Can a mortality excess in remote areas of Australia be explained by Indigenous status? A case study using neonatal mortality in Queensland

OBJECTIVE: To assess the extent to which indigenous status confounds the association between remoteness and neonatal mortality in Queensland. METHODS: We used routine data from the Queensland Perinatal Data Collection. Poisson regression modelling was used to assess confounding. RESULTS: Babies born to Indigenous mothers have mortality rates 2.42 times those of the rest of the population, regardless of whether they live in urban, rural or remote areas (95% CI 2.09-2.80). The babies of non-Indigenous women who live in remote areas have a low risk of neonatal death, similar to their rural and urban counterparts. CONCLUSION: In Queensland, the key demographic variable that determines neonatal mortality is indigenous status, not remoteness. IMPLICATIONS: Policymakers should not assume that an excess of a particular health problem in remote areas necessarily reflects equal disadvantage for all the Australians who live there.     

Quality comparison of electronic versus paper death certificates in France, 2010

Background

National cancer survival statistics are available for the total Australian population but not Indigenous Australians, although their cancer mortality rates are known to be higher than those of other Australians. We aimed to validate analysis methods and report cancer survival rates for Indigenous Australians as the basis for regular national reporting.

Methods

We used national cancer registrations data to calculate all-cancer and site-specific relative survival for Indigenous Australians (compared with non-Indigenous Australians) diagnosed in 2001-2005. Because of limited availability of Indigenous life tables, we validated and used cause-specific survival (rather than relative survival) for proportional hazards regression to analyze time trends and regional variation in all-cancer survival between 1991 and 2005.

Results

Survival was lower for Indigenous than non-Indigenous Australians for all cancers combined and for many cancer sites. The excess mortality of Indigenous people with cancer was restricted to the first three years after diagnosis, and greatest in the first year. Survival was lower for rural and remote than urban residents; this disparity was much greater for Indigenous people. Survival improved between 1991 and 2005 for non-Indigenous people (mortality decreased by 28%), but to a much lesser extent for Indigenous people (11%) and only for those in remote areas; cancer survival did not improve for urban Indigenous residents.

Conclusions

Cancer survival is lower for Indigenous than other Australians, for all cancers combined and many individual cancer sites, although more accurate recording of Indigenous status by cancer registers is required before the extent of this disadvantage can be known with certainty. Cancer care for Indigenous Australians needs to be considerably improved; cancer diagnosis, treatment, and support services need to be redesigned specifically to be accessible and acceptable to Indigenous people.     

At risk in two worlds: Injury mortality among Indigenous people in the US and Australia, 1990–92

This paper outlines the commonalties and unique differences in injury experience among the Indigenous people in the United States and Australia. Injury mortality rates among Indigenous people in the United States and Australia are approximately 2–3 times greater than rates for the non-Indigenous population in each country. Motor vehicle-related injuries accounted for one-third of the injury deaths for Native Americans and Australian Aboriginals. Suicide accounted for more deaths in Native Americans (15.5 per 100,000) than it did for Australian Aboriginals (11.1 per 100,000), whereas the injury death rate in Australian Aboriginals due to poisoning was almost twice that of Native Americans. Culturally appropriate interventions tailored to specific local settings and problems will be necessary to reduce injury mortality among Indigenous people.     

Cervical cancer mortality in Australia: contrasting risk by Aboriginality, age and rurality

