This report brings together, from a wide variety of sources, information about the health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples. Much of the data comes from sources that cover all Australians but which separately identify Indigenous Australians. Other sources include special purpose ABS surveys, such as the 1994 National Aboriginal and Torres Strait Islander Survey (NATSIS), the 2002 National Aboriginal and Torres Strait Islander Social Survey (NATSISS), the Indigenous supplement to the 2001 National Health Survey (NHS (I)), administrative data from government systems and data from service delivery programs that are Indigenous specific.
The report primarily presents a broad picture at the national level and, wherever possible, uses existing and new data sources to reflect the diversity of the Indigenous population, including a separate chapter about Torres Strait Islander people. Also where possible, changes over time in the health and welfare outcomes for Indigenous people are described. The disparities in health and welfare between Indigenous and non-Indigenous Australians are also explored.
Chapter 1 (Introduction) provides a very brief overview of the new and important data sources used in the preparation of this report. Over the last decade there have been significant improvements in the quantity and quality of information about the health and welfare of Aboriginal and Torres Strait Islander peoples. The AIHW and ABS have initiated, and continue to drive, programs in partnership with state and territory authorities to improve the completeness with which Aboriginal and Torres Strait Islander peoples are recorded in a wide range of administrative data sets, and to develop and expand regular Indigenous surveys, including the 2002 NATSISS and the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS).
Indigenous information development is guided and progressed through a number of national committees, in particular the National Advisory Group on Aboriginal and Torres Strait Islander Health Information and Data (NAGATSIHID), providing advice on national priorities, developing work programs and monitoring progress. One example of recent data development was the inclusion in the 2004–05 NATSIHS of a module, auspiced by NAGATSIHID, to assess social and emotional wellbeing among Indigenous Australians.
A report on Indigenous data developments and information governance arrangements will be available later this year from the ABS web site (www.abs.gov.au) and the AIHW web site (www.aihw.gov.au).
TRENDS IN HEALTH AND WELFARE
Where possible, changes over time in the health and welfare of Indigenous Australians have been identified in this report. Some of these changes, highlighted below, are reported in more detail in the individual topic chapters.
Education is generally considered to be a key factor in improving the health and wellbeing of Indigenous Australians, and there have been significant improvements in educational participation and attainment in recent years. Between 1996 and 2004, there were steady increases in Indigenous primary and secondary school enrolments and in apparent retention rates. The proportion of Indigenous people aged 25–64 years who had a non-school qualification rose from 20% in 1994 to 32% in 2002.
Employment, and income gained through employment, is important for the wellbeing of people. Between 1994 and 2002, the proportion of Indigenous people aged 18–64 years in mainstream employment rose from 31% to 38% and the unemployment rate fell from 24% to 13%.
Housing has been identified as a major factor affecting the health and wellbeing of Indigenous Australians. From 1994 to 2002, the proportion of Indigenous households that were owner/purchaser households had increased from 26% to 30%.
There were significant declines in recorded Indigenous mortality in Western Australia for both males and females between 1991 and 2002. There was also a significant decline in recorded infant mortality in Western Australia, South Australia and the Northern Territory over the same period. Of the main causes of death examined, only mortality from diseases of the circulatory system showed a consistently significant decline. While the analyses in this report support a conclusion that Indigenous mortality has declined, it is important to note that estimates of the magnitude of the trend could also reflect changes in reporting Indigenous status in deaths registrations.
THE DEMOGRAPHIC, SOCIAL AND ECONOMIC CONTEXT
The Aboriginal and Torres Strait Islander population of Australia is projected to have grown to about 492,700 by mid-2005. Indigenous people represent 2.4% of the total Australian population. The Indigenous population is relatively young, with a median age of 21 years compared to 36 years for the non-Indigenous population.
In 2001, 30% of the Indigenous population lived in major cities, 43% in regional areas and 26% in remote areas. The majority of Indigenous people live in New South Wales (29% of the Indigenous population) and Queensland (27%), Western Australia (14%) and the Northern Territory (12%). Indigenous people comprise about 30% of the Northern Territory population but less than 4% in all other state/territory populations. Indigenous people remain disadvantaged, compared to other Australians, across a range of areas of social concern. Indigenous people continue to experience lower levels of employment (and higher levels of unemployment than non-Indigenous people, with Indigenous adults in 2002 being more than twice as likely to be unemployed (13%) as non-Indigenous adults (4.6%). The real mean equalised gross household income of Indigenous people was $394 per week in 2002, equal to 59% of that of non-Indigenous adults in 2002.
