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Social Determinants

The origins of health behaviours are located in a complex range of environmental socio-economic, family and community factors. 'Inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces' (Commission on Social Determinants of Health 2008). Studies have found that between one-third and one-half of the health gap between Aboriginal and Torres Strait Islander peoples and non‑Indigenous Australians is associated with differences in socio-economic status such as education, employment and income (Booth et al. 2005; DSI Consulting 2009).

In 2012–13, an estimated 43% of Indigenous adults had incomes in the bottom 20% of equivalised gross weekly household Australian incomes. Those Indigenous Australians in the bottom income quintile were less likely to have completed Year 12 (15%) than those in the top two income quintiles (45%). Those in the top income quintiles were more likely than those in the bottom income group to be employed (91% compared with 15%) and less likely to smoke (67% compared with 44%). Those in the lowest income group were more likely than those in the highest groups to be unable to raise $2,000 in a week for something important (77% compared with 17%), have days without money for basic living expenses (55% compared with 17%) and to live in an overcrowded household (23% compared with 3%).

A recent study in the NT of life expectancy at birth for Indigenous and non‑Indigenous Australians using data from the period 1986 to 2005 found that socio-economic disadvantage was the leading risk factor accounting for one-third to one-half of the gap in life expectancy between Indigenous and non‑Indigenous Australians (Zhao et al. 2013a). The AIHW analysed data from the 2004–05 Health Survey and found that selected social determinants such as education, employment status, overcrowding and household income together with risk factors explained up to 46% of the health gap between Indigenous and non‑Indigenous Australians (AIHW 2014d).

Figure 8 - Proportion of the health gap explained by social determinants and behavioural risk factors
proportion of the health gap

Figure 8 shows the proportion of the health gap explained by social determinants and behavioural risk factors. The AIHW analysed data from the 2004-05 Health Survey and found that selected social determinants such as education, employment status, overcrowding and household income explained up to 46% of the health gap between Indigenous and non-Indigenous Australians.

Source: Australia's Health 2014 (AIHW 2014d)

Connectedness to family and community, land and sea, culture and identity have been identified as integral to 'health' from an Aboriginal perspective (NAHASWG 1989). Analysis of 2008 Social Survey data found a clear association between cultural attachment and positive socio-economic outcomes and wellbeing (Dockery 2011).

Social determinants and health risk behaviours

Evidence from general population studies shows that modifiable risk factors act, in various combinations, to increase the risks for adverse health outcomes such as ischaemic heart disease, stroke, diabetes and some cancers. Health behaviours also affect biological risk factors such as high body mass, high cholesterol levels and hypertension. Other health behaviours such as infant breastfeeding, adequate diet and physical exercise have a protective impact on health.

Figure 9 shows that a higher proportion of Aboriginal and Torres Strait Islander peoples who complete Year 12 are not daily smokers (72%) compared with those whose highest year of schooling was Year 10 or below (49%). Similarly, those who were employed were more likely not to smoke (63%) than those who were unemployed (40%) (see Figure 10).

Figure 9 Relationship between highest year of school completed and health risk factors, Indigenous adults, 2012–13
highest year of school completed and health risk factors

Figure 9 shows the proportion of risk factors among Aboriginal and Torres Strait Islander peoples whose highest year of school completed is Year 9 or below, and those whose highest year of school completed is Year 12. Data is reported for the following risk factors: Not current smoker; not overweight/obese; excellent/good health status and eats fruit daily. Figure 9 shows that a higher proportion of Aboriginal and Torres Strait Islander peoples who complete Year 12 do not smoke (72%) compared to those whose highest year of schooling was Year 10 or below (49%).

Source: ABS and AIHW analysis of 2012–13 AATSIHS

Figure 10 Relationship between employment and risk factors, Indigenous adults, 2012–13
relationship between employment and risk factors

Figure 10 shows the relationship between employment and risk factors for Indigenous adults in 2012–13. Data is reported for the following risk factors: Not current smoker; not overweight/obese; excellent/good health status and eats fruit daily. Figure 10 shows that a higher proportion of Aboriginal and Torres Strait Islander peoples who were employed were more likely not to smoke (63%) than those who were unemployed (40%).