BACKGROUND: The poor health status of Australia's indigenous population is reflected in relatively high mortality rates from almost all causes, including preventable causes such as cervical cancer, where the rate is six to eight times that of non-Aboriginal women. However, there is little information on the geographical distribution of risk, an important issue for service deployment. This study examined the risk of death from cervical cancer in relation to Indigenous status, age and rurality. METHODS: Data from death registers from Australian states and territories who have identified Aboriginal people were examined for 1986-1997 to obtain a list of all deaths where the primary cause was cancer of the cervix. The data categorized females by 5-year age group, by metropolitan, rural or remote category and by Indigenous status. Mean age at death and standardized mortality ratios for deaths from cervical cancer were calculated for Aboriginal compared with non-Aboriginal women in metropolitan, rural and remote areas. RESULTS: The risk of death from cervical cancer for Aboriginal women compared with non-Aboriginal women increased by 4.3-fold for metropolitan areas, 9.7-fold for rural areas and 18.3-fold for remote areas. CONCLUSIONS: Aboriginal women in rural and remote areas of Australia are at significantly higher risk of death from cancer of the cervix than either Aboriginal women in metropolitan areas or non-Aboriginal women in any area. This result raises questions about access to services for prevention and early diagnosis and other factors that might impact on the incidence and natural history of the disease.     

Sampling and recruitment methodology for a national eye health survey of Indigenous Australians

Objective: To review the process of sample selection and highlight the methodological difficulties encountered during a nationwide survey of Indigenous Australians, to determine the prevalence and causes of vision impairment and evaluate access to and utilisation of eye care services. Methods: Using a multi‐stage, random cluster sampling methodology, 30 geographic areas stratified by remoteness, were selected to provide a representative population of approximately 3,000 Indigenous Australians aged 5–15 and 40 years and older, and a small non‐Indigenous sample in selected remote areas. Recruitment was adapted to local conditions. The rapid assessment methodology included a questionnaire, tests of visual acuity, trachoma grading, frequency doubling perimetry and non‐mydriatic fundus photography. Results: The number of people examined was 2883/3662 (78.7%) Indigenous and 136 (83.4%) non‐Indigenous. The percentage of the expected population who were enumerated during the survey varied; discrepancies were largest in urban areas (34.5%) compared to very remote areas (97.1%). Conclusions: The unexpected variation in predicted population numbers and participation rates could be explained in part by local circumstances, degree of urbanisation, interpretation of the definition of ‘Indigenous’ and time constraints. Implications: For successful recruitment, a community‐specific approach is essential, including collaboration with local organisations and liaison with health workers of each gender.     

Decreasing rates of natural deaths in a remote Australian Aboriginal community, 1996–2010

Objective : To examine the trends of all‐cause natural mortality for people aged 15 years and over in a remote Australian Aboriginal community between 1996 and 2010. Methods : The annual population in the community by gender and age group was obtained from the Australian Bureau of Statistics (ABS). All known deaths and all records of start of renal replacement therapy (RRT) for renal failure were recorded between 1996 and 2010. Five‐year aggregated death rates were calculated and the changes in natural mortality over the interval were evaluated. Mortality was compared with those of the Northern Territory (NT) Indigenous and non‐Indigenous people as a whole from 1998 to 2006. Results : Rates of natural deaths were lower in the third interval 2006–2010 relative to the first interval 1996–2000, with higher, but more rapidly falling rates for females than males. Reductions were prominent for both sexes in the 65 and over age groups, but death rates in females of earlier middle age also trended lower. The trends applied whether or not the starting of RRT was considered as a natural death. There was a similar trend in rates of natural death in the aggregate Indigenous population of NT. Conclusions: The downward trends probably reflect improvements in risk factor status since the 1960s, all‐of‐life health interventions, as well as better chronic disease management in the last two decades. The higher death rates in females than males in this community remain unexplained, but the rapid rate of decline of female death rates predicts that this gap will soon be minimised.     

Excess Indigenous mortality: are Indigenous Australians more severely disadvantaged than other Indigenous populations?