EDUCATION AND HEALTH
While international research has clearly established that higher levels of educational attainment are associated with better health outcomes, there has been little investigation into whether this relationship applies to Indigenous Australians. The ways in which health impacts on educational attainment, however, are better understood. Hearing loss as the result of chronic ear infection, and poor nutrition are the two health issues that are commonly identified as being the most detrimental to Indigenous educational outcomes. Research has shown that both of these conditions are associated with poor school attendance and achievement.
Despite the significant improvements in the educational participation and attainment of Indigenous Australians in recent years, Indigenous people were about half as likely as non-Indigenous people to have a non-school qualification in 2002 (32% compared with 57%). While Indigenous students comprised 3% of the total vocational education and training student population in 2003, they continue to be under-represented in the higher education sector, accounting for only 1% of the total higher education population in 2003.
Indigenous households are much less likely than other Australian households to be owner/purchaser households and much more likely to live in some form of social housing such as state or territory owned housing or Indigenous or mainstream community housing.
Among Indigenous households in non-remote areas, 34% were home owners, 32% were private or other renters and 24% were renting from state or territory housing authorities. Reflecting, in part, the availability of different tenure options, about half of Indigenous households in remote areas were renting from Indigenous or mainstream community housing providers and only 14% were home owners.
Some Indigenous households, especially those in remote areas, live in conditions that do not support good health. In 2002, some 9% of Indigenous households in Australia were living in overcrowded conditions, which can contribute to the spread of infectious diseases and put stress on basic household facilities. The highest rate of overcrowding occurred in households that were renting from Indigenous or mainstream community housing providers (34%).
Dwelling condition and connection to essential services are also important issues in relation to Indigenous community housing. There were 1,882 temporary or improvised dwellings in discrete Indigenous communities in 2001, while for permanent dwellings in these communities, 31% required major repair or replacement and 153 had no organised sewerage supply.
DISABILITY AND AGEING
In 2002, 36% of Indigenous people aged 15 years or over had a disability or long-term health condition and 8% had a profound or severe core activity limitation, meaning that they always or sometimes needed assistance with core activities of daily living (self-care, mobility and communication). Although these estimates are not strictly comparable with those for the non-Indigenous population, it is estimated that Indigenous people were at least twice as likely to have a profound or severe core activity limitation as non-Indigenous people.
The prevalence of disability among Indigenous people is higher at all ages. In 2002, over two-thirds of people aged 55–64 years, and one-half of people aged 45–54 years had a disability or long-term health condition. The earlier onset of disability or long-term health conditions with a profound or severe core activity limitation indicates the comparatively higher need for service provision for Indigenous people with a disability at younger ages.
MOTHERS AND CHILDREN
Indigenous mothers are more likely to have their babies at younger ages than other mothers. The average age of Indigenous mothers who gave birth in 2003 was 25 years, compared with an average age of 31 years for other mothers. For the period 2000–02, 78% of Indigenous mothers who gave birth were aged under 30 years, compared with 49% of other mothers. In 2003, the total fertility rate (TFR) for Indigenous women was estimated to be 2.15 babies, compared with 1.76 babies for the total Australian population.
Babies with an Indigenous mother were twice as likely (13% of births) to be low birthweight babies (those weighing less than 2,500 grams at birth) as babies with a non-Indigenous mother (6%). The perinatal mortality rate for babies with an Indigenous mother in Queensland, South Australia, Western Australia and the Northern Territory was about twice that for babies with a non-Indigenous mother.
Breastfeeding and effective vaccination have many positive effects on the survival chances, growth, development and health of infants. In 2001, a high proportion of Indigenous mothers living in remote areas (95%) and non-remote areas (83%) had breastfed their children. In 2003, Aboriginal and Torres Strait Islander children had lower vaccination coverage than other children at 12 months of age (82% compared with 91%), but by two years of age, they had comparable vaccination coverage (91%).
In 2003–04, Indigenous infants were more likely to be hospitalised than other infants, while Indigenous and other children aged 1–14 years were hospitalised at similar rates. In the period 1999–2003, the mortality rate for Indigenous infants in Western Australia, South Australia, Queensland and the Northern Territory was almost three times that for non-Indigenous infants. The death rate of Aboriginal and Torres Strait Islander children
aged 1–14 years was more than twice that of non-Indigenous children of the same age in these jurisdictions.
In 2002, after adjusting for age differences between the populations, Indigenous Australians were twice as likely to report their health as fair or poor as non-Indigenous Australians. Levels of reported fair or poor health were higher for those in the lowest income quintile for equalised household income, for those who were unemployed or not in the labour force, and for those whose highest year of school completed was Year 9 or below.
