There is a substantial body of evidence that the experience of the child in utero, at the time of birth and in infancy and childhood has the potential to impact on health throughout life (Eades 2004; Barker 1993; Power et al. 2013). The WHO (2000) recommends a life course approach to health acknowledging that there are critical periods of growth and development in utero, early infancy, during childhood and adolescence that impact on social and cognitive skills, habits, coping strategies and physical health. These then interact with biological factors, social experiences and risk behaviour to either attenuate or exacerbate long-term risks to health (Cable 2014). Family-centred primary health care approaches move beyond providing care to the individual patient, to seeing them as embedded in a family and taking a life course approach (Griew et al. 2007). Studies have identified that Aboriginal and Torres Strait Islander concepts of family are important to consider (Lohoar et al. 2014) and that engaging with Aboriginal and Torres Strait Islander patients and families in a respectful and culturally competent way is a key success factor for preventative health and health care service delivery (Griew et al. 2007). Working collaboratively with and learning from Aboriginal and Torres Strait Islander patients, families, interpreters, cultural mentors, Aboriginal health workers and other co-workers has also been identified as critical (NHMRC 2005). These approaches aim to support people to proactively manage their health across the life course.
Maternal health and parenting
Maternal health is one of the priority areas of reform identified by Australian governments. Antenatal care provides opportunities to address health risks and support healthy behaviours throughout pregnancy and into the early years of childhood. Access to antenatal care is high for Indigenous women, and similar to that for non‑Indigenous women, but often occurs later in the pregnancy and less frequently. Compared with women who received care in the first trimester, women who received no antenatal care were 3 times as likely to have a pre-term or low-weight baby and 6–7 times as likely to have a pregnancy that resulted in perinatal death, regardless of Indigenous status.
Smoking increases the risk of adverse events in pregnancy (such as miscarriage, ectopic pregnancy, pre-term labour and antepartum haemorrhage), and is also associated with poor perinatal outcomes (such as low birthweight), and respiratory illnesses (such as bronchitis or pneumonia) during the child's first year of life (see measure 2.21). In 2011, Aboriginal and Torres Strait Islander mothers were 4 times as likely to smoke during pregnancy as non‑Indigenous mothers. Smoking rates for Indigenous mothers were similar across geographic areas and age groups. For non‑Indigenous mothers, rates were higher in younger age groups. Smoking during pregnancy for both Indigenous and non‑Indigenous mothers is associated with higher prevalence of pre-term birth and a higher proportion of low birthweight babies. Smoking is also associated with a higher rate of perinatal deaths, which occur for Indigenous mothers at 1.2 times the rate of non‑Indigenous mothers (see measure 1.21). Reducing smoking continues to be a priority.
For Aboriginal and Torres Strait Islander mothers, the percentage of low birthweight births was highest for those in the 35 years and over age group (19%) and 12–13% for the other age groups (including teenagers). However, teenage pregnancies can have other impacts such as on education and employment opportunities.
Childhood (0–14 years)
Improving the health, social and environmental factors of babies and young children is likely to have positive flow-on effects for the remainder of the life cycle. By the age of three years, the brain has reached 90% of its adult size and many of the neural pathways have developed (MCEEDYA 2010). Programmes that target the first six to eight years of life are more successful at improving developmental outcomes than later interventions (Harrison et al. 2012). There are strong associations between the quality of care a child receives during the early years and physiological impacts leading to disease susceptibility, future vulnerability and resilience (Mitchell et al. 2014).
The Longitudinal Study of Indigenous Children (Wave 3) found that most Indigenous children (77%) were not at high risk of developing clinically significant behavioural problems, while 23% were at high risk (LSIC 2012). In Wave 4 of this study the main risk factors for social and emotional difficulties were having a close family member arrested, in jail or having problems with the police; being cared for by someone other than their regular carer for at least a week; and children being scared by other people's behaviour (LSIC 2013). Indigenous children who experienced three or more major life events (such as death/illness of a family member, moving house/housing problems, carer returning to job/study, new baby) had higher social and emotional difficulties scores (DSS 2014). In the 2001–02 WA Aboriginal Child Health Survey, 26% of Indigenous children aged 4 to 11 years were at high risk of clinically significant behavioural problems compared with 17% of non‑Indigenous children (De Maio et al. 2005). Those children living in families with poor parenting/family functioning (e.g. poor communication and decision making, poor emotional support, limited time spent together) were twice as likely to be at risk of emotional and behavioural difficulties (Zubrick et al. 2005).