BACKGROUND: International targets for reducing health inequalities, such as the Millennium Development Goals, are stated in terms of national targets. However, dramatic health differentials exist within countries, even developed ones. Studies indicate that the Indigenous population of Australia suffers a life expectancy disadvantage greater than differentials found in Indigenous populations of other developed countries. We re-examine recent national mortality levels and trends of Indigenous Australians. METHODS: Analyses of Indigenous mortality are plagued by 'numerator-denominator bias', whereby reporting of Indigenous status differs in deaths (numerators) and population (denominators). We apply demographic evaluation methods developed to address such problems to data from the 1991, 1996 and 2001 censuses of Australia and to the death registration data for the period. RESULTS: The propensity of Australia's population to report Indigenous status increased between each census, particularly between 1991 and 1996, while recording of deaths as Indigenous increased sharply. Adjusted for bias, the Indigenous population had a life expectancy approximately 13 years below that of the non-Indigenous population, a 2-year greater disadvantage than recently estimated for the Maori in New Zealand. Indigenous mortality fell during the 1990s, but slightly more slowly than that of non-Indigenous Australians, leaving differentials slightly increased. CONCLUSIONS: Around the world Indigenous populations are estimated to suffer a mortality disadvantage compared with non-Indigenous populations. However, establishing the magnitude of and trend in the disadvantage is difficult because of bias. Using appropriate methods to adjust for bias, the Indigenous population of Australia is estimated to suffer a life expectancy shortfall of about 13 years, greater than similar gaps in other developed countries.     

The real divide: the use of algorithm‐derived Indigenous status to measure disparities in sudden unexpected deaths in infancy in Queensland

Objective : To investigate the under‐identification of Indigenous ^? ? Due to repeated use throughout this paper the term Indigenous people will be respectfully used when referring to individuals who identify as Aboriginal and/or Torres Strait Islander.
infants in death records and examine the impact of a multi‐stage algorithm on disparities in sudden unexpected deaths in infancy (SUDI). Methods : Data on SUDI in Queensland between 2010 and 2014 were linked to birth and death registrations, health data, and child protection and coronial records. An algorithm was applied to cases of SUDI and population data to derive Indigenous status. Numbers, proportions and rates of SUDI were compared. Results : Using multiple sources of Indigenous status resulted in a 64.9% increase in the number of infants identified as Indigenous. The Indigenous SUDI rate increased by 54.3%, from 1.38 to 2.13 per 1,000 live births after applying the algorithm to SUDI and live births data. Conclusions : Applying an algorithm to both numerator and denominator data reduced numerator‐denominator incompatibility, to more accurately report rates of Indigenous SUDI and measure the gap in Indigenous infant mortality. Implications for public health : Estimation of the true magnitude of the disparity is restricted by under‐identification of Indigenous status in death records. Data linkage improved the reporting of Indigenous infant mortality. Accuracy in reporting of measures is integral to determining genuine progress towards Closing the Gap.     

Trends in birth rates for teenagers in Queensland, 1988 to 1997: an analysis by economic disadvantage and geographic remoteness

OBJECTIVE: To investigate trends in the birth rate for teenagers in Queensland, stratified by geographic remoteness and economic disadvantage. METHOD: This was an analysis of routine data for the period 1988 to 1997. The number of births were obtained from the Queensland Perinatal Data Collection. Population data (the denominators for the rates) were obtained from the Australian Bureau of Statistics. Economic disadvantage was based on place of usual residence of the mother. Because of differences in physical, social and psychological development, the data were analysed in three age groups: 13 to 14 years, 15 to 17 years and 18 to 19 years. RESULTS: Birth rates to teenagers who live in disadvantaged areas were 2 to 4 times higher than the rates for all of Queensland and 10 to 20 times higher than the rates in affluent areas. The trend analysis showed that the rates are decreasing in urban-affluent areas (about 2.5% per year), while they have remained stable, but extremely high in disadvantaged-remote areas, and are increasing (about 5% per year) in disadvantaged-urban areas. CONCLUSIONS: The relatively low and stable rates for all of Queensland have hidden marked variations in the trends for areas defined according to economic disadvantage and remoteness. The rates were especially high and showed no improvement over time in remote disadvantaged areas, which have a large indigenous population. IMPLICATIONS: In some areas of Queensland births to teenagers is a pressing problem, especially because it can perpetuate a cycle of limited educational opportunities, social isolation and reliance on welfare.     

