Factors contributing to Indigenous health

Health risk factors

Selected health risk and protective factors

The factors contributing to the poor health status of Indigenous people should be seen within the broad context of the 'social determinants of health' [1][2]. These 'determinants', which are complex and interrelated, include income, education, employment, stress, social networks and support, working and living conditions, gender, and behavioural aspects, all of which are 'integrated' in terms of autonomy and the capacity to participate fully in society [3]. Related to these are cultural factors, such as traditions, attitudes, beliefs, and customs. Together, these social and cultural factors also have a major influence on a person's behaviour [1][2].

Information about some of these determinants is available (see 'The context of Indigenous health'), but attention tends to be focused on the so-called 'health risk and protective factors', including those summarised in the following sections. These risk and protective factors are more proximal to adverse health outcomes, but the interpretation of the following information needs to recognise the potential roles of the underlying determinants of health.

Nutrition

The nutritional status of Indigenous people is influenced by socio-economic disadvantage, and geographical, environmental, and social factors [4][5]. Poor nutrition is a common risk factor for overweight and obesity, malnutrition, CVD, type 2 diabetes, and tooth decay [5][6]. The National Health and Medical Research Council (NHMRC) has endorsed a number of dietary guidelines for children, adolescents, adults, older Australians, women of childbearing age, and pregnant women [5]. The NHMRC guidelines recommend that adults consume a minimum of two serves of fruit and five serves of vegetables per day, selected from a wide variety of types and colours [7]. The guidelines also recommend including reduced-fat varieties of milk, yoghurts and cheeses, and choosing foods low in salt.

According to the 2004-2005 NATSIHS, the majority of Indigenous people aged 12 years and over reported eating fruit (86%) and vegetables (95%) on a daily basis [8]; however, 13% of Indigenous respondents reported no usual daily fruit intake (compared with 7% of non-Indigenous respondents) and 5% reported no usual daily vegetable intake (compared with 1% of non-Indigenous respondents).

Levels of fruit and vegetable consumption were different for Indigenous people living in remote and non-remote areas, at least partly due to the poor accessibility and availability of fruit and vegetables in remote areas [8]. The 2004-2005 NATSIHS found that 42% of Indigenous people aged 12 years or older living in non-remote areas consumed the recommended number of servings of fruit and 10% consumed the recommended number of servings of vegetables per day (Indigenous people living in remote areas were not asked how many serves of fruit and vegetables they consumed; the questions were amended to whether they usually ate fruit and/or vegetables each day.) The proportions of Indigenous people aged 12 years and older living in remote areas who did not consume these dietary items daily was substantially higher than for their counterparts living in non-remote areas – 15% and 2% respectively for vegetable consumption, and 20% and 12% respectively for fruit consumption.

The Footprints in time: longitudinal study of Indigenous children reported that levels of relative isolation affected the diet of study children aged between 2-7 years in 2010 [9]. Cereals, protein, and fruit and vegetables were the types of food eaten by most children across all locations, but children in areas of high isolation were more likely to have eaten protein and bush tucker, and less likely to have eaten snacks and dairy food. Around 78% of all the children drank water and 7.1% ate bush tucker.

More than three-quarters (76%) of Indigenous people aged 12 years or older living in non-remote areas reported in the 2004-2005 NATSIHS that they usually drank whole milk (including full-cream powdered milk), with only 19% drinking reduced fat and/or skim milk [8]. The consumption of reduced fat and/or skim milk was very low (6%) among Indigenous people living in remote areas, with 87% reporting that they drank whole milk.

Around 83% of Indigenous people aged 12 years or older living in remote areas reported 'sometimes' or 'usually' adding salt after cooking, compared with two-thirds (66%) of those living in non-remote areas in the 2004-2005 NATSIHS [8].

The 2004-2005 NATSIHS also addressed the question of food security by asking respondents aged 15 years and older whether they had run out of food in the previous 12 months [10]. ‘Running out of food but able to get food by other means’ was reported by 28% of Indigenous people living in remote areas (seven times more common than among non-Indigenous people) and by 12% of Indigenous people living in non-remote areas (four times more common than among non-Indigenous people) [11]. ‘Going without food when they could not afford to buy more’ was reported by approximately 8% of Indigenous people living in non-remote areas (four times more common than among non-Indigenous people), and by approximately 7% of those living in remote areas (seven times more common than among non-Indigenous people).

