The socioeconomic pattern of health and developmental outcomes among Aboriginal and Torres Strait Islander children

The pervasive health and social disadvantage faced by Aboriginal and Torres Strait Islander peoples is an acknowledged part of Australian society. The contemporary data reveal striking inequalities between Indigenous and non-Indigenous Australians in most measurable aspects of wellbeing across the life cycle. This reflects a postcolonial history of marginalisation and exclusion from mainstream society, dispossession of traditional lands, forced separation from family and kinship networks, and racism. Despite an increased awareness and disapproval of these inequalities in health, the inequalities persist.The lack of progress in the face of public disapproval and progressive government support underscores the fact that we still do not adequately understand the fundamental causes of Indigenous ill health and disease. A small body of research in Australia has highlighted that socioeconomic status (SES) accounts for a portion of the gap in health but this does not imply that they account for health differences within Indigenous population groups. A robust international literature has consistently shown that socioeconomic factors influence population health. These factors reflect the way in which society is ordered according to wealth, prestige, power, social standing or one’s control over economic resources, and their pattern of association with health has almost always depicted better health for those who are better off— that is, the health of population groups normally follows a gradient pattern. Despite the ubiquity of this observation in the empirical literature, there is uncertainty as to whether it applies to Aboriginal and Torres Strait Islander populations in Australia.Accordingly, this thesis has aimed to assess the pattern of socioeconomic disparities in the health and development of Indigenous populations in Australia, with a specific focus on children. The three key objectives were to: • Describe the developmental status of Indigenous children and the mechanisms that influence this status; • Determine the pattern of association between socioeconomic factors and physical and mental health outcomes; and • Reveal the significant differences (and similarities) in the socioeconomic pattern of child health between Indigenous and non-Indigenous populations, and articulate these in terms of their direction, shape and magnitude.The objectives of the study were primarily assessed using a quantitative analytic framework applied to four existing population-representative datasets: the 2008 National Aboriginal and Torres Strait Islander Social Survey, the 2000–2002 Western Australian Aboriginal Child Health Survey, the 2004–05 National Aboriginal and Torres Strait Islander Health Survey and 2004–05 National Health Survey. Simple univariate and cross-tabulation data were used to describe population characteristics, while the relationships between socioeconomic indicators and health outcomes were assessed using a range of regression techniques. Multilevel models are an important feature of this study, and have enabled a more accurate estimation of the effects of individual and area-level measures of SES on health. Generalised Additive Models were used to account for the possible non-linear nature of associations between continuous SES variables and physical health outcomes, with results presented as non-parametric spline curves. The mechanisms linking SES and mental health were explored using a stepwise approach to the regression analysis. All data in all chapters were weighted to reflect population benchmarks.The findings highlighted that there were significant socioeconomic disparities in the health of Indigenous children in Australia, although the direction, shape and magnitude varied, by both socioeconomic measure and health outcome. While the socioeconomic patterns of Indigenous child health are not universal, they are more consistent for mental than physical health. In addition, the thesis has shown that both conventional and alternative notions of SES can influence health patterns. The largest disparities in child physical health were observed for area-level SES indicators, while housing characteristics and area-level SES both had a strong direct effect on child mental health.The thesis has demonstrated that the patterns of socioeconomic disparities in child health differ markedly in Indigenous and non-Indigenous populations—at least in non-remote settings. It was not uncommon for the magnitude of disparity to be larger in the Indigenous population. These findings lend support to the notion that socioeconomic factors have a differential impact on the health of Indigenous and non-Indigenous populations. The implication of this for policy is that a single approach to stimulating socioeconomic conditions will not have equal benefits to child health outcomes in Indigenous and non-Indigenous populations. While the evidence here underscores the validity of the well-worn edict that “one size does not fit all” in Indigenous health policy, it also reinforces the need to examine health disparities within and across Indigenous and other population groups in order to better inform policy and practiceCollectively, the results have provided clear evidence that socioeconomic factors matter to both the physical and mental health of Aboriginal and Torres Strait Islander children. The diversity of findings implies that SES factors are one facet of the unique and complex set of factors that influence Aboriginal child health and wellbeing.This thesis has made several original contributions to the literature on social inequalities in Indigenous health in Australia and the broader field of social determinants of health. It is one of the few studies internationally to explicitly look at the socioeconomic patterning of health in an Indigenous population, and the first to examine these patterns among Indigenous children using population-representative data. In doing so, the study has begun to bridge the knowledge gap on social inequalities in Aboriginal health in Australia, and will facilitate a better grasp of the complex underlying mechanisms that determine Aboriginal health.For policy, this knowledge can lead to more effective government decision-making in terms of targeting social determinants of health that are of particular significance for Aboriginal populations. It is hoped that the findings of the thesis can provide directions for future research and insights to policy that will, ultimately, increase the pace of change toward health equity in Australia