Research supports the importance of the amount of speech directed to infants in the development of vocabulary and communication skills (Weisleder et al. 2013). In this study, one toddler heard more than 12,000 words of child-directed speech words over the course of a 10 hour day, while another only heard 670. Infants who experienced more child-directed speech became more efficient in processing familiar words in real time and had larger vocabularies by the age of 24 months. Socio-economic status alone did not determine the quality of the child's language experience.
Analysis of the 2008 Social Survey has found an association for Indigenous Australians between strong cultural attachment and positive outcomes on a range of socio-economic indicators including health status, education and employment (Dockery 2011). Providing children with a positive sense of themselves facilitates a strong foundation in resilience (Eades 2004). In the 2001–02 Western Australia Aboriginal Child Health Survey, those children who reported experiences of racism in the previous 6 months were more than twice as likely to be at high risk of emotional and behavioural difficulties as those who had not experienced racism (Zubrick et al. 2005). Exposure to racial discrimination during school years is a key health risk factor in the development of depressive symptoms in young people (Priest et al. 2014). Interventions to address exposure to racism within childhood and adolescence are an opportunity to foster resilience throughout life-stages (Bodkin-Andrews et al. 2014).
The measure of community functioning (see measure 1.13) finds that in 2008 the majority of Indigenous children aged 0–14 years attended a cultural event in the last 12 months (70%), 42% of 3–14 year olds spent time with an Indigenous elder, 76% slept well and 74% of children aged 4–14 years spent at least 60 minutes every day being physically active. Informal learning activities were undertaken with most children aged 0–14 years (94%).
In 2009–13, the mortality rate for Aboriginal and Torres Strait Islander children aged 0–4 years was 1.9 times the non‑Indigenous rate (169 per 100,000 compared with 89 per 100,000). The leading causes of death for Indigenous infants were conditions originating in the perinatal period (see measure 1.20) while injury accounted for over half (53%) of the deaths in the 1–4 year old group. Injury was also the leading cause of death for Indigenous 5–14 year olds (50%).
Immunisation is highly effective in reducing illness and death caused by vaccine-preventable diseases. As at December 2013, immunisation coverage was high for Indigenous children, and by 2 years of age, the immunisation coverage (91.4%) was similar to other Australian children (92.2%) (see measure 3.02). Gaps in immunisation still exist for 1 year olds (86% coverage for Indigenous 1 year olds compared with 90% for others).
Ear disease (particularly middle ear infections) is significantly higher for Indigenous children aged 0–14 years (approximately twice the rate for non‑Indigenous children in 2012–13 self-reported survey data). The rate of myringotomy procedures in hospital (an incision in the eardrum to relieve pressure caused by excessive build-up of fluid) was 1.8 per 1,000 for both Indigenous and non‑Indigenous patients (AIHW 2014f). In 2013–14, wait times for surgery were slightly longer for Indigenous patients (58 days) compared with other Australian patients from public hospital waiting lists (54 days) (AIHW 2014g). In 2008–13, GPs managed ear problems for Indigenous children aged 0–14 years at similar rates to other Australian children (107 compared with 101 per 1,000 encounters). The current rate of GP management may still be below what is needed given the higher prevalence of ear disease.
In the 2008 National Indigenous Eye Health Survey, 1.5% of Aboriginal and Torres Strait Islander children had low vision and 0.2% blindness. Trachoma rates are very high in some Indigenous communities. In 2012, data on trachoma in children in 204 at-risk communities in NT, SA, WA and Qld combined found that 25% of communities screened had endemic trachoma (over 5% of children with active trachoma).
Data on dental health show that a higher proportion of Indigenous children had decayed, missing or filled teeth compared with non‑Indigenous children in each age group 5 to 15 years (see measure 1.11). Dental disease in childhood is readily treated but Aboriginal and Torres Strait Islander children do not have ready access to dental care with cost and geography being significant barriers. In 2008, most Indigenous children in the 5–15 years age group (71%) reported cleaning their teeth once or twice per day.
In the two years to June 2013, hospitalisation rates for respiratory disease (see measure 1.04) for Indigenous children aged 0–4 years were 1.7 times the rate for non‑Indigenous children. Between 2004–05 and 2012–13 there has been a significant increase (23%) in hospitalisation rates for Indigenous children for respiratory disease and an increase in the difference in rates with non‑Indigenous children.
In 2012–13, a much higher proportion of Aboriginal and Torres Strait Islander children aged 0–14 years lived in households with a regular smoker (57%) compared with non-Indigenous children (26%), particularly households where smoking occurs indoors (28% and 12%). The proportions have fallen from 68% in 2004–05 to 57% in 2012–13, but the disparities remain in comparison with non‑Indigenous children.