The 2004-2005 NATSIHS examined associations between dietary behaviour and income, educational attainment, and self-reported health [11]. Indigenous people who reported no usual daily intake of fruit or vegetables were more likely to be in the lowest quintile of income. Low fruit and vegetable intake was also associated with smoking tobacco and risky/high risk alcohol consumption.

In attempting to address the issue of food security in the NT, the Australian Government established a licensing regime for community stores as part of the NTER in 2007 [12]. An evaluation of the Community stores licensing program concluded that licensing had positively impacted food security, particularly with regard to the quality, quantity, and range of healthy foods available in the remote stores involved in the project. The licensing program was extended in 2012 to operate throughout the NT, except in major centres [13].

Physical activity

The National physical activity guidelines for Australians recommends moderate physical activity on most, preferably all, days of the week to improve health and reduce the risk of chronic disease and other conditions [14][15]. At least 60 minutes of activity is recommended for children, and at least 30 minutes for adults; these amounts can be in blocks of activity or accumulated throughout the day in short bursts [15]. Low levels of physical activity have been shown to be a risk factor for CVD, type 2 diabetes, certain cancers, depression and other social and emotional wellbeing conditions, overweight and obesity, and a weakened musculoskeletal system [16][14][15].

The 2008 NATSISS and the 2004-2005 NATSIHS are the two most recent sources of information on the physical activity levels of Indigenous people [8][16]. Data from the 2008 NATSISS reveal that almost two-thirds (64%) of Indigenous children aged 4-14 years had taken part in some form of physical activity or sport in the 12 months prior to the survey (Derived from [17]). Almost three-quarters (74%) of Indigenous children in this age-group had been physically active for at least 60 minutes on every day in the week before the survey, and only 3% had not had any activity [16].

Of all Indigenous children 4-14 years who participated in some form of physical activity or sport, males had slightly higher levels of participation (52%) than did females (48%) (Derived from [17]). Among Indigenous children, the highest level of participation in physical activity was for children living in inner/outer regional areas (45%), followed by those living in major cities (34%), and remote/very remote areas (22%). Of children participating in physical activity, the highest proportions were in NSW and Vic (both 30%), and the lowest in ACT (0.9%).

For adults, self-reported data from the 2008 NATSISS show that almost one-third (30%) of Indigenous people aged 15 years and over had taken part in some type of physical activity or sport in the previous 12 months (Derived from [17]). Participation levels were higher among Indigenous males (38%) than among Indigenous females (23%); levels decreased with age for both sexes from around 47% for the 15-24 years age-group to around 4% for the 55 years and over age-group. For both sexes, participation levels were highest for people living in inner/outer regional areas (42%), followed by major cities (36%), and remote/very remote areas (23%). The states/territories with the highest participation levels were NSW (30%) followed closely by Qld (27%), and the lowest levels were found in the ACT (1.3%); proportions for both Indigenous males and Indigenous females followed similar trends.

Of all Indigenous people 15 years and older who took part in physical activity, around 89% identified their status as Aboriginal, around 5.6% identified as Torres Strait Islander, and around 5.4% identified as both Aboriginal and Torres Strait Islander (Derived from [17]). The levels of participation in physical activity were similar for each of these Indigenous groups: Aboriginal people (30%), Torres Strait Islanders (33%), and Aboriginal and Torres Strait Islanders (32%).

In the 2004-2005 NATSIHS, after age-adjustment, just over half (51%) of Indigenous people surveyed in non-remote areas reported their physical activity level as sedentary (very low or no physical activity) compared with around one-third (33%) of non-Indigenous people [18]. Around one-quarter (27%) of Indigenous people reported low levels of activity compared with over one-third of non-Indigenous people (36%). Only one-fifth (21%) of Indigenous people reported moderate or high levels compared with one-third (31%) of non-Indigenous people.

Indigenous females had a greater proportion of sedentary activity levels than did Indigenous males (51% compared with 42%) [18]. The highest levels of sedentary or low levels of activity were reported among the older age-groups, including 45-54 years (83%) and 55 years and over (85%). The highest levels of moderate to high physical activity levels were reported for age-groups 15-24 years (32%) and 25-34 years (27%). Indigenous people reported higher proportions of sedentary activity levels than did non-Indigenous people across all states and territories, with levels highest for Indigenous people in NSW (78%) and Tas (70%).

Between 2001 and 2004-2005, levels of sedentary physical activity among Indigenous people aged 15 years and older increased from 37% to 47% [18]. The disparity between Indigenous people and non-Indigenous people in relation to sedentary physical activity levels also increased between 2001 and 2004-2005 from 11% to 18%.

