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Aboriginal and Torres Strait Islander Health Performance Framework (HPF) 2012

Social determinants

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The origins of health behaviours are located in a complex range of environmental socioeconomic, family and community factors. 'Inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces' (Commission on Social Determinants of Health 2008).

A number of studies have found that between one-third and one-half of the health gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians is associated with differences in socioeconomic status such as education, employment and income (Booth et al. 2005a; DSI Consulting Pty Ltd et al. 2009)

Measures such as community functioning (1.13) show that Aboriginal and Torres Strait Islander peoples draw strength from a range of health determinants such as connectedness to family, land, culture and identity. Analysis of 2008 NATSISS data has found a clear association between cultural attachment and positive socioeconomic outcomes and wellbeing (Dockery 2011). A ten-year study of Aboriginal and Torres Strait Islander peoples in Central Australia identified that connectedness to culture, family and land, and opportunities for self-determination were likely to be associated with lower mortality and morbidity rates in homelands residents compared to other Indigenous NT residents. The study also found that the conventional measures of employment, income, housing and education did not account for this difference (Rowley et al. 2008)

The literature provides evidence that racism is a determinant and driver of inequalities in health (McDermott 2012; Harris et al. 2006). There are a number of pathways from racism to ill health, including: reduced access to societal resources such as education, employment and medical care; inequitable exposure to risk factors, stress and cortisol dysregulation affecting mental health, immune, endocrine, cardiovascular and other physiological systems; and injury from racially motivated assault. Longitudinal and cross sectional studies both nationally and internationally have found a strong association between experiences of racism and ill health and psychological distress, mental health conditions, and risk behaviours such as substance use (Gee et al. 2009; Paradies 2006a). The 2008 NATSISS found that 27% of respondents reported experiencing racism. Other studies have found self-reported experiences of racism among Aboriginal and Torres Strait Islander peoples range from 16–97% depending on the aspects of racism researched (Paradies 2011). Analysis of the 2004–05 NATSIHS data found that after accounting for a range of contributing factors, racism was significantly associated with poor self-assessed health status, psychological distress and substance use (Paradies 2007).

Analysis of the 2004–05 NATSIHS show that Aboriginal and Torres Strait Islander peoples in the highest income quintiles were more likely than those in the lowest quintile to visit a dentist and less likely to be admitted to hospital in the last 12 months or visit casualty/outpatients or a doctor in the last two weeks. A similar pattern was found for education, labour force status and housing tenure.

Evidence from general population studies shows that modifiable risk factors act, in various combinations, to increase the risks for adverse health outcomes such as ischaemic heart disease, stroke, diabetes and some cancers. Health behaviours also affect biological risk factors such as high body mass, high cholesterol levels and hypertension. Other health behaviours such as infant breastfeeding, adequate diet and physical exercise have a protective impact on health. The figures below show strong associations between key social factors and health behaviours, highlighting the importance of understanding the underlying social context.

Figure 5—Relationship between highest year of school completed and risk factors, Indigenous Australians, 2004–05

Figure 6—Relationship between income and risk factors, Indigenous Australians, 2004–05

Current smoker status:

Figures 5 and 6 show that a higher proportion of Aboriginal and Torres Strait Islander peoples who had completed Year 12 do not smoke (71%) compared to those whose highest year of schooling was Year 9 or below (42%). This relationship was also apparent for income. Similarly, those who were employed were more likely to not smoke (59%) than those who were unemployed (24%). These relationships were also similar for the non-Indigenous population.

Alcohol consumption:

As reported for measure 2.16, 46% of Aboriginal and Torres Strait Islander peoples were low risk drinkers and 35% had abstained from drinking alcohol in the last 12 months, while 17% reported drinking at chronic risk/high risk levels. Those who had completed Year 12 were less likely to report short-term risky/high risk drinking at least once per week in the last 12 months compared with those whose highest year of schooling was Year 9 or below.

Physical activity:

In 2004–05, 7% of Indigenous Australians aged 15 years and over reported 'high' levels of physical activity, 18% 'moderate', 28% 'low' and 47% 'sedentary'. Those who had completed Year 12 were less likely to be sedentary than those whose highest year of schooling was Year 9 or below (see Figure 5).

Dietary behaviours:

Indigenous Australians are twice as likely to report no usual daily fruit intake and 7 times as likely to report no daily vegetable intake as non-Indigenous Australians (see measure 2.19). Associations with socioeconomic status are also evident. Aboriginal and Torres Strait Islander peoples in the highest quintile of equivalised income were more likely to report daily fruit and vegetable intake.

Figure 7—Relationship between social determinants of health and self-assessed health status of good/excellent, Indigenous Australians, 2008

Figure 8—Relationship between risk factors and self-assessed health status of good/excellent, Indigenous Australians, 2004–05

Self-assessed health status:

In 2008, 84% of Indigenous Australians in the highest household income quintiles reported good/excellent health status, compared with 65% of those in the lowest quintile. Approximately 76% of those who had completed Year 12 reported good/excellent health status, compared with 66% of those who had completed Year 9 or below (see measure 1.17). In 2004–05, those who did not smoke, those who reported high levels of physical activity and those who reported daily fruit and vegetable intake were more likely to report good/excellent health status.

Figure 9—Relationship between risk factors and not having heart/circulatory disease, Indigenous Australians, 2004–05

Heart/circulatory conditions:

In 2004–05, those who reported high physical activity levels and those who were not overweight/obese were more likely to not have heart/circulatory problems.

Diabetes:

Those who were overweight/obese were more likely to have diabetes than those who were not.

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