The conditions which account for most of the consultations by Indigenous Australians with General Practitioners, and are the main reasons for hospitalisation of Indigenous Australians, are circulatory diseases, diabetes, respiratory diseases, musculoskeletal conditions, kidney disease, eye and ear problems and mental and behavioural disorders.
Indigenous Australians experience an earlier onset of most chronic diseases, have more GP consultations for the management of certain diseases and are more likely to be hospitalised than other Australians. For example, the prevalence of diabetes among Indigenous Australians was nearly four times the prevalence reported by non-Indigenous Australians; diabetes was managed at a rate of 7 per 100 encounters with Indigenous Australians compared to 3 per 100 encounters with all Australians and Indigenous Australians were hospitalised for diabetes at five times the rate of other Australians.
Hospitalisation rates were 12 times higher for Indigenous Australians than for other Australians for care involving dialysis, and twice those for other Australians for both respiratory diseases and injury.
HEALTH RISK FACTORS
The relative socioeconomic disadvantage experienced by Aboriginal and Torres Strait Islander people compared with non-Indigenous people places them at greater risk of exposure to behavioural and environmental health risk factors.
In 2002, about half (49%) of the Indigenous population aged 15 years or over smoked on a daily basis. One in six (15%) reported consuming alcohol at risky or high risk levels in the last 12 months and just over one-half (51%) had not participated in sport or physical recreation activities during this period. One-quarter (24%) of Indigenous people living in non-remote areas reported having used illicit substances in the 12 months prior to interview and 40% reported having tried at least one illicit drug in their lifetime. With the exception of substance use, these behavioural risk factors were associated with poorer self-assessed health among Indigenous people in 2002.
In 2002, about eight in ten (82%) Indigenous people reported experiencing at least one life stressor in the last 12 months and nearly one-quarter (24%) reported being a victim of physical or threatened violence during this period. Higher rates of fair or poor health and health risk behaviour were reported among Indigenous people who had been exposed to these environmental risk factors. Indigenous people who had been removed from their natural families as children also reported poorer health outcomes in comparison to those who were not removed from their families.
In the period 1996–2001, the life expectancy at birth for Indigenous Australians was estimated to be 59.4 years for males and 64.8 years for females, compared with 76.6 years for all males and 82.0 years for all females for the period 1998–2000, a difference of approximately 17 years for both males and females.
For the period 1999–2003, in Queensland, South Australia, Western Australia and the Northern Territory, 75% of recorded Indigenous male deaths and 65% of Indigenous female deaths occurred before the age of 65 years. This compared with 26% and 16%, respectively, of deaths of non-Indigenous males and females. For all age groups below 65 years, the age-specific death rates for persons identified as Indigenous in the selected jurisdictions were at least twice those for other Australians. The largest differences occurred at ages 35–44 and 45–54 years where the death rates for Indigenous Australians were five times those recorded for non-Indigenous Australians.
Based on 1999–2002 year of occurrence of death and 2003 year of registration of death, the three leading causes of death for Aboriginal and Torres Strait Islander peoples in the four jurisdictions were diseases of the circulatory system, injury (predominantly accidents, intentional self-harm and assault) and cancer.
Over the period 1999–2003, Indigenous males and females died at almost three times the rate of non-Indigenous males and females. Indigenous Australians also had higher rates of mortality from all major causes of death. For example, mortality rates for Indigenous males and females for endocrine, nutritional and metabolic diseases (including diabetes) were around seven and 11 times those for non-Indigenous males and females.
Deaths where multiple causes were reported were more common among Indigenous males and females. For example, 19% of deaths among Indigenous males and 21% of deaths among Indigenous females recorded five or more causes of death, compared with 14% and 13% of non-Indigenous male and female deaths respectively.
HEALTH SERVICES PROVISION ACCESS AND USE
Overall, estimated expenditure on health services provided to Aboriginal and Torres Strait Islander peoples during 2001–02 was $3,901 per person. This was 18% higher (ratio 1.18:1) than the estimated expenditure on services delivered to non-Indigenous Australians. The ratio of per capita expenditure on Indigenous Australians to non-Indigenous Australians varies considerably by type of service. Aboriginal and Torres Strait Islander peoples were more intense users of community health centres (where the per capita expenditure rate ratio was 6.5, public health (2.9) and admitted and non-admitted patient services within the public hospital system (1.6 and 1.9 respectively) compared with medical services (0.4) and pharmaceuticals (0.3).