Bodyweight

The standard measure for classifying a person's weight for height is body mass index (BMI – weight in kilograms divided by height in metres squared) [19]. Being overweight (BMI 25.0 to 29.9) or obese (BMI of 30.0 or more) increases a person's risk for CVD, type 2 diabetes, certain cancers, and some musculoskeletal conditions. A high BMI can be a result of many factors, either alone or in combination, such as poor nutrition, physical inactivity, socioeconomic disadvantage, genetic predisposition, increased age, and alcohol and tobacco use [7]. Being underweight (BMI less than 18.5) can also have adverse health consequences, including decreased immunity (leading to increased susceptibility to some infectious diseases) and osteoporosis (bone loss) [19]. The 2003 NHMRC dietary guidelines for adults recommend that adults prevent weight gain by being physically active and eating according to their energy needs [7].

Overweight and obesity contributed 11% to the total burden of disease among Indigenous people in 2003, second only to tobacco [20]. It is possible, however, that this may be an under-estimate because optimal BMI cut-offs are still uncertain for the Indigenous population (due to differences in body shape and other physiological factors) [21]. It has been suggested that a BMI of 22 might be a more appropriate than 25 as a measure of acceptable weight for Indigenous people. There is also evidence that measuring the waist to hip ratio (WHR) in Indigenous people is more sensitive and easier to measure than BMI [22][23].

Based on BMI information collected as a part of the 2004-2005 NATSIHS, 57% of Indigenous people aged 15 years or older were classified as overweight or obese, with slight differences according to remoteness of residence (the lowest proportion was 55% in major cities and the highest was 62% in remote areas) [8]. A higher proportion of Indigenous males (34%) than Indigenous females (24%) was overweight, but Indigenous females were more likely than Indigenous males to be obese (34% compared with 28%) [18]. After age-adjustment, the level of being overweight or obese was 1.2 times higher for Indigenous people than for their non-Indigenous counterparts [8].

In 2004-2005, Indigenous people aged 18 years or more were more likely to be overweight or obese if [18]:

• their self-reported health status was fair/poor (68%) compared with those whose health was excellent/very good (55%)
• they had three or more long-term health conditions (65% compared with 56% of those with no long-term health conditions)
• they had circulatory problems (72% compared with 57% of those without circulatory problems)
• they had diabetes (83% compared with 57% of those without diabetes).

The prevalence of overweight and obesity among Indigenous adults living in non-remote areas increased steadily from 51% in 1995, to 56% in 2001, and to 60% in 2004-2005 [18].

Overweight and obesity were slightly more common overall among Torres Strait Islander people aged 15 years or older (61%) than among Aboriginal people in that age-range (56%) (the difference is not statistically significant) [8]. The level of overweight and obesity was particularly high among Torres Strait Islanders living in the Torres Strait area, with 86% having a BMI of 25.0 or greater.

A 2012 study of Indigenous youths in the Torres Strait (aged 5 to17 years) found that 46% were overweight or obese and 35% had central obesity26 [24]. Females had higher levels of central obesity (50%) than did males (18%). The study also found a consistent association between overweight/obesity and low levels of physical activity.

A study in central Australia found that 21% of Indigenous youths (aged 3 to 17 years) were overweight and 5.4% were obese (there was no difference between males and females) [25]. In comparison, the NHS 2007-2008 reported 17% of all Australian children aged 5 to 17 years were overweight and 8% obese [26].

In 2004-2005, around 4.4% of Indigenous people aged 15 years or older were underweight, with about 2.8% of Indigenous men and 6.0% of Indigenous women having a BMI of less than 18.5 [18]. Indigenous adults were also more likely to be underweight if:

• they were current smokers (6.0%), compared with those who were ex-smokers (1.9%) or who had never smoked (3.2%)
• they did not have a non-school qualification (5.7% compared with 2.1% who had achieved a non-school qualification)
• they engaged in low to moderate levels of physical activity (6.6% compared with 0.7% who engaged in high levels of physical activity)
• they reported not eating fruit daily (6.2% compared with 4.1% who reported eating fruit daily)
• they reported not eating vegetables daily (8.3% compared with 4.1% who ate vegetables daily).