Source: ABS and AIHW analysis of 2012–13 AATSIHS

In 2012–13, 38% of Indigenous adults in non‑remote areas reported levels of physical activity sufficient to meet the recommended guidelines. Indigenous adults who had completed Year 12 were 1.5 times as likely to have done sufficient physical activity compared with those who left school at Year 9 or below (44% compared with 29%). In 2012–13, 26% of Indigenous Australians aged 15 years and over abstained from alcohol in the last 12 months.

Social determinants and health outcomes

A multivariate analysis of the 2004–05 Health Survey found that selected social determinants and risk factors combined explained up to 46% of the gap in health outcomes between Indigenous and non‑Indigenous Australians. Key factors were household income, education and employment (AIHW 2014d). The relationships are complex and mediated by interactions with other factors. A study of the NT population found a relationship between mortality/morbidity and socio-economic quintile (Zhao et al. 2013b).

Figure 11 - Mortality rate ratios by socioeconomic quintiles, NT
mortality rate ratios by socioeconomic quintiles

Figure 1 shows the results of a study of the NT population which found a relationship between mortality/morbidity and socioeconomic quintile.

Source: Zhao et al. 2013

Relationships between individual social determinants and health outcomes are evident. Further multivariate analysis will be undertaken once the detailed results of the 2012–13 Health Survey have been released to researchers. In 2012–13, rates of high blood pressure (measured and/or self-reported) were higher for Indigenous Australians who completed school before Year 10 (38%) compared with those who completed Year 12 (18%). Rates were also higher for those living in the most socio-economically disadvantaged areas (28%) compared with those in the most advantaged areas (22%). Rates of diabetes were also higher for those in the most socio-economically disadvantaged areas (16%) compared with advantaged areas (9%) and also for those who finished school in Year 9 or below (23%) compared with Year 12 (7%). High/very high psychological distress levels were also associated with lower income, lower educational attainment and unemployment.

In 2012–13, 46% of Indigenous Australians in the highest household income quintiles reported very good/excellent health status, compared with 32% of those in the lowest quintile. Approximately 49% of those who had completed Year 12 reported good/excellent health status, compared with 29% of those who had completed Year 9 or below. Those who were employed were more likely to report very good/excellent health (46%) than those unemployed (40%) (see measure 1.17).

Aboriginal and Torres Strait Islander peoples in the highest income quintiles were less likely than those in the lowest income quintile to visit casualty /outpatients in the last 2 weeks.

Figure 12 Relationship between high blood pressure and social factors, Indigenous Australians, 2012–13
relationship between high blood pressure and social factors

Figure 12 shows Relationship between high blood pressure and social factors for Indigenous Australians in 2012–13. In 2012–13, rates of measured high blood pressure were higher for Indigenous Australians who completed school before Year 10 (38%) compared to those who completed Year 12 (18%). Rates were also higher for those living in the most socioeconomically disadvantaged areas (28%) compared to those in the most advantaged areas (22%).

Source: ABS and AIHW analysis of 2012–13 AATSIHS

Figure 13 - Relationship between excellent/very good self-assessed health and social factors, Indigenous Australians, 2012–13
excellent/very good self-assessed health and social factors

Figure 13 shows the proportion of selected social determinants of health among Aboriginal and Torres Strait Islander peoples who self-assessed their health status as good/excellent. In 2012–13, 53% of Indigenous Australians in the most relatively advantaged socioeconomic quintile reported very good/excellent health status, compared with 36% of those in the most relatively disadvantaged quintile. Approximately 49% of those who had completed Year 12 reported good/excellent health status, compared with 29% of those who had completed Year 9 or below. Those who were employed were more likely to report very good/excellent health (46%) than those unemployed (40%).

