3.03 Health promotion
Why is it important?
Aboriginal and Torres Strait Islander peoples currently experience higher levels of morbidity and mortality from potentially avoidable conditions than other Australians. In 2008–12, 75% of Indigenous deaths before the age of 75 years were potentially avoidable, with half potentially preventable through primary intervention (prevention). Compared with non-Indigenous Australians, mortality rates for avoidable and preventable deaths were 3 times as high (see measure 1.24). Exposures to risk through behaviours such as smoking were also higher (see Health Behaviour measures).
Health promotion is the process of enabling people to increase control over their health and its determinants, and thereby improve their health (WHO 2005). Health promotion activities are designed to improve or protect health within social, physical, economic and political contexts. Health promotion includes public policy interventions (e.g. packaging of cigarettes, seat belt laws), information to support healthy lifestyles (e.g. smoking, alcohol and drug use, physical activity, diet), social marketing (e.g. sunscreen, safe sex) and mass media campaigns (e.g. drink-driving, road safety). Health promotion also includes empowering individuals, strengthening community capacity and addressing determinants of health.
Currently there are limited methods for measuring the nature, level, and reach of health promotion programmes and activities.
Estimating expenditure on health promotion for Indigenous Australians is difficult as it is often embedded within other funding sources and programmes (e.g. funding for GPs, primary health care and mainstream health promotion activities). In 2010–11, state and territory government expenditure on public health for selected health promotion activities was estimated to be around $41 for each Indigenous Australian and $15 for each non-Indigenous Australian. In addition, expenditure for the prevention of hazardous and harmful drug use was estimated to be $39 per Indigenous Australian and $6.80 per non-Indigenous Australian. Australian Government expenditure on public health services was $106 per person for Indigenous Australians; however, this includes a broad set of activities from which health promotion could not be separated out.
In the 2012–13 Health Survey, 46% of Indigenous Australians aged 15 years and over who had consulted a doctor in the last 12 months reported discussing lifestyle issues. Issues discussed included reaching a healthy weight (50%), improving diet (44%), reducing or quitting smoking (43%), increasing physical activity (30%), drinking alcohol in moderation (16%), safe sexual practices (12%) and family planning (10%). Indigenous Australians in the NT and in remote areas were less likely to have accessed a doctor in the last 12 months and also less likely to have discussed lifestyle issues than those living in other areas. Females were more likely to have discussed lifestyle issues with a doctor than males (50% and 41% respectively), while discussions on drinking alcohol in moderation were more common for males (26%) than for females (8%).
Based on GP survey data for the period April 2008 to March 2013, selected clinical treatments related to health promotion accounted for 31% of all clinical treatments and therapeutic procedures provided by GPs to Indigenous Australians. This included general 'advice/education', which accounted for an estimated 11% of all clinical and therapeutic treatments, followed by 'counselling/advice related to nutrition and weight' (6%) and 'advice/education/treatment' (5%). 'Counselling/advice related to smoking' was provided in 3% of all clinical and therapeutic treatments provided to Indigenous Australians. After adjusting for differences in the age structure of the two populations, the rate at which GPs provided counselling, advice and education about smoking was 2.4 times higher, and about alcohol was 2 times higher, at encounters with Indigenous patients than those with other Australian patients. Overall, the rates of GP treatments for selected clinical health promotion were similar between Indigenous and other Australian patients (1.1 times).
In 2012–13, nearly all (99.5%) Aboriginal and Torres Strait Islander primary health care services offered health promotion/education programmes, 88% maternal and child health care, 86% antenatal care, 85% child immunisation, 79% healthy lifestyle programmes, 78% adult immunisation promotion, 69% sexual health promotion and 65% substance-use/drug and alcohol programmes. Aboriginal and Torres Strait Islander primary health care services offered a range of health promotion activities including antenatal groups (78%), physical activity/healthy weight programme activities (59%), and living skills groups such as dietary and nutrition (55%). Health promotion activities are also a key feature of programmes run by Aboriginal and Torres Strait Islander substance-use-specific services, with 65% running men's groups and 62% women's groups, living skills groups and physical activity/healthy weight programmes.
As of June 2011, 88% of organisations funded through the former Healthy for Life programme provided brief interventions for smoking and 86% for alcohol, while 93% had programmes for nutrition, and 92% for physical activity and emotional wellbeing.