Immunisation

Vaccination has been very successful in contributing to improvements in Indigenous health and child mortality in recent decades, but some vaccine-preventable diseases are still experienced at higher rates among Indigenous people than among non-Indigenous people [27]. In response, the immunisation recommendations for Indigenous people differ from those for the general population for certain diseases, such as invasive pneumococcal disease and influenza among adults, and TB, HAV, Hib, and pneumococcal disease among children.

Data for immunisation levels among Indigenous children and adults come from two main sources: the Australian Childhood Immunisation Register (ACIR), and self-reported data from the 2004-2005 NATSIHS [18][8].

The most recently published information about immunisation coverage for Indigenous children are to 31 December 2009[18]. Coverage for all vaccines was lower for Indigenous children than for non-Indigenous children across the three recorded age-groups: 1 year (7.9% lower); 2 years (4.0% lower); and 5 years (4.6% lower).

For the 1 year age-group, the greatest difference in overall vaccination coverage was in WA, where coverage for Indigenous children was significantly lower (17% lower) than for non-Indigenous children (rate ratio 0.8) [18]. Nationally, the greatest difference in vaccine coverage was for polio, which was 7.7% lower among Indigenous children than among non-Indigenous children (rate ratio 0.9).

For the 2 years age-group, WA also had the greatest difference in vaccination, with coverage for Indigenous children 18% lower that for non-Indigenous children (rate ratio 0.8) [18]. Nationally, the greatest difference in vaccine coverage was for Hib; coverage for Indigenous children was 3.6% lower than for non-Indigenous children (rate ratio 0.96).

For the 5 years age-group, the greatest difference in overall vaccination was in the ACT, where coverage was 17% lower for Indigenous children than for non-Indigenous children, (rate ratio 0.8, not statistically significant) [18]. Nationally, the greatest difference in vaccine coverage was for diphtheria, tetanus, and pertussis (DTP), with coverage for Indigenous children 4.5% lower than for non-Indigenous children (rate ratio 0.95).

Immunisation coverage for Indigenous children has varied over the years [18]. Combined data for NSW, Vic, WA, SA and the NT for 2001-2009 reveal that relative coverage was at its best in 2004 in the 1 year age-group with a rate difference of 6.3% (lower among Indigenous children than among non-Indigenous children). The rate difference then increased steadily to 10% in 2008, and decreased slightly to 9.0% in 2009. For the 2 years age-group, the smallest rate difference occurred in 2006 (0.7% difference, lower among Indigenous children than among non-Indigenous children), and steadily increased to a difference of 6.1% in 2009. The 5/6 year age-group followed a similar pattern; the smallest difference occurred in 2005 (0.3% difference, lower among Indigenous children than among non-Indigenous children), and increased steadily to 4.5% difference in 2009.27

The 2004-2005 NATSIHS reported that 88% of Indigenous children aged 0-6 years living in non-remote areas were fully immunised against the diseases included in the NHMRC vaccination schedules [8]. This figure is based on a general question about immunisation, however, and is almost certainly an over-estimate. Information from the available immunisation records suggests the proportion of Indigenous children aged 0-6 years who were fully immunised is lower: the proportions for the separate vaccines were diphtheria and tetanus (79%), pertussis (whooping cough) (74%), HBV (83%), polio (79%), Hib (73%), and measles, mumps, and rubella (MMR) (85%).

Three-fifths (60%) of Indigenous people aged 50 years or older reported to the 2004-2005 NATSIHS that they had been vaccinated against influenza in the previous 12 months, with vaccination levels higher for people living in remote areas (80%) than for those living in non-remote areas (52%) [8]. Indigenous females had slightly higher vaccination coverage (61%) than did Indigenous males (58%). These levels were higher than those for non-Indigenous people (46%). Similarly, vaccination levels for pneumonia in the previous 5 years were higher for Indigenous adults aged 50 years or older (remote: 56%; non-remote: 26%; all: 34%; female: 37%; male: 31%) than those for their non-Indigenous counterparts (20%).

According to the 2004-2005 NATSIHS, Indigenous people aged 65 years or older had higher levels of coverage for influenza in the previous 12 months (84%) than did non-Indigenous people of the same age-group (73%) [18]. Reported coverage of pneumonia vaccination was also slightly higher among Indigenous people 65 years or older (48%) than among their non-Indigenous counterparts (43%).

