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

Tier 1—Life expectancy and wellbeing—1.18 Social and emotional wellbeing

The HPF was designed to measure the impact of the National Strategic Framework for Aboriginal and Torres Strait Islander Health (NSFATSIH) and will be an important tool for developing the new National Aboriginal and Torres Strait Islander Health Plan (NATSIHP).

Page last updated: 15 November 2012

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' (SHRG 2004). 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 socioeconomic deprivation' (NPHP 2006).
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 et al. 2008).

Indigenous Australians have higher levels of morbidity and mortality from mental illness, assault, self-harm and suicide than other Australians. These and many other measures indicate that a significant gap exists between the overall level of social and emotional wellbeing for Indigenous Australians 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. This survey shows that Aboriginal and Torres Strait Islander peoples retain strong links to their traditional culture. In 2008, 62% of Aboriginal and Torres Strait Islander peoples aged 15 years and over reported they identified with a clan or language group, 25% lived on traditional lands, and 63% had attended cultural events in the last 12 months. Family and community attachments are important factors in the lives of Indigenous Australians (see measure 1.13). Eighty-nine per cent reported that they could get support from outside the household in time of crisis. Approximately 89% also reported that they had been involved in social activities in the last three 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. This was linked to higher rates of psychological distress.

Psychological distress

In 2008, 32% of Aboriginal and Torres Strait Islander peoples aged 18 years and over reported high levels of psychological distress. After adjusting for differences in the age structure of the two populations, this was 2.5 times the rate for non-Indigenous adults. Rates were higher 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. The proportions of people reporting high/very high levels of 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, lower education attainment and unemployment.

Life stressors

In 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 (4.9) than those living in regional or remote areas (around 4.3). They were also more likely to have reported serious illness or disability, mental illness and/or involuntary loss of a job. Those living in remote areas tended to report death of a family member or close friend and overcrowding as stressors more often than those living in non-remote areas.

Research has shown that parental stress caused by factors such as unemployment and financial problems is associated with emotional or behavioural difficulties in children and decreased utilisation of health services for the child's needs (Ou et al. 2010; Strazdins et al. 2010).Top of page

Depression and racism

Research in the NT has found a significant association between interpersonal racism and depression among Aboriginal and Torres Strait Islander peoples after adjusting for socio-demographic factors. Lack of control, stress, negative social connections and reactions to racism such as feeling ashamed, amused or powerless were each identified in the relationship between racism and depression (Paradies et al. 2012).

Social and emotional wellbeing of children

The 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 likely to be 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 six months were more than twice as likely to be at high risk of emotional and behavioural difficulties than those who had not experienced racism.Top of page

Suicidal behaviour of teenagers

In 2001–02, an additional survey was administered to young people aged 12–17 years in WA 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 six 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 issues

In the period July 2008 to June 2010, mental health-related conditions were the principal reason for 7% of hospital admissions (excluding dialysis) for Aboriginal and Torres Strait Islander peoples in the jurisdictions with adequate data quality (NSW, Victoria, Qld, WA, SA and the NT combined). Indigenous men were hospitalised for mental health-related conditions at 2.2 times the rate of other Australian males, and Indigenous females at 1.5 times the rate for other Australian females. Between 1998–99 and 2009–10 there was a 12% increase in hospitalisations for mental health related conditions for Indigenous females, with no significant increase for males. Since 2004–05, however, rates have increased significantly for both Indigenous males and females (9%).

The most common reasons for mental health-related hospitalisation were mental and behavioural disorders due to psychoactive substance use (36% of episodes); schizophrenia (25%); mood disorders (15%); and neurotic, stress-related disorders (14%). Indigenous hospitalisation rates for mental health-related issues were highest in the 25–44 year age groups. Rates were lowest in very remote areas. Rates varied between jurisdictions. The highest rates were for SA (45 per 1,000). In the NT, mental health-related hospitalisation rates were very low for both Indigenous Australians and other Australians (15 and 7 per 1,000 respectively).

Other services

BEACH survey data collected from April 2006 to March 2011 suggest that 11% of all problems managed by GPs among Indigenous patients were for mental health-related problems. Depression was the most frequently reported mental health-related problem managed by GPs for Indigenous Australians, followed by drug misuse, anxiety, alcohol use and then tobacco use. Depression was the most common mental health-related problem managed for other Australians.

Mortality for mental health issues

Deaths due to self-harm (suicide) accounted for 4% of Aboriginal and Torres Strait Islander deaths between 2006 and 2010 in the jurisdictions with adequate data quality (NSW, Qld, WA, SA and the NT combined). After adjusting for differences in the age structure of the two populations, the rate of suicide among Aboriginal and Torres Strait Islander peoples was twice that of non-Indigenous Australians. In addition, mental health-related conditions accounted for a further 2.8% of deaths among Indigenous Australians, and the rate was 1.4 times the rate for non-Indigenous Australians.Top of page

Implications:

Data on this issue are incomplete, including for children. 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 Aboriginal and Torres Strait Islander families and communities, the health sector, housing, education, employment and economic development, family services, crime prevention and justice, and Aboriginal community controlled organisations. 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 (SHRG 2004). Recent suicide prevention studies have identified the need to focus on protective factors, such as community connectedness, strengthening the individual and rebuilding family, as well as culturally based programs that include traditional elements (Dudgeon et al. 2012; Tighe et al. 2012).