Access to services is affected by a number of factors including the proximity of the service, availability of transport, affordability, availability of culturally appropriate services and the involvement of Indigenous people in the delivery of health services. Approximately one in five Indigenous people living in remote areas in 2002 had difficulty understanding and/or being understood by service providers and around one-half did not have a working telephone in the home. In 2001, Indigenous people were under-represented in selected health-related occupations, comprising around 1% of Australians employed in this area. Aboriginal and Torres Strait Islander people were somewhat better represented in welfare and community-related occupations (2.6%). In 2003 Indigenous students were under-represented among those completing graduate courses in health (1.0%), but higher proportions of Indigenous people were commencing health and welfare-related courses (1.7% and 2.3% respectively).
Despite likely under-counting of Aboriginal and Torres Strait Islander people in hospital records, in 2003–04, Indigenous males and females were about twice as likely to be hospitalised as other males and females, with the greatest differences in rates being in the age groups 35–44 years, 45–54 years and 55–64 years. Once in hospital however, Indigenous patients were less likely to undergo a procedure than other patients. While hospitalisation rates for Indigenous Australians are several times those for other Australians, most of the difference is due to high rates of care involving dialysis and hospitalisations for other potentially preventable chronic conditions. Indigenous males and females were hospitalised for care involving dialysis at 9 and 17 times the rate of other Australian males and females, and for potentially preventable chronic conditions they were hospitalised at seven times the rate of other Australians.
In 2004, the proportion of Australian Government supported child care services used by Aboriginal and Torres Strait Islander children was 2%; Indigenous children used these services at less than half the rate for non-Indigenous children. Of all Indigenous children in Australian Government supported child care services, 51% were in long day care centres, 16% were in before/after school care and 9% were in family day care. This compared to 59%, 25% and 14% of other children respectively.
Aboriginal and Torres Strait Islander children were over-represented in the child protection systems across most of Australia, with ratios of 10:1 in Victoria and 8:1 in Western Australia and South Australia. The rate of Indigenous children being placed under care and protection orders and in out-of-home care was higher than the rate for other children in all jurisdictions. Just over two-thirds of children in out-of-home care were placed with Indigenous relatives/kin (38%) or with other Indigenous caregivers (30%). These are the preferred placements under the Aboriginal Child Placement Principle that has been adopted by all jurisdictions.
Rates of incarceration in juvenile detention centres for Indigenous Australians aged 10–17 years are much higher than those for other young Australians in all jurisdictions. In 2002–03, 40% of 10–17 year olds in detention centres in Australia were Indigenous.
In 2003–04, 6,524 people, 3.5% of those receiving Commonwealth-State Disability Agreement funded services were identified as Indigenous. The proportion of people who received CSTDA-funded services who were of Indigenous origin varied by service type. Respite (5%), community support (5%) and accommodation (4%) services had an above-average proportion of Indigenous service users. On the other hand, service users of employment (3%) and community access (3%) services had a smaller Indigenous representation than in the overall population.
Aboriginal and Torres Strait Islander people utilise aged care services at a younger age, consistent with poorer health status and lower life expectancy. Of those admitted to permanent or respite residential care during 2003–04, almost 29% were under 65 years of age, compared with fewer than 5% of other Australians. Of all Indigenous Australians receiving Community Aged Care Packages at 30 June 2004, 46% were aged below 65 years compared with 8% among other Australians. Of all clients receiving home and community care, 18% of Indigenous clients were aged 75 years or over compared with 57% of other clients.
TORRES STRAIT ISLANDER PEOPLES
Torres Strait Islander people comprise 11% of Australia's Indigenous population. Around one in seven Torres Strait Islander people (14%) live in the Torres Strait Area, with a further 45% in other parts of Queensland and 18% in New South Wales.
While Torres Strait Islander people have their own distinctive cultural identity, they share many of the characteristics of Indigenous Australians generally. They are a relatively young population, with a higher birth rate and lower life expectancy than the non-Indigenous population. Like other Indigenous Australians, Torres Strait Islander people are actively involved in community life. The 2002 NATSISS show that a majority of Torres Strait Islander people (89%) had been involved in social activities in the last 3 months, while in the preceding year, 70% had attended cultural event(s), 51% had participated in sport or physical recreation activities, and 29% in voluntary work.
The various measures of educational attainment, labour force participation and associated economic status indicate that Torres Strait Islander people experience similar levels of disadvantage as other Indigenous Australians. In 2002, Torres Strait Islander people were less likely than non-Indigenous people to have completed Year 12 (26% compared with 44%); less likely to have a non-school qualification (33% compared with 57%); almost four times as likely to be unemployed (22% compared with 6%); and more than twice as likely to be living in a low income household (46% compared with 20%).
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