Breastfeeding

Breast milk, which is the natural and optimum food for babies, contains proteins, fats and carbohydrates at levels that are appropriate for an infant's metabolic capacities and growth requirements [5]. It also has anti-infective properties and contains immunoglobulins, which provide some immunity against early childhood diseases [28]. The NHMRC recommends that as many infants as possible are exclusively breastfed until 6 months-of-age and that mothers then continue breastfeeding until 12 months-of-age [29].

According to the 2010 Australian National Infant Feeding Survey, breastfeeding initiation levels were similar among Indigenous and non-Indigenous mothers (87% and 90%, respectively), but levels of exclusive breastfeeding declined more rapidly among Indigenous mothers [30]. At 6 months of age, only 11% of Indigenous babies were exclusively breastfed, compared with 27% of non-Indigenous babies. Around 60% of Indigenous children aged 0-6 months were being breastfed at the time of the survey compared with 68% of non-Indigenous babies.

The more comprehensive 2004-2005 NATSIHS found that more than four-fifths (84%) of Indigenous mothers aged 18-64 years reported having breastfed their children, which is similar to the level in 2001 (86%) [8]. The proportion of women who breastfed their children was higher in remote areas (92%) than in non-remote areas (80%).

According to the 2004-2005 NATSIHS, two-thirds (66%) of Indigenous children aged 0-3 years living in non-remote areas were reported to have been breastfed for some period of time [8]. This level is slightly lower than the 72% found among non-Indigenous children. A similar proportion of Indigenous and non-Indigenous infants had been breastfed for 6-12 months (19% and 22% respectively) and for 12 months or more (11% and 14% respectively). Around 13% of Indigenous children aged 0-3 years were being breastfed at the time of the survey.

The findings of the 2000-2002 WAACHS suggest that mothers of Indigenous children were more likely to initiate breastfeeding and breastfeed for longer than mothers in the general population, particularly those living in more isolated areas [31].

The Footprints in time – the longitudinal study of Aboriginal children collected data from eleven sites (rural, remote and urban) around Australia in 2008-2009 [32]. Data on breastfeeding from this study showed that 80% of Indigenous children in the study had been breastfed at some time during their early years, and 22% of Indigenous infants had been breastfed for at least 12 months. This study found that children living in more remote areas had been breastfed for a slightly longer period of time than those living in other areas.

Tobacco use

Tobacco use increases the risk of chronic disease, including CVD, certain cancers, and lung diseases, as well as a variety of other health conditions [33]. Tobacco use is also a risk factor for complications during pregnancy and is associated with preterm birth, LBW, and perinatal death. Environmental tobacco smoke (passive smoking) is of notable concern to health, with children particularly susceptible to problems that include middle ear infections, asthma, and SIDS.

In 2003, tobacco use was the leading cause of burden of disease and injury among Indigenous people, responsible for 12% of the total burden of disease [20]. Tobacco use accounted for one-in-five deaths in the Indigenous population.

According to the 2008 NATSISS, almost one-half (47%) of Indigenous people aged 15 years or older reported that they were current smokers [34]. Almost two-thirds (62%) of Indigenous current daily smokers reported trying to quit or reduce their smoking in the 12 months prior to interview [35]. More than one-third (34%) of Indigenous people reported that they had never smoked [34]. The proportion of Indigenous men who were current smokers (49%) was slightly higher than the proportion of Indigenous women who were current smokers (45%). A higher proportion of Indigenous people living in remote/very remote areas (53%) reported being current smokers than those living in inner/outer regional areas (47%) or major cities (42%) [36]. The proportions of current smoking were similar for Torres Strait Islanders (44%) and Aboriginal people (47%) [37]. After age-adjustment, the proportion of current smokers among Indigenous people was 2.3 times higher than the proportion among non-Indigenous people [16]. This ratio is similar to that reported for the 2010 National Drug Strategy Household survey (NDSHS) [38].

The overall proportion of Indigenous smokers in 2008 (47%) represents a slight decline from the levels in 1994 (52%) and 2002 (51%) [39][34]. Importantly, this overall decline has been accompanied by a decline in smoking intensity [40]. Heavy tobacco use, defined as smoking more than 20 cigarettes per day, declined among Indigenous people from 17% in 1994 to 9.4% in 2008; light tobacco use (smoking one to 10 cigarettes per day) increased from 17% to 22% over the same period; there was no significant difference in the smoking of 11 to 20 cigarettes per day.

High rates of smoking have been reported for Indigenous mothers [41]. In 2009, almost 50% of Indigenous mothers reported smoking during pregnancy; this level is 3.8 times that of their non-Indigenous counterparts.

