Aboriginal and Torres Strait Islander people in very remote communities report a lack of working facilities for the storage and preparation of food. Fresh fruit and vegetables also cost more than other less healthy options and are harder to access. Access to clean water, working sewerage and electricity supply is also limited in some remote communities. These facilities are essential to support health and reduce infections.

Racism and Racial Discrimination

Racism takes many forms. Racial discrimination involves any act where a person is treated unfairly or vilified because of their race, colour, descent, national or ethnic origin. Racism can occur systemically, as a result of policies, conditions and practices that affect a broad group of people.²⁴

Aboriginal and Torres Strait Islander peoples continue to experience high levels of racism in Australia, across multiple settings.²⁵ Racial discrimination, however, is hard to measure. Between 16% and 93% of Aboriginal and Torres Strait Islander people report experiencing racial discrimination, responses being dependent on the questions asked and the nature of the study.

Australian research shows that the experience of discrimination is linked to poor self-assessed health status, stress-related diseases, psychological distress, diabetes, smoking and substance use²⁶and generally has a negative impact on health.²⁷ Further, recent research shows that three out of four Aboriginal and Torres Strait Islander people regularly experienced race discrimination when accessing primary health care, contributing to some people not being diagnosed and treated for disease in its early stages.²⁸

Safety

Being in an environment where personal safety is at risk, or in a social setting where violence is common, has negative health effects.²⁹ High levels of violence can impact directly through injuries and harm as well as through anxiety and depression, heart disease and other diseases, and suicide.³⁰ Studies have found a link between income inequality and violence and between experience of discrimination and racism and high levels of violence. In 2008, 24% of Aboriginal and Torres Strait Islander adults reported they had experienced violence or threats of violence in the last 12 months.

Contact with the criminal justice system

In 2008, 3% of Indigenous Australians reported they had been imprisoned in the last five years. However, Indigenous Australians are over-represented in the prison population. In June 2011, there were 7,655 prisoners who identified as Aboriginal and Torres Strait Islander; this was 26% of the prisoner population. In addition, many Aboriginal and Torres Strait Islander offenders have multiple periods of incarceration. Nearly three-quarters (74%) of Aboriginal and Torres Strait Islander prisoners had a prior adult imprisonment under sentence, compared with just under half (48%) of non-Indigenous prisoners.³¹ These prisoners are more likely to experience mental health and substance use problems, hearing loss and ill health. A recent study has found that released prisoners have an increased risk of death compared to the general population, particularly in the first four weeks after release.³²Imprisonment also impacts on families and children, increases stress and has adverse employment and financial consequences.

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6. Booth A & Carroll N (2005). The health status of Indigenous and non-Indigenous Australians. Canberra: Centre for Economic Policy Research, ANU.
7. Australian Health Ministers’ Advisory Council (2010). Aboriginal and Torres Strait Islander Health Performance Framework Report 2010. Canberra: AHMAC.
8. Kalb, G. Le, T. and F, Leung. 2011. Decomposing differences in labour force status between Indigenous and non-Indigenous Australians, Melbourne Institute of Applied Economic and Social Research, Melbourne.
9. Culture and Closing the Gap – Fact Sheet. Office for the Arts, Australian Government Department of the Prime Minister and Cabinet.
10. Social Health Reference Group (2004). National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Well Being 2004–2009.
11. Griew, R, Tilton, E, Stewart, J, Eades, S, Lea, T, Peltola, C, Livingstone, L, Harmon, K & Dawkins, Z (2007). Family Centred Primary Health Care. Canberra: Department of Health and Ageing.
12. Dockery AM (2011). Traditional culture and the wellbeing of Indigenous Australians: an analysis of the 2008 NATSISS. CLMR Discussion Paper Series 2011/01. Centre for Labour Market Research, Curtin Business School, Curtin University.
13. Heckman, J (2001). Invest in the Very Young. Chicago: Ounce of Prevention Fund and the University of Chicago Harris, School of Public Policy Studies.
14. Australian Bureau of Statitsics, 4704.0 - The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, cat. no. 4704.0, Oct 2010. (Psychological Distress)
15. Australian Government (2011). Closing the Gap: Prime Minister’s Report 2011, Canberra.
16. Shonkoff, J.P (2009) Investment in Early Childhood Development Lays the Foundation for a Prosperous and Sustainable Society, Encyclopaedia on Early Childhood Development, accessed 13 August 2012.
17. Wong, MD, Shapiro, MF, Boscardin, WJ & Ettner, SL (2002). Contribution of major diseases to disparities in mortality. New England Journal of Medicine; 347(20):1585–1592.
18. Centre for Medicare Education 2000; National Centre for Education and Training Statistics & ABS 2008.
19. Lowry, D & Moskos, M. 2007 “Labour Force Participation as a Determinant of Indigenous Health” in Anderson I, Baum, F & Bentley, M (eds), 2007, Beyond Bandaids: Exploring the Underlying Social Determinants of Aboriginal Health. Papers from the Social Determinants of Aboriginal Health Workshop, Adelaide, July 2004. Cooperative Research Centre for Aboriginal Health, Darwin.
20. Ibid.
21. Hunter, B. & Gray, M. 2012. “Determinants of Indigenous Labour Force Participation Following a Period of Strong Economic Growth” Centre for Aboriginal Economic Policy Research Working Paper no 81/ 2012
22. Turrell, G & Mathers, CD (2000). Socioeconomic status and health in Australia. The Medical Journal of Australia; 172(9):434–438.
23. Australian Institute of Health and Welfare (2005). Indigenous housing needs 2005: a multi-measure needs model. Canberra: AIHW.
24. Australian Human Rights Commission, National Anti-Racism Partnership and Strategy, Discussion Paper, 2012, p3.
25. Ibid.
26. Paradies, Y (2007). Exploring the health effects of racism for Indigenous people. Presented at the Rural Health Research Colloquium, Tamworth, NSW.
27. Paradies, YC & Cunningham, J (2008). Development and validation of the Measure of Indigenous Racism Experiences (MIRE). Int J Equity Health; 7:9.
28. Australian Human Rights Commission, National Anti-Racism Partnership and Strategy, Discussion Paper, 2012, p3.
29. Willis, M (2010). Community safety in Australian Indigenous communities: service providers’ perception. Research and Public Policy Series no. 110.
30. Vos, TB, Barker, Stanley, L & Lopez, AD (2007). The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003. Brisbane: School of Population Health, University of Queensland.
31. ABS 4517.0 - Prisoners in Australia, 2011.
32. Butler, T, & Milner, L (2003). The 2001 New South Wales Inmate health survey. Sydney: NSW Corrections Health Service; Hobbs, M & Krazlan, K, et al (2006). Mortality and morbidity in prisoners after release from prison in Western Australia 1995-2003, Research and Public Policy Services no 71; Kinner, S & Preen, D et al (2011). Counting the cost: estimating the number of deaths among recently released prisoners in Australia. 195: 64-68; Levy, M (2005). Prisoner health care provision: Reflections from Australia. International Journal of Prisoner Health. 1 (1): 65-73.

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