Evidence on the effectiveness of health promotion is mixed across a range of settings and disease types with some approaches more effective than others for different population groups (Jackson et al. 2005; Liu et al. 2012). A recent literature review found that while Indigenous health promotion tools were widely available, only 15% had been evaluated, and only half of these evaluations were considered comprehensive (McCalman et al. 2014). While studies can model the continued effectiveness of health promotion interventions, there is limited evidence on long-term behavioural change (Merkur et al. 2013). A small study of urban Indigenous young people found no change in behaviours but some change in knowledge and attitudes following health promotion interventions in school (Malseed et al. 2014). At the heart of health promotion is effective communication that takes into account language and world view to support people to live healthy lives (Vass et al. 2011).
Factors in designing effective health promotion interventions for Indigenous communities include: involving local Indigenous people in design and implementation of programmes; acknowledging different drivers that motivate individuals; building effective partnerships between community members and the organisations involved; cultural understanding and mechanisms for effective feedback to individuals and families; developing trusting relationships, community ownership and support for interventions (Black 2007). Family-centred approaches across the life course have also been recommended in the prevention of chronic disease (Griew et al. 2007).
Aboriginal and Torres Strait Islander peoples are a major target audience of the National Tobacco Campaign (NTC), and specific advertising (Break the Chain) has been developed and placed in a range of Indigenous and mainstream media channels. Evaluation of this campaign found that it resonated well with the target audience, with strong levels of recall of messages about smoking affecting others (Department of Health & ORIMA 2013a).
In addition the Quit for You, Quit for Two component of the NTC targeting pregnant women and their partners included materials depicting Indigenous women. Evaluation research found that these materials effectively communicated their key messages to Aboriginal and Torres Strait Islander audiences. The campaign successfully promoted positive attitudes and intentions towards not smoking (Department of Health & ORIMA 2013b).
The Regional Tackling Smoking and Healthy Lifestyle teams deployed under the Tackling Indigenous Smoking programme, a component of the Australian Government's Indigenous Australians' Health Programme aim to actively promote quitting, smoke-free environments and encourage healthier lifestyle choices through facilitating culturally secure community education, health promotion and social marketing activities. The Government is committed to ensuring that programmes to address high rates of smoking are based on the most up-to-date evidence, and are delivered in a way that is appropriate, effective and efficient. As a result, the Government is undertaking an independent review of the Tackling Indigenous Smoking programme in 2014–15. The review will establish a new evidence base and provide recommendations on the best way to reduce Aboriginal and Torres Strait Islander smoking rates.
There was a decline in Indigenous smoking rates between 2002 and 2012–13 (see measure 2.15) following a period of stable Indigenous smoking rates. This decline suggests that the targeted tobacco control measures introduced over this period may be starting to support healthy lifestyle choices by Indigenous Australians.
The Care for Kids' Ears initiative aims to increase awareness of ear disease and hearing loss in Aboriginal and Torres Strait Islander communities. It provides information resources for use by health professionals, and in communities and schools. The smartphone apps and kiosks across 32 Aboriginal and Torres Strait Islander primary health care services provide a resource across 22 Indigenous languages on key ear health information (available from the campaign website). Evaluation research demonstrates a strong level of awareness, with four in ten mothers able to identify the campaign, and those exposed to the messages having had an increased knowledge of key symptoms and preventive behaviours (DoHA 2013).
Communications activities to support the HPV Vaccination Program and the Influenza Vaccination Program include specific components for Aboriginal and Torres Strait Islander communities. These components include distribution of tailored resources to schools and stakeholders, as well as targeted public relations activities and social media engagement.
The Strong Spirit Strong Future Healthy Women and Pregnancies project promotes the uniqueness of Aboriginal culture as a central strength in guiding efforts to manage and reduce alcohol and other drug-related harm in Aboriginal communities in WA. Culturally secure resources, workforce development initiatives and community awareness campaigns are key components of the project.
Health services juggle resources for health promotion against the immediate need of patients for treatment and disease management (Baum et al. 2013)
Figure 3.03-1 shows In the 2012–13 Health Survey, 46% of Indigenous Australians aged 15 years and over who had consulted a doctor in the last 12 months reported discussing lifestyle issues. Issues discussed included reaching a healthy weight (50%), improving diet (44%), reducing or quitting smoking (43%), increasing physical activity (30%), drinking alcohol in moderation (16%), safe sexual practices (12%) and family planning (10%)
Source: ABS and AIHW analysis of AATSIHS 2012–13
Figure 3.03-2 shows that Indigenous Australians living in remote areas were less likely to have accessed a doctor in the last 12 months and also less likely to have discussed lifestyle issues than those living in other areas.
Source: ABS and AIHW analysis of AATSIHS 2012–13