In 2008, 16% of Indigenous children aged 0-3 years and 23% of Indigenous children 4-14 years lived with someone who usually smoked inside the house [42][43]. For Indigenous people aged 15 years and older the proportion was 26% [35].

Alcohol use

Alcohol-related harm, which includes chronic diseases, accidents and injury, and is not limited to the user, but extends to families and the broader community [44]. Consumption of alcohol in pregnancy can affect the unborn child leading to foetal alcohol spectrum disorder (FASD), an umbrella term that describes a range of conditions (comprising abnormalities such as growth retardation, characteristic facial features, and central nervous system anomalies (including intellectual impairment)) [45]. These disorders are incurable, but wholly preventable.

In 2003, the burden of disease attributable to alcohol among Indigenous people was more than twice that among other Australians (5.4% compared with 2.3%) [46][47]. Of 11 selected risk factors, alcohol was the fifth leading cause of the burden of disease among Indigenous people [46]. The highest levels of disease burden attributable to alcohol among Indigenous people were for injury (22%), mental disorders (16%), and cancers (6.3%).

Extent of alcohol use among Indigenous people

Surveys have shown consistently that Indigenous people are less likely to drink alcohol than non-Indigenous people, but those who do drink are more likely to consume it at harmful levels [8][38]:

• The 2008 NATSISS found that 35% of Indigenous people aged 15 years or older were abstainers; this level of abstinence is more than 2.5 times that of the Australian population aged 15 years or older reported in the 2007-2008 NHS (13%) [26][48].
• The 2004-2005 NATSIHS found that 24% of Indigenous people aged 18 years or older had never consumed alcohol or had not done so for more than 12 months; after age-adjustment, abstinence was 1.9 times more common among Indigenous people than among non-Indigenous people [18].
• The 2004-2005 NATSIHS found that 17% of Indigenous men and 11% of non-Indigenous men aged 18 years or older had never consumed alcohol or had not done so in the previous 12 months; the proportions for Indigenous and non-Indigenous females were 30% and 20%, respectively [18].
• The 2008 NATSISS found that 37% of Indigenous people aged 15 years and over reported binge drinking at risky/high risk levels (based on the largest quantity of alcohol used in a single day in the two weeks prior to interview), similar to the level reported in the 2002 NATSISS (35%) [35].
• The level of long-term risky/high risk drinking among Indigenous people in 2008 (17%) (based on daily consumption of alcohol and the frequency of consumption in the previous 12 months) was similar to that reported in 2002 (15%)[35]. Long-term risky/high risk drinking was reported by 16% of Indigenous young people aged 15-24 years in 2008, an increase from 11% in 2002, which was due to a significant rise in the level of risky/high risk drinking among young males (from 11% in 2002 to 19% in 2008) [49]. Comparable estimates are not available for non-Indigenous people, due to differences in the questions asked in the 2007-08 NHS.)

The most recent comparable Indigenous/non-Indigenous information for risky/high risk alcohol consumption is available from the 2004-2005 NHS and the 2004-2005 NATSIHS, which found that 55% of Indigenous people were binge drinking (drinking at short-term risky/high risk levels based on the amount of drinks consumed in any one day) and 17% were drinking at long-term risky/high risk levels (based on the amount of drinks consumed per day and the total for the week)[18]. After age-adjustment, Indigenous people were twice as likely as non-Indigenous people to have consumed alcohol at short-term risky/high risk levels at least once a week in the previous 12 months. This is likely to be an underestimate of the ratio of short-term risky/high risk drinkers, however, as it does not take into account the higher level of abstinence in the Indigenous population. Overall, Indigenous and non-Indigenous people were equally as likely to drink at long-term risky/high risk levels (15% and 14% respectively). But, when the greater level of abstinence in the Indigenous population is accounted for, Indigenous people were around 1.5 times as likely as non-Indigenous people to drink at long-term risky/high risk levels.

Analysis of information collected by the 2008 NATSISS on alcohol consumption during pregnancy found that 80% of mothers of Indigenous children aged 0-3 years did not drink during pregnancy, 16% drank less alcohol than usual, and 3.3% drank the same or more alcohol during pregnancy [18]. The proportion of mothers who drank the same or more alcohol during pregnancy was greatest in Tas/ACT (6.0%), followed by Vic (5.4%), and WA (5.0%).