Source: ABS and AIHW analysis of 2012–13 AATSIHS

Figure 14 Relationship between high blood pressure and selected health outcomes, Indigenous Australians, 2012–13
high blood pressure and selected health outcomes

Figure 14 shows the proportion of risk factors among Aboriginal and Torres Strait Islander peoples with high blood pressure in 2012–13. Data is reported for the following health outcomes: obesity; self assessed health; diabetes and kidney disease. In 2012–13, 37% of those who were obese had high blood pressure compared with 18% of those not obese; 51% of those with diabetes had high blood pressure compared to 23% of those without and 57% of those with kidney disease had high blood pressure compared with 26% of those without.

Source: ABS and AIHW analysis of 2012–13 AATSIHS

Figure 15 Relationship between income and determinants of health, Indigenous adults, 2012–13
relationship between income and determinants of health

Figure 15 shows the relationship between income and determinants of health for Indigenous adults in 2012–13. Data is reported for the following factors: Not current smoker; completed Year 12; Has a non-school qualitifaction and home owner. In 2012–13, an estimated 43% of Indigenous adults had incomes in the bottom 20% of equivalised gross weekly household Australian incomes. Those Indigenous Australians in the bottom income quintile were less likely to have completed Year 12 (15%) than those in the top two income quintiles (45%). Those in the top income quintiles were more likely than those in the bottom income group to be employed (91% compared to 15%) and less likely to smoke (67% compared to 44%).

Source: ABS and AIHW analysis of 2012–13 AATSIHS

Health as a determinant of social outcomes

A wide range of literature has shown evidence of the influence of health on educational participation and attainment. In the US, children with developmental disabilities have been shown to have twice the number of school days lost as other children, while childhood disability is estimated to cause 24 million days lost from school each year (Boyle et al. 1994; Newacheck et al. 1998). In Australia, analysis of health surveys and social surveys have found an association between health and education. In 2012–13, 20% of Indigenous children aged 5–14 years had days away from school in the last 2 weeks due to illness/injury. Analysis by the AIHW using 2004–05 Health Survey and 2008 Social Survey data has found that the odds of an Indigenous Australian child aged 5–17 years with poor self-assessed health status currently studying were one-fifth that of an Indigenous child with excellent self-assessed health status (odds ratio of 0.225) (see HPF Detailed Analysis). Analysis of the Longitudinal Study of Indigenous children has found that 83% of Indigenous children with better health attended school at least 80% of the time compared with 65% of the time for children with poorer health (DSS 2014).

Illness, injury and disability are the main reason people leave the workforce in Australia, aside from reaching retirement (ABS 2013i). Results from analysis of the HILDA survey show that the probability of being employed for men with poor self-reported health was lower than those with good health (Cai et al. 2007). Analysis by the Australian Bureau of Statistics has found that a range of chronic illnesses, such as arthritis, asthma, cancer, diabetes and heart disease, negatively impact on labour force participation (ABS 2014k). Analysis of the 2004–05 Health Survey found significant associations between most measures of health (self-assessed health, having circulatory conditions, diabetes, arthritis, disability) and employment outcomes for Indigenous Australians. For example, Indigenous Australians aged 15–64 who reported poor or fair self-assessed health were less likely to be working full-time than those not in the labour force (odds ratios of 0.110 and 0.305, respectively). Similarly, people with disability were less likely to be working full-time (odds ratio of 0.154) (see HPF Detailed Analysis for details).

After adjusting for education levels, geographic dispersion and self-assessed health status, the gap in labour force participation between Aboriginal and Torres Strait Islander peoples and non‑Indigenous Australians drops by two-thirds (ABS 2014k)—see figure 16.

Figure 16 - Standardised labour force participation rates by Indigenous status, persons aged 15-64 years, 2012–13
standardised labour force participation rates

Figure 16 shows standardised labour force participation rates by Indigenous status for persons aged 15-64 years in 2012–13. After adjusting for education levels, geographic dispersion and self-assessed health status, the gap in labour force participation between Aboriginal and Torres Strait Islander peoples and non‑Indigenous Australians drops by two-thirds.

Source: ABS (2014k)