Effective strategies to strengthen the mental health and wellbeing of Aboriginal and Torres Strait Islander people

Introduction: The purpose of this paper is to draw on Aboriginal and Torres Strait Islander (Indigenous) perspectives, theoretical understandings, and available evidence to answer questions about what is required to effectively address Indigenous people’s mental health and social and emotional wellbeing. Social and emotional wellbeing is a multifaceted concept. Although the term is often used to describe issues of ‘mental health’ and ‘mental illness’, it has a broader scope in that Indigenous culture takes a holistic view of health. It recognises the importance of connection to land, culture, spirituality, ancestry, family and community, how these connections have been shaped across generations, and the processes by which they affect individual wellbeing. It is a whole-of-life view, and it includes the interdependent relationships between families, communities, land, sea and spirit and the cyclical concept of life–death–life. Importantly, these concepts and understandings of maintaining and restoring health and social and emotional wellbeing differ markedly to those in many non-Indigenous-specific (or mainstream) programs that tend to emphasise an individual’s behavioural and emotional strengths and ability to adapt and cope with the challenges of life. This paper explores the central question of ‘what are culturally appropriate mental health and social and emotional wellbeing programs and services for Indigenous people, and how are these best delivered?’. It identifies Indigenous perspectives of what is required for service provision and program delivery that align with Indigenous beliefs, values, needs and priorities. It explores the evidence and consensus around the principles of best practice in Indigenous mental health programs and services. It discusses these principles of best practice with examples of programs and research that show how these values and perspectives can be achieved in program design and delivery. This paper seeks to provide an evidence-based, theoretically coherent discussion of the factors that influence the effective development, implementation and outcomes of initiatives to address Indigenous mental health and wellbeing issues. It seeks to assess whether the current investment in Indigenous people’s mental health is aligned with available evidence on what works. To this end, the paper reviews Australian literature and government health, mental health and social and emotional wellbeing policies and programs. The scope of programs and their criteria for inclusion in this paper are informed by the Key Result Area 4, Social and Emotional Wellbeing objectives, within the National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003–13: Australian Government Implementation Plan 2007–2013. This paper acknowledges the holistic nature of health, mental health and wellbeing, and the effects of Australia’s colonial history and legacy on the contemporary state of Indigenous social and emotional wellbeing. It recognises that there is a complex relationship between social and emotional wellbeing, harmful substance misuse, suicide, and a range of social and economic factors. Although this paper encompasses the broad priorities identified within the key Indigenous mental health policies and frameworks, it does not provide a detailed discussion of programs and resources that, although relevant here, are covered in a number of existing Closing the Gap Clearinghouse resource sheets and issues papers (see Appendix 1). These interweavings and overlaps are not surprising given the complexity and interconnectedness of the issues and determinants that are being addressed to strengthen Indigenous mental health and wellbeing

Socioeconomic disparities in the mental health of Indigenous children in Western Australia

Background: The burden of mental health problems among Aboriginal and Torres Strait Islander children is a major public health problem in Australia. While socioeconomic factors are implicated as important determinants of mental health problems in mainstream populations, their bearing on the mental health of Indigenous Australians remains largely uncharted across all age groups. Methods: We examined the relationship between the risk of clinically significant emotional or behavioural difficulties (CSEBD) and a range of socioeconomic measures for 3993 Indigenous children aged 4–17 years in Western Australia, using a representative survey conducted in 2000–02. Analysis was conducted using multivariate logistic regression within a multilevel framework. Results: Almost one quarter (24%) of Indigenous children were classified as being at high risk of CSEBD. Our findings generally indicate that higher socioeconomic status is associated with a reduced risk of mental health problems in Indigenous children. Housing quality and tenure and neighbourhood-level disadvantage all have a strong direct effect on child mental health. Further, the circumstances of families with Indigenous children (parenting quality, stress, family composition, overcrowding, household mobility, racism and family functioning) emerged as an important explanatory mechanism underpinning the relationship between child mental health and measures of material wellbeing such as carer employment status and family financial circumstances.Conclusions: Our results provide incremental evidence of a social gradient in the mental health of Aboriginal and Torres Strait Islander children. Improving the social, economic and psychological conditions of families with Indigenous children has considerable potential to reduce the mental health inequalities within Indigenous populations and, in turn, to close the substantial racial gap in mental health. Interventions that target housing quality, home ownership and neighbourhood-level disadvantage are likely to be particularly beneficial