Hospitalisation

For Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in the two-year period July 2008 to June 2010, 2% of all hospitalisations were for a principal diagnosis related to alcohol use (excluding dialysis) [33]. After age-adjustment, Indigenous males were hospitalised at five times and Indigenous females at four times the rates of their non-Indigenous counterparts. Almost nine-tenths (86%) of hospitalisations related to alcohol use were for ICD ‘Mental and behavioural disorders due to alcohol use’, including acute intoxication, dependence syndrome, and withdrawal state. The hospitalisation rate for alcoholic liver disease among Indigenous people was six times the rate for non-Indigenous people.

Hospitalisation rates with a principal diagnosis related to alcohol use for Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in 2008-10 varied by level of remoteness. Rates were highest for Indigenous people living in remote areas (14 per 1,000) and lowest for those living in very remote areas (7 per 1,000) [33].

Mortality

There were 382 Indigenous deaths related to alcohol use in NSW, Qld, WA, SA and the NT in the five-year period 2006-2010 [33]. After age-adjustment, death rates for Indigenous males and females were five and eight times higher respectively than those for their non-counterparts. Almost seven-tenths (68%; 261 deaths) of deaths were attributed to alcoholic liver disease, with a death rate six times higher for Indigenous people than for non-Indigenous people. The death rate for alcohol-related deaths attributed to mental and behavioural disorders was seven times higher and the rate for alcohol-related deaths attributed to alcohol poisoning five times higher than those of non-Indigenous people.

Illicit drug use

Illicit drug use describes the use of those drugs that are illegal (e.g. cannabis, heroin, ecstasy, and cocaine), the use of volatile substances (e.g. petrol, glue, and solvents), and the non-medical use of prescribed drugs (e.g. pain killers (analgesics)) [19]. Illicit drug use is a risk factor for ill-health, including conditions such as HIV/AIDS, hepatitis, poisoning and self-inflicted injury, and can cause death.

Illicit drug use accounted for 2.0% of the overall burden of disease in Australia in 2003; it accounted for 8.0% of the mental health burden of disease, and 3.6% of the injury burden of disease [47]. For the same year, illicit drug use was responsible for 3.4% of the burden of disease among the Indigenous population; the highest level of disease burden attributable to illicit drugs was for mental health (13%) and injury (3.6%) [46].

Extent of illicit drug use among Indigenous people

Almost one-quarter (23%) of Indigenous people aged 15 years or over reported in the 2008 NATSISS that they had used an illicit substance in the 12 months prior to interview [18]. This level was 1.6 times that reported in the 2010 NDSHS for the non-Indigenous population aged 14 years or over (14%) [38], but less than that reported by Indigenous people aged 18 years or over (28%) in the 2004-2005 NATSIHS [8].

According to the 2008 NATSISS, the illicit substances used most commonly by Indigenous Australians aged 15 years or over were cannabis (17% used in the previous 12 months and 36% ever used), pain killers (4.5% and 7.4%), amphetamines (4.0% and 11%), ecstasy (3.3% and 7.7%), and petrol and other inhalants (0.4% and 5.8%) [18]. The three illicit drugs most commonly used in the previous 12 months were the same in 2008 as those reported in the 2004-2005 NATSIHS, but reported use had declined: cannabis (from 23% in 2004-2005 to 17% in 2008), amphetamines (from 7% to 4.0%), and pain killers (from 6% to 4.5%) [18][8].

Use of illicit drugs in the previous 12 months was reported more by Indigenous people aged 15 years or over living in non-remote areas than by those living in remote areas (24% compared with 17%) in the 2008 NATSISS [18]. Similarly, the proportion of Indigenous people who had ever used illicit substances was higher for those living in non-remote areas (47%) than in remote areas (31%). There were higher proportions of use for all types of drug among Indigenous people living in non-remote areas compared with those living in remote areas, both for 'use in the last 12 months' and 'for having ever used an illicit substance'.

According to the 2008 NATSISS, illicit drug use in the previous 12 months was highest among Indigenous people aged 18-24 years (32%), 25-34 years (26%), and 35-44 years (20%) [18]. The proportions of people who had used drugs in the previous 12 months were at least 1.5 times higher for males than for females within each age-group except the 15-17 years age-group where proportions were similar (16% and 14% respectively).