The Aboriginal and Torres Strait Islander Healing Foundation received funding of $26.6 million over four years in the 2009–10 Budget to establish the Healing Foundation. The Healing Foundation focuses on grassroots healing initiatives, health promotion, education and skills training in the prevention and treatment of trauma, and building the evidence base on healing by evaluating and documenting best practice in health services. The Australian Government has committed to supporting the social and emotional wellbeing of the Stolen Generations, their families and communities through the Social and Emotional Wellbeing Program. This includes providing funding to eight Link Up services across Australia to provide counselling, family tracing and reunion services to members of the Stolen Generations.

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 are influenced by factors beyond the health system. Work to renew the social and emotional wellbeing framework is also underway. The Mental health: Taking Action to Tackle Suicide package includes $30.2 million under the Community prevention for high risk groups measure that targets groups and communities at high risk of suicide, including Indigenous Australians. The Australian Government specifically committed $6 million of these funds over four years from 2011–12 for community based suicide prevention activities targeting Indigenous Australians. The Indigenous Suicide Prevention Advisory Group is guiding the approach to this expenditure and the development of the first national Aboriginal and Torres Strait Islander Suicide Prevention Strategy. Under the National Mental Health Program, $1 million over 2011–12 and 2012–13 is being provided to expand the Empowerment Program to eight Indigenous urban, regional and remote localities around Australia. This project builds on the Kimberley pilot in 2011 in response to a rise in suicides in that region.Top of page

The Targeted Community Care (Mental Health) Program (TCC) provides community-based mental health services to improve the capacity of individuals, families and carers affected by mental illness to participate socially and economically. Indigenous Australians are a key target group for the program. In the period 1 July to 31 December 2011, Indigenous people constituted 9.2% of total TCC clients. As part of the National Mental Health Reform Budget 2011–12 package an additional $269.3 million will be invested in the TCC over five years. The Australian Government is also investing $1.5 million over five years to fund a national survey and other activities to help build understanding of the wellbeing of Australian children aged 8 to 14 years. National Health Reform is also an important foundation for taking mental health forward.
Figure 63—Proportion of people who reported high or very high levels of psychological distress, by Indigenous status and age group, persons aged 18 years and over, 2008
Figure 63—Proportion of people who reported high or very high levels of psychological distress, by Indigenous status and age group, persons aged 18 years and over, 2008
(a) Age-standardised
Source: AIHW analysis of the 2008 NATSISS and 2007–08 NHS
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Figure 64—Mental health-related mortality rates per 100,000, by Indigenous status and age group, NSW, Qld, WA, SA and the NT, 2006–10
Figure 64—Mental health-related mortality rates per 100,000, by Indigenous status and age group, NSW, Qld, WA, SA and the NT, 2006–10
(a)Age-standardised
Source: AIHW analysis of the 2008 NATSISS and 2007–08 NHS
Table 17—Age-standardised hospitalisations of Indigenous Australians for top 4 principal diagnosis of mental health‑related conditions, by type of condition and sex, NSW, Victoria, Qld, WA, SA and the NT, July 2008 to June 2010
Male—rate per 1,000Male—ratioFemale—rate per 1,000Female—ratioPersons—rate per 1,000Persons—ratio
Mental & behavioural disorders due to psychoactive substance use
12.5
4.0
7.3
3.4
9.8
3.7
Schizophrenia, schizotypal and delusional disorders
7.4
3.2
5.2
2.7
6.3
3.0
Mood disorders
3.5
1.0
4.8
0.7
4.2
0.8
Neurotic, stress-related disorders
2.9
1.2
3.9
1.3
3.4
1.3
Total mental health related conditions1
28.9
2.2
24.6
1.5
26.7
1.8
1Includes mental health related conditions in addition to those listed above (see Technical appendix).
Source: AIHW analysis of National Hospital Morbidity Database
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Figure 65—Proportion of people reporting selected stressors, by remoteness area, Indigenous persons aged 18 years and over, 2008
Figure 65—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 18—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:
= Low/moderate
(%)
Level of
psychological distress:
= High/very high
(%)
Total population
66.7
31.7
Self-assessed health status:
Excellent/very good
78.1
20.3
Good
67.3
31.2
Fair/poor
46.7
51.7
Highest year of school completed:
Year 9 or below
60.4
37.1
Year 10
69.3
29.9
Year 12
73.3
25.5
Personal income:
1st quintile (lowest)
59.9
37.6
5th quintile (highest)
78.8
20.5
Housing:
Owner
75.3
24.2
Renter
63.1
34.9
Employment status:
Employed
74.3
24.7
Unemployed
53.7
45.9
Not in labour force
58.9
38.3
Source: AIHW analysis of the 2008 NATSISS
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Figure 66—Age standardised hospitalisation rates for mental health-related conditions, by Indigenous status

Figure 66—Age standardised hospitalisation rates for mental health-related conditions, by Indigenous status
Source: AIHW analysis of National Hospital Morbidity Database
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Figure 67—Age-specific hospitalisation rates for a principal diagnosis of mental health-related conditions, by Indigenous status, NSW, Vic., Qld, WA, SA and NT, July 2008 to June 2010

Figure 67—Age-specific hospitalisation rates for a principal diagnosis of mental health-related conditions, by Indigenous status, NSW, Vic., Qld, WA, SA and NT, July 2008 to June 2010
Source: AIHW analysis of National Hospital Morbidity Database
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