Early Vocabulary Development of Australian Indigenous Children: Identifying Strengths

The current study sought to increase our understanding of the factors involved in the early vocabulary development of Australian Indigenous children. Data from the Longitudinal Study of Indigenous Children were available for 573 Indigenous children (291 boys) who spoke English ( = 37.0 months, = 5.4 months, at wave 3). Data were also available for 86 children (51 boys) who spoke an Indigenous language ( = 37.1 months, = 6.0 months, at wave 3). As hypothesised, higher levels of parent-child book reading and having more children’s books in the home were associated with better English vocabulary development. Oral storytelling in Indigenous language was a significant predictor of the size of children’s Indigenous vocabular

Mapping the citation network on vitamin D research in Australia: a data-driven approach

Vitamin D research can vary geographically, as vitamin D status is influenced by latitude, season, dietary intake, body mass index, ethnicity, and public health initiatives. Over the last two decades, research on vitamin D has increased in Australia, where the potential for sun exposure (a major source of vitamin D) is high. We aimed to identify key topics and gaps in vitamin D research in Australia using a data-driven approach. A literature search limited to Australian studies was conducted in the Web of Science Core Collection database. Citation network analysis was conducted to identify clusters and sub-clusters, depicted using word clouds. Topic analysis of each cluster and sub-cluster was conducted to identify topics and sub-topics, respectively. From 934 publications (over the period 1984–2022), nine topics and 60 sub-topics were identified. The nine topics were: vitamin D in vulnerable populations and its impact on child development; impact of sun exposure and ultraviolet-B radiation on various health conditions; vitamin D and falls and fractures in older adults; vitamin D and its association with health outcomes; vitamin D from sun exposure; testing of vitamin D status in Australia; vitamin D, calcium, and musculoskeletal health; vitamin D status and knee osteoarthritis; and vitamin D status and exercise performance in athletes. There were limited publications on vitamin D in Aboriginal and Torres Strait Islander peoples and dietary vitamin D. We have provided an overview of vitamin D research in Australia. The research trends and knowledge gaps identified can guide future research to better inform public health initiatives in Australia

Awareness and impact of the 'Bubblewrap' advertising campaign among Aboriginal smokers in Western Australia

Background Antismoking mass media campaigns have been shown to reduce smoking prevalence in the mainstream community, however there is little published research on their effect on Aboriginal Australian smokers. Objectives To evaluate the awareness and impact of a mainstream mass media advertising campaign (the ‘Bubblewrap’ campaign) on Aboriginal smokers in the state of Western Australia. Methods A personal intercept survey was conducted in July 2008 across three sites (the Perth metropolitan area and the non-metropolitan towns of Kalgoorlie and Broome). An opportunity or convenience sampling strategy was used to recruit Aboriginal participants, and face-to-face interviews were conducted with 198 Aboriginal smokers to ascertain awareness of the campaign advertisements, whether they were seen as believable and relevant, and the impact the advertisements had on smoking behaviour.Results The majority of the participants interviewed had seen and/or heard the ‘Bubblewrap’ campaign advertisements, although there was considerably greater awareness of the television advertisement than the radio advertisements. Both forms of advertising were considered to be believable and relevant by the majority of Aboriginal smokers. Most of the smokers interviewed thought about cutting down and/or quitting after seeing or hearing the advertisements. Conclusions Our findings suggest that mainstream antismoking mass media campaigns can positively influence the thoughts and behaviours that Aboriginal smokers have, and exhibit, towards quitting smoking. Notwithstanding this, advertisers should continue to look for better ways to incorporate Aboriginal themes in campaign messages. Future mainstream antismoking campaigns should source sufficient funds to ensure that advertising messages reach the large Aboriginal populations in regional and remote Australia

Hospital and emergency department discharge against medical advice in Western Australian Aboriginal children aged 0–4 years from 2002 to 2018: A cohort study