Northern Territory indigenous life expectancy improvements, 1967-2004

OBJECTIVE: To assess the extent of changes in life expectancy at birth for the Indigenous population of the Northern Territory (NT) over the period 1967-2004, and to determine which age-specific mortality rates were mostly responsible for such change. METHODS: Life expectancy at birth figures were obtained via life table calculations using a high-quality and internally consistent dataset of NT Indigenous deaths and populations covering the period 1967-2004. A life expectancy at birth age decomposition technique was then applied. RESULTS: Indigenous life expectancy at birth has risen considerably in the NT, increasing from about 52 years for males and 54 years females in the late 1960s to about 60 years for males and 68 years for females in recent years. Significantly, for NT Indigenous females the gap with total Australian life expectancy has narrowed. CONCLUSIONS: In contrast to popular perception, Indigenous life expectancy in the Northern Territory has improved substantially from the late 1960s to the present. IMPLICATIONS: The widespread pessimism that surrounds Indigenous health and mortality is largely unfounded, at least for the NT. Although much remains to be done to reduce Indigenous mortality, the results in this paper demonstrate that improvements are occurring and that sustained and increased effort is worthwhile and will succeed.     

Smoking behaviours in a remote Australian Indigenous community: the influence of family and other factors

In Australia, tobacco smoking is more than twice as common among Indigenous people as non-Indigenous people. Some of the highest smoking rates in the country are in remote Indigenous communities in the Northern Territory of Australia. Owing to this high prevalence, tobacco use today is the single biggest contributing risk factor for excess morbidity and mortality among Indigenous Australians. Despite this, there is a lack of published research which qualitatively explores the social context of Indigenous smoking behaviour or of meanings and perceptions of smoking among Indigenous people. The aim of this study was to understand why Indigenous people start to smoke, the reasons why they persist in smoking and the obstacles and drivers of quitting. We conducted semi-structured interviews with a purposive sample of 25 Indigenous community members in two remote communities in the Northern Territory and 13 health staff. The results indicate that there is a complex interplay of historical, social, cultural, psychological and physiological factors which influence the smoking behaviours of Indigenous adults in these communities. In particular, the results signal the importance of the family and kin relations in determining smoking behaviours. While most community participants were influenced by family to initiate and continue to smoke, the health and well being of the family was also cited as a key driver of quit attempts. The results highlight the importance of attending to social and cultural context when designing tobacco control programs for this population. Specifically, this research supports the development of family-centred tobacco control interventions alongside wider policy initiatives to counter the normalisation of smoking and assist individuals to quit.     

Risk of death for young ex‐prisoners in the year following release from adult prison

Background : In the community, all‐cause mortality rates among those younger than 25 years are considerably lower than those of older adults and are largely attributable to risk‐taking behaviours. However, given the unique health profiles of prisoners, this pattern may not be replicated among those leaving prison. We compared rates and patterns of mortality among young and older ex‐prisoners in Queensland, Australia. Methods : We linked the identities of 42,015 persons (n=14,920 aged <25 years) released from adult prisons in Queensland, Australia with the Australian National Death Index. Observations were censored at death or 365 days from release. We used Cox proportional hazards regression to explore associations between mortality and demographic and criminographic characteristics. We used indirect standardisation to compare rates of all‐cause mortality for both age groups with those for the general population. We calculated proportion of deaths across specific causes for each age group and relative risks for each cause for young versus older ex‐prisoners. Results : Being young was protective against death from all causes (AHR=0.7, 95% CI 0.5–0.8); however, the elevation in risk of all‐cause death relative to the general population was greater for those aged less than 25 years (SMR=6.5, 95% CI 5.3–8.1) than for older ex‐prisoners (SMR=4.0, 95% CI 3.5–4.5). Almost all deaths in young ex‐prisoners and the majority of those in older ex‐prisoners were caused by injury or poisoning. Conclusions : Young people are at markedly increased risk of death after release from prison and the majority of deaths are preventable.     