In non-remote areas, around twice as many males as females had used cannabis (23% compared with 12%), amphetamines (5.4% compared with 2.7%), and ecstasy (4.3% compared with 2.3%) in the previous 12 months [18]. Between 2002 and 2008, use of cannabis decreased slightly from 19% to 17% (due to a decrease in use by females from 16% to 12%); use of amphetamines in the previous 12 months decreased slightly from 4.7% to 4.0% (due to a decrease in use by females from 4.5% to 2.7%, despite a slight rise in use by males from 4.9% to 5.4%); and use of ecstasy in the previous 12 months increased from 1.9% to 3.3% (due to a doubling in use by males from 2.2% to 4.3% and an increase in use by females from 1.6% to 2.3%).

The 2008 NATSISS found that among Indigenous people aged 15 years or over, a higher proportion of 'recent illicit substance users' were current daily smokers (68%) and risky/high-risk drinkers (8.1%) compared with those who had 'never used an illicit substance' (35% and 3.2% respectively) [18]. Similarly, higher proportions of Indigenous people who had experienced stressors in the last 12 months were more likely to be 'recent substance users' than 'never used illicit substances'; of those who had experienced violence, around 12% were 'recent substance users' compared with 4.6% who 'never used illicit substances'.

Hospitalisation

Between July 2008 and June 2010, there were 4,537 hospital separations related to substance use among Indigenous people in NSW, Vic, Qld, WA, SA and the NT, accounting for around 1% of all Indigenous hospitalisations (excluding those for dialysis) [33]. Detailed information is not available for 2008-10, but in the two-year period July 2006 to June 2008, the leading cause of substance use-related hospitalisations was ICD 'Mental/behavioural disorders related to cannabinoids', which was responsible for 15% of drug related hospitalisations [18]. Poisoning resulting from 'use of antiepileptic, sedative-hypnotic and anti-Parkinson's drugs', and 'psychotropic drugs (including antidepressants)' were the second equal most common cause of drug-related hospitalisation, each accounting for 14% of all these hospitalisations.

Hospitalisations related to substance use among Indigenous people occurred at more than twice the rate of the non-Indigenous population in 2008-10 and 2006-08 [18][33]. Detailed information is not available for 2008-10, but in 2006-08 hospitalisations of Indigenous people for 'mental/behavioural disorders related to substance use' occurred at almost five times the rate of the non-Indigenous population from the 'use of cannabinoids', and at around three times the rate from the 'use of multiple drug and psychoactive substances', and the 'use of other stimulants'. Hospitalisations of Indigenous people from 'use of opioids' occurred at around twice the rate of non-Indigenous people, and at 39 times the rate from the 'use of volatile solvents'.

In relation to remoteness of residence, Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in the period June 2007 to June 2009 were hospitalised with a principal diagnosis related to drug use at 2.9 times the rate of non-Indigenous people in major cities, 2.6 times the rate in inner regional areas, 2.1 times the rate in outer regional areas, 2.4 times the rate in remote areas, and 1.3 times the rate in very remote areas [18].

According to the 2008 NATSISS, 95% of mothers of Indigenous children aged 0-3 years did not use illicit drugs during pregnancy [18]. Around 4% of mothers of Indigenous children in NSW, Qld, Tas/ACT and the NT used illicit drugs during pregnancy. The proportion of mothers of Indigenous children who did use drugs during pregnancy was highest in Vic (9.3%), followed by WA (8.5%), and SA (6.1%).

Mortality

The rate of drug-induced deaths was around 1.5 times higher for Indigenous people living in NSW, Qld, WA, SA and the NT in 2005-2009 than for their non-Indigenous counterparts (7.8 compared with 5.3 per 100,000) (Table 28) [50]. Rates were higher for Indigenous people than for non-Indigenous people in NSW, WA and SA, but similar in Qld. Rates for Indigenous males (9.5 per 100,000) were higher than those for Indigenous females (6.1 per 100,000).

Sixty-three of the deaths of Indigenous people living in NSW, Qld, WA, SA and the NT in 2003-2007 were attributed to drug use [51]. More than one-half (52%) of these deaths were due to accidental poisoning from narcotics, and 17% from accidental poisoning from organic solvents. In comparison, there were 993 drug-related deaths among their non-Indigenous counterparts, 53% of which were due to accidental poisoning from narcotics and 28% from accidental poisoning from antidepressants.

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Endnotes

26. Central obesity (a high waist circumference) indicates an accumulation of fat around body organs such as the heart, liver, kidney and pancreas. Individuals with central obesity are at high risk of developing chronic diseases such as heart disease and diabetes.

27. Due to the change in reporting practices from the 6 years age-group to the 5 years age-group, figures for should be viewed with some caution.