Background: Discharge against medical advice (DAMA) is a priority issue for the health system. Little is known about the factors associated with DAMA for Aboriginal and/or Torres Strait Islander (Aboriginal) children in Australia. Objectives: Investigate the associations between DAMA for hospital admissions and emergency department (ED) presentations and: (i) child, family and episode of service characteristics and (ii) 30-day readmission/ re-presentation. Methods: We conducted a cohort study of Aboriginal children born in Western Australia (2002–2013) who had ≥ 1 hospital admissions (n = 16,931) or ED presentations (n = 26,546) within the first 5 years of life. The outcome of interest was hospital and ED DAMA and adjusted odds ratio were derived using multilevel mixed-effects logistic regression. Results: In the Hospital Cohort, there were 43,149 hospitalisations for 16,931 children, with 684 hospitalisations (1.6%) recorded as DAMA. In the ED Cohort, there were 232,082 ED presentations in 26,546 children, with 10,918 ED presentations (4.7%) recorded as DAMA. DAMA occurring in hospitals between 2014 and 2018, the adjusted odds decreased by 75% compared to the period between 2002 and 2005. The adjusted odds of ED DAMA increased by 46% over the same period. Hospital admissions in regional and remote hospitals were almost seven times the adjusted odds of DAMA compared with hospital admissions in Perth metropolitan hospitals. The adjusted odds of ED DAMA decreased by 12% for ED presentations in regional and remote hospitals compared to those in Perth metropolitan hospitals. There was no evidence of hospital DAMA being associated with hospital readmission within 30 days and limited evidence of ED DAMA being associated with re-presenting to an ED within 30 days. Conclusions: The study identified several important determinants of DAMA, including admission status, triage status, location and calendar year. These findings could inform targeted measures to decrease DAMA, particularly in regional and remote communities

Breastfeeding duration and residential isolation amid Aboriginal children in Western Australia

Objectives: To examine factors that impact on breastfeeding duration among Western Australian Aboriginal children. We hypothesised that Aboriginal children living in remote locations in Western Australia were breastfed for longer than those living in metropolitan locations. Methods: A population-based cross-sectional survey was conducted from 2000 to 2002 in urban, rural and remote settings across Western Australia. Cross-tabulations and multivariate logistic regression analyses were performed, using survey weights to produce unbiased estimates for the population of Aboriginal children. Data on demographic, maternal and infant characteristics were collected from 3932 Aboriginal birth mothers about their children aged 0–17 years (representing 22,100 Aboriginal children in Western Australia). Results: 71% of Aboriginal children were breastfed for three months or more. Accounting for other factors, there was a strong gradient for breastfeeding duration by remoteness, with Aboriginal children living in areas of moderate isolation being 3.2 times more likely to be breastfed for three months or more (p <0.001) compared to children in metropolitan Perth. Those in areas of extreme isolation were 8.6 times more likely to be breastfed for three months or longer (p <0.001). Conclusions: Greater residential isolation a protective factor linked to longer breastfeeding duration for Aboriginal children in our West Australian cohort

Early mortality among Aboriginal and Non-Aboriginal women who had a preterm birth in Western Australia: A population-based cohort study

Background: Having a preterm ( \u3c 37 weeks\u27 gestation) birth may increase a woman\u27s risk of early mortality. Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have higher preterm birth and mortality rates compared with other Australian women. Objectives: We investigated whether a history of having a preterm birth was associated with early mortality in women and whether these associations differed by Aboriginal status. Methods: This retrospective cohort study used population-based perinatal records of women who had a singleton birth between 1980 and 2015 in Western Australia linked to Death Registry data until June 2018. The primary and secondary outcomes were all-cause and cause-specific mortality respectively. After stratification by Aboriginal status, rate differences were calculated, and Cox proportional hazard regression was used to estimate adjusted hazard ratios (HR) and 95 % confidence intervals (CI) for all-cause and cause-specific mortality. Results: There were 20,244 Aboriginal mothers (1349 deaths) and 457,357 non-Aboriginal mothers (7646 deaths) with 8.6 million person-years of follow-up. The all-cause mortality rates for Aboriginal mothers who had preterm births and term births were 529.5 and 344.0 (rate difference 185.5, 95 % CI 135.5, 238.5) per 100,000 person-years respectively. Among non-Aboriginal mothers, the corresponding figures were 125.5 and 88.6 (rate difference 37.0, 95 % CI 29.4, 44.9) per 100,000 person-years. The HR for all-cause mortality for Aboriginal and non-Aboriginal mothers associated with preterm birth were 1.48 (95 % CI 1.32, 1.66) and 1.35 (95 % CI 1.26, 1.44), respectively, compared with term birth. Compared with mothers who had term births, mothers of preterm births had higher relative risks of mortality from diabetes, cardiovascular, digestive and external causes. Conclusions: Both Aboriginal and non-Aboriginal women who had a preterm birth had a moderately increased risk of mortality up to 38 years after the birth, reinforcing the importance of primary prevention and ongoing screening