The Australian Early Development Census (AEDC) is a measure of children's development in the first year of school with teacher assessments across five domains—physical health and wellbeing; social competence; emotional maturity; language and cognitive skills; and communication skills and general knowledge. As with all assessments the AEDC has its limitations. Indigenous children were twice as likely as non‑Indigenous children to be developmentally vulnerable on at least one domain of the AEDC in 2012. This rose to 3 times as high in very remote areas (63% of Indigenous children compared with 20% of non‑Indigenous children)(Cabinet 2014).
The Australian Early Development Census is a measure of children's development in the first year of school with teacher assessments across five domains—physical health and wellbeing; social competence; emotional maturity; language and cognitive skills; and communication skills and general knowledge. Indigenous children were twice as likely as non-Indigenous children to be developmentally vulnerable on at least one domain of the AEDC in 2012.
Source: Commonwealth of Australia (2014)
The proportion of Aboriginal and Torres Strait Islander students achieving the reading, writing and numeracy benchmarks in Years 3, 5, 7 and 9 remain below the corresponding proportions of non‑Indigenous students. The proportions of Indigenous students achieving literacy and numeracy benchmarks remain lower for students living in remote and very remote areas. This relationship was also evident for non‑Indigenous students, but was much less marked, resulting in a much larger gap between Indigenous and non‑Indigenous results in remote areas than in metropolitan areas.
Adolescent and youth health (15–24 years)
Young people in this age group do not use primary health care services frequently; however, the lifestyle factors leading to chronic diseases in later life are often established in this age group. Studies have found that empowering families and communities to work with youth on preventative health and to develop a positive sense of themselves are important in providing a strong foundation for long and healthy lives (Eades 2004; Williamson et al. 2010).
In 2012–13, the age group least likely to be consuming adequate serves of fruit and vegetables were those aged 18–24 years; however, the highest levels of physical activity were among Indigenous Australians in this age group. Over the last decade, the 15–17 year age group had the largest decline in smoking rates (33% to 19%). An Australian 12-month longitudinal study examined the predictors of change in adolescent smoking behaviour across three analytic models based on data from Years 7–10 (Mazanov et al. 2008). Results suggest that for males, the frequency of risk-taking behaviour and a male best friend who was a smoker were effective predictors of smoking behaviour changes, while for females the key predictor was whether at least one parent was a smoker. In 2008, 23% of Indigenous school students aged 12–15 years reported smoking in the last 12 months and 12% were current smokers. Approximately 5% of total students were current smokers. Around 27% of Indigenous students had never consumed alcohol while 23% had consumed alcohol in the past week. Around 23% of Indigenous students reported they had used illicit substances with cannabis being the most common (20%) (White et al. 2009).
In 2008 two-thirds (66%) of Aboriginal and Torres Strait Islander people aged 15–34 years recognised their homelands, 63% had attended a cultural event in the last 12 months, 78% had friends they could confide in, 89% felt able to have a say with family and friends most or all the time, and 96% had contact with family or friends outside of the household at least once per week. The majority of Indigenous young people had participated in sport or social activities in the preceding three months (90%). Most young people felt safe at home during the day (93%) and after dark (77%). In 2012–13, 69% of Indigenous youth aged 15–24 years had no disability or long-term health condition.
Education is a key factor in improving health and wellbeing. The pathways between education and health are complex and are interrelated with employment, income, psycho-social resources such as a sense of control, and practical skills that allow individuals to better manage their health (Griew et al. 2007). Over time there have been improvements in the proportion of Indigenous students remaining in school to Year 10 and Year 12, although Indigenous retention rates remain lower than for other students (see measure 2.05). The Vocational Education and Training (VET) sector also provides large numbers of Aboriginal and Torres Strait Islander peoples with non‑school education training opportunities. During 2012, there were approximately 9,600 course completions in the VET sector by Indigenous Australians aged 15–24 years, representing 7% of the Aboriginal and Torres Strait Islander population in this age group, compared with 8% for other Australians. In 2012–13, 60% of Indigenous Australians aged 15–24 were not studying compared with 40% of non‑Indigenous Australians of the same age; and 60% of Indigenous youth aged 17–24 years were not fully engaged in study or work, 2.4 times the non‑Indigenous rate (25%). Rates ranged from 52% in major cities to 84% in very remote areas.
Aboriginal and Torres Strait Islander youth experience a number of challenges compared with non‑Indigenous Australian youth including higher rates of high/very high levels of psychological distress (comparisons are for 18–24 year olds) (see measure 1.18), and lower levels of employment (see measure 2.07). Aboriginal and Torres Strait Islander youth had higher rates of contact with the criminal justice system (see measure 2.11). In 2012–13, Indigenous youth were 14 times as likely as non‑Indigenous youth to be under supervision in the youth justice system. Disproportionate representation of Indigenous youth in contact with the justice system impacts on a range of areas including physical health and the social and emotional wellbeing of families and communities (see measure 1.18).