Use of measures of socioeconomic deprivation in planning primary health care workforce and defining health care need in Australia

Objective: To examine whether measures of remoteness areas adequately reveal high need populations, measured against socioeconomic disadvantage and physician to population ratios. Design: Exploratory spatial analysis of relationships between remoteness areas, medical workforce supply and the index of relative socioeconomic disadvantage (IRSD). Bivariate analyses examined associations between remoteness areas and IRSD. From this analysis, a composite score of deprivation was constructed combining measures of remoteness areas, physician to population ratios and IRSD, and validated against health outcome measures. These measures included avoidable mortality per 100 000, risk behaviour rate per 1000, diabetes rate per 1000. All analyses were conducted at the statistical local area level and weighted to be population representative. Results: The percentage of small areas and populations within the most socioeconomically disadvantaged quintile rose with increasing remoteness. However, 12.8% of small areas within major cities and 40.7% of outer regional areas were also within the lowest socioeconomic quintile. There was a strong relationship between our composite score of deprivation and avoidable mortality, risk rate, diabetes rate and per cent Indigenous. Regression analysis examined the relationship between each element of the composite score and health outcomes. This revealed that the association between avoidable mortality and remoteness was lost after controlling for per cent Indigenous. Conclusions: Using remoteness areas alone to prioritise workforce incentive programs and training requirements has significant limitations. Including measures of socioeconomic disadvantage and workforce supply would better target health inequities and improve resource allocation in Australia.     

First-time hospital admissions with illicit drug problems in indigenous and non-indigenous Western Australians: an application of record linkage to public health surveillance

OBJECTIVE: To monitor incidence rates of first-time hospital admission with an illicit drug problem in the Indigenous and non-Indigenous populations of Western Australia in 1980-95. METHOD: Some 10,533 first admissions among 16,294 total admissions mentioning any of 19 groups of illicit drug problems were identified using linked hospital separation data from the WA Health Services Research Linked Database. RESULTS: Trends in age-standardised rates showed two distinct features: a rapid acceleration in first-time admission rates commencing from about 1991; and a cross-over of the rates in Indigenous and non-Indigenous people. In 1980, the rates were 9.2 per 100,000 PY in Indigenous and 16.4 per 100,000 PY in non-Indigenous people. By 1995, the respective rates were 180.7 and 95.5 per 100,000 PY. Largest proportional increases were observed in first-time admissions mentioning amphetamine dependence or abuse, although increases were seen also in problems due to opiates, hallucinogens, cocaine and cannabis. CONCLUSION: The results are consistent with data on the rising use of injectable amphetamines and other illicit drugs, especially among Aboriginal people. IMPLICATIONS: Urgent attention is required to identify ways of reducing health problems due to illicit substance use in both Indigenous and non-Indigenous Australians.     

Does relative remoteness affect chronic disease outcomes? Geographic variation in chronic disease mortality in Australia, 2002–2006

Objective : To examine the variation of chronic disease mortality by remoteness areas of Australia, including states and territories. Methods : Australian Bureau of Statistics (ABS) death registration data, by Statistical Local Area (SLA), were used to identify chronic disease mortality by remoteness category for states and territories and Australia. The analysis used multiple cause of death for six common chronic diseases: diabetes, ischaemic heart disease, stroke, hypertension, chronic obstructive pulmonary disease and renal disease. ABS correspondence files were used to adjust the SLA level death records and population. Results : The chronic disease mortality rate for Australian residents living in a very remote area (512 per 100,000 persons) was respectively 1.3, 1.4, 1.5, and 1.6 times higher than Remote, Outer Regional, Inner Regional and Major Cities categories. This pattern was consistent for the two age groups of 35–64 years and 65 years and over, all six chronic diseases and all states and territories except Victoria. Conclusion and implications : This study shows that chronic disease mortality increases with increasing relative remoteness. The results highlight the importance and opportunity to redress poorer health outcomes for rural and remote area populations. The study is limited by absence of reliable Indigenous identification in national death data.     