In the 15–24 year age group, males made up 69% of deaths during the period 2008–12. For Indigenous Australians, suicide and transport accidents were the leading cause of death in this age group. For non‑Indigenous Australians in this age group, the leading causes of death were transport accidents followed by suicide. The Indigenous suicide rate was 5 times the non‑Indigenous rate and transport accidents 2.4 times (ABS 2014f).
Adults (25–54 years)
For Indigenous Australians in the 25–34 year age group, external causes (including suicide and transport accidents) were the leading cause of death. Rates were higher for Indigenous Australians than non‑Indigenous Australians for deaths due to external causes (3.3 times for suicide, 3.5 times for transport accidents) (ABS 2014f). Premature mortality from chronic diseases, such as circulatory disease, cancer, diabetes and respiratory diseases is also a major concern for Indigenous Australians aged 25–34; mortality rates due to ischaemic heart disease were 10.5 times those of non‑Indigenous Australians in the same age group.
In the 35–54 year age groups chronic disease was the leading cause of death. In 2008–12, premature mortality rates from chronic disease (before the age of 75 years) were higher for Indigenous Australians than non‑Indigenous Australian (2.7 times) in the jurisdictions with adequate data (NSW, Qld, SA, WA and NT combined). Rates for Indigenous Australians were highest in the NT (816 per 100,000) and lowest in NSW (334 per 100,000). In the 35–44 years age group in the NT, Indigenous mortality rates from chronic disease were 13.5 times the non‑Indigenous rate (529 compared with 39 per 100,000). In 2012–13, after adjusting for differences in the age structure of the two populations, Indigenous adults were 1.2 times as likely to have high measured blood pressure as non‑Indigenous adults. For Indigenous Australians, rates started rising at younger ages and the largest gap was in the 35–44 year age group.
While hospitalisations for injury reflect hospital attendances for a condition rather than the extent of the problem in the community, injury was the second most common reason for Indigenous Australians being hospitalised after dialysis. Hospitalisation rates for injury peaked in the early adult age groups and have had a much greater impact on the young and middle-aged when compared with non‑Indigenous hospitalisations for injury, which reflects higher rates of falls for elderly people.
Over the longer term there has been a significant increase in Indigenous employment; however, there has been no progress on the employment target since 2008. In 1994, 38% of the Indigenous working age population (aged 15–64 years) were employed (SCRGSP 2014a). This increased to a peak of 54% in 2008 and then fell to 48% in 2012–13. Between 2008 and 2012–13 there has been an increase of 6.9 percentage points in the employment gap between Indigenous and non‑Indigenous working age (up from 21.2 to 28.1 percentage points). The Indigenous unemployment rate is currently 21%, which is 4 times the non‑Indigenous unemployment rate of 5%. In 2008, many Indigenous Australian adults were seeking to improve their knowledge, skills and qualifications, with 33% intending to study in the future. Indigenous Australians in the 45–54 year age group were more likely to recognise their homelands or traditional country than those in the 18–24 year age group (75% compared with 60%).
55 years and older
The role of leadership in supporting healthy families and communities is important and better measurement of this is needed. Leadership is a theme within the measure of community functioning (see measure 1.13) used to describe strong vision and direction from Elders (both male and female) in family and community and strong role models who make time to listen and advise.
Home ownership increased with age, from 28% in the 18–24 year age group to 45% in the 55 years and over age group in 2011. These rates are below those for non‑Indigenous home ownership (84% of those aged 55 years and over).
Higher education statistics for 2012 show that for those aged 55 years and over, university completion rates per 100 in the population were the same for both Indigenous and non‑Indigenous Australians.
Those in the 55 years and over age group had the highest rate of reporting their health as 'fair' or 'poor' (45% for Indigenous Australians and 24% for non‑Indigenous Australians). A study in NSW has confirmed the need for appropriate mental health services and disability support services for older Aboriginal people (Gubhaju et al. 2013).
National prevalence of dementia in the Australian Indigenous population is not yet available; however, estimates in the NT suggest a much higher prevalence and incidence of dementia and a younger onset of the disease when compared with non-Indigenous Australians (Li et al. 2014; Radford et al. 2014). Older people with a reduced degree of functional capacity require a range of services. Aged care is usually provided in combination with basic medical services, prevention, rehabilitation or palliative care services. The age for accessing the Home and Community Care Program has been adjusted to take account of the younger age at which Indigenous Australians may begin to suffer from serious chronic illness.