Betting on the evidence: Reported gambling problems among the Indigenous population of the Northern Territory

Objectives: To address a shortfall in evidence with which to justify gambling‐specific interventions for the Indigenous population, we analysed two surveys (2002 National Aboriginal and Torres Strait Islander Social Survey and General Social Survey) that contain information on reported gambling problems for the NT. Methods: Estimates of reported gambling problems are presented for each state and territory by remoteness for the Indigenous and total population for 2002. Factor analysis was used to identify the relationship between gambling problems and other negative life events for the NT Indigenous and total population. Results: High levels of reported gambling problems were apparent for the Indigenous population particularly in the remote parts of the NT and Queensland. Gambling problems were associated with other stressors relating to social transgressions. Among the NT Indigenous population, gambling problems were correlated with levels of crowding, community involvement, personal and community violence and self‐assessed health status. Conclusions: The high levels of reported gambling problems suggest that gambling is causing significant problems for Indigenous people. The multivariable adjusted associations indicate that gambling‐related problems are intimately connected to a range of community contexts. Implications: Policies of intervention need to address broader social and environmental contexts that are intrinsically associated with gambling (and associated problems), in addition to public education in harm associated with gambling and provision of counselling services to assist problem gamblers.     

Impact of Haemophilus influenzae type b (Hib) vaccination on Hib meningitis in children in Far North Queensland, 1989 to 2003.

Over the four years 1989 to 1992 there were 28 cases of Haemophilus influenzae type b (Hib) meningitis in children aged under five years in Far North Queensland. Thirteen (46%) of the cases were in Indigenous children, indicating that the rate of the disease was about 3.5 times greater in these children than in non-Indigenous children. However, no cases of Hib meningitis have occurred in Indigenous children in Far North Queensland in the 10 years following the addition of Hib vaccines to the Australian Standard Vaccination Schedule in 1993. There was only one case of Hib meningitis, in a (vaccinated) non-Indigenous child, between 1994 and 2003. About 70 cases of Hib meningitis in children were prevented by Hib immunisation in Far North Queensland between 1994 and 2003; possibly as many as five deaths and 12 cases with neurological sequelae were also prevented.     

Scottish mortality rates 2000-2002 by deprivation and small area population mobility

Despite recent increases in life expectancy, inequalities in mortality in Scotland have been widening. Previous research has suggested that one of the potential drivers of geographical inequalities in health is the process of selective migration. Although support for the effect of selective migration on widening geographic inequalities in health has been mixed, several studies have shown that people in good health move away from deprived areas while people in poor health move towards more deprived areas. In this paper, we examine mortality rates in Scotland by area deprivation and population mobility. Previous research in Scotland has shown that the relationship between population mobility and migration disappears once deprivation is accounted for. However, the authors measure population mobility over a longer time period than we do here and at a different geographical level. We consider small area population mobility on the basis of moves made in the year prior to the 2001 Scottish census. Areas were classified as one of four types: decreasing, increasing or stable (with high or low turnover). Mortality rates, calculated for the period 2000-2002, were found to be highest in deprived areas that had declined in population over the previous year. In the most deprived quintile, the causes of death contributing disproportionately to the excess mortality in decreasing areas were causes linked to alcohol and drug use, suicides and assault. Focussing on those individuals in the most deprived areas who live in areas that are declining in population could help to reduce widening inequalities for these causes of death. This work shows the extent to which population migration can influence small areas over a relatively short time period and gives some insight into potential factors, not measured by traditional indices of area level deprivation, which may lead to differences in the health status of areas.