The health of urban Aboriginal people: insufficient data to close the gap

The Australian Government has made a commitment to reducing Indigenous disadvantage, including closing the life-expectancy gap within a generation, and to halving the gap in mortality rates for children under 5 years of age within a decade.1 The Burden of disease and injury in Aboriginal and Torres Strait Islander peoples report showed the potential for a very significant overall health gain in Australia from improving the health of Indigenous Australians.2 This report also showed that 60% of the health gap between Indigenous and non-Indigenous Australians is attributable to the health of Indigenous people living in non-remote areas of Australia. Indigenous Australians in remote areas experience greater health disadvantage, but because of their smaller numbers, contribute 40% of the health gap.

An increasing number of Indigenous people live in urban areas and large regional centres. At the 2006 census, the Australian Bureau of Statistics estimated that 32% of Indigenous people in Australia lived in major cities, 21% lived in inner regional Australia, 22% in outer regional Australia, 9% in remote Australia and 15% in very remote Australia. In total, 53% of Indigenous people (70% of those living non-remotely) live in cities or regional centres.3 This is a small increase from the 50% of Indigenous people who were reported to be living in major cities and inner regional Australia in 2001.4

There is some limited evidence that Indigenous people living in urban areas experience different health problems from those in rural and remote areas. For example, children in urban areas have been found to have higher rates of asthma, dental decay and mental health problems, while those in remote areas have higher rates of infectious disease.2,5,6

Closing the gap between non-Indigenous and Indigenous health by 2020 will require policies and programs that address the diverse health needs of Indigenous people wherever they live. Research contributes to the ways in which nations conceptualise and understand Indigenous health disadvantage, and to the framework within which policies and programs are developed and, over time, evaluated. The role of research in addressing Indigenous health disadvantage has been acknowledged in major national reports such as the House of Representatives inquiry into Indigenous Health in 2000 (Health is life), which recommended that the National Health and Medical Research Council (NHMRC) contribute 5% of the medical research budget to Indigenous health.7 In responding to this report of the Senate, the NHMRC conducted national consultations with Indigenous communities, researchers and policymakers to establish a national “road map” for Indigenous health research. The participants in these consultations also nominated factors that influenced their prioritisation of particular issues for research. Research that “could make a difference to Aboriginal and Torres Strait Islander health” and “addressed research gaps” influenced the priority they assigned to particular health issues.8 The final report of community consultations for the road map noted that “while it was accepted that some Aboriginal and Torres Strait Islander populations had been the subject of significant amounts of research, there were many others who had experienced none at all, and had identified their circumstances as requiring research attention” and that “urban and urban fringe populations were identified as a significant research gap, especially considering that the largest concentrations of Aboriginal and Torres Strait Islander populations are located in urban settings”.9 Although some commentators argue that Indigenous people plead for less research and more action, the NHMRC road map consultations included large numbers of Indigenous people and the outcome was a call for more targeted research, conducted in effective partnerships with Indigenous people, rather than a call for a reduction in health research. There are numerous examples of where funded research outcomes are integrated into policy review documents to guide health care.10-12

We conducted a brief review to increase our understanding of the extent to which recent original research publications in Australia address the health of urban Indigenous people and may contribute to guiding the policy and practice required to help close the 60% health gap experienced by Indigenous people who live in non-remote areas of Australia. The methods and major findings of this review are summarised in the Box. Our review identified articles that included any separate information about urban Indigenous people, and therefore provides the most generous possible estimate of the amount of research addressing the health of urban Indigenous people.

Our findings in this review highlight the sparse data about the health of the 53% of Indigenous people who live in urban areas. We located only 63 studies in the past 5 years that addressed the health of urban Indigenous people — that is, 11% of all articles about Indigenous health during this period. A previous study has reported a similar lack of data about urban Indigenous child health.13

A greater understanding of the health needs of Indigenous Australians living in urban areas will be required to close the gap between the life expectancy of Indigenous and non-Indigenous Australians. We do not suggest that there should be any reduction in efforts to meet the health needs of Indigenous people living in remote areas, who experience greater levels of health disadvantage as demonstrated by the burden of disease report.2 However, if Australia is to reduce the disproportionate burden of illness experienced by Indigenous people living in non-remote areas, a greater and more targeted investment in understanding their health needs will be required.

Our review also suggested that a greater research emphasis on the health of Indigenous children in urban areas and on intervention research is required. The Australian Government has recognised that investment in preventing disease in childhood will be critical to the long-term effort to improve Indigenous health,1 but we found only 23 studies about the health of urban Indigenous children. A more evidence-informed approach to improving Aboriginal health will also require research that goes beyond describing health problems to actually testing the impact of policies and programs. We located only 11 studies that tested approaches to improving health among urban Indigenous people, and a similar finding has been previously reported about Indigenous research generally in Australia and overseas.14,15 The paucity of information about the health of urban Indigenous people is conflated with the limited amount of intervention research in this area, resulting in a very small evidence base about what works to improve the health of Indigenous people.

Overall, our review supports the original findings of the NHMRC road map consultations that there are too few data about the health of urban Aboriginal people and few publications that report the effectiveness of interventions designed to increase our understanding of how to act to close the gap,16 and other similar findings have been reported.13 There were too few studies about any aspect of urban indigenous health to give a meaningful understanding of either health needs or current service provision, and very little research about the impact of programs or policies.

Several factors may underpin the lack of research into the health of urban Indigenous people. First, there are particular challenges in undertaking high-quality and culturally appropriate research in urban areas. There are often no geographic boundaries that indicate a community or that separate Indigenous people from non-Indigenous people. This means that different approaches are needed to partner with Aboriginal people in the research and to recruit participants. In our review, it was perhaps not surprising to find that the most common approach (in 21 out of 63 studies) was to work with Aboriginal Community Controlled Health Services (ACCHSs). These services provide a structure for establishing research partnerships, providing advice and endorsement of the value of the study and recruiting participants. The proportion of Indigenous people using ACCHSs in urban areas is unknown, although it is likely that those with more chronic and complex health needs will be overrepresented. ACCHSs also offer an opportunity to test interventions that, if effective, could be integrated into routine care. It is notable that, of the 21 studies based in ACCHSs, eight were intervention studies.17-24

A second factor in the lack of research may be that there is a perception that research into the health of urban Indigenous people is less important because their health disparity is smaller than that of Indigenous people living in remote areas, and because the nature and causes of their health needs are similar to those of other disadvantaged people. However, Indigenous people living in non-remote areas make a significant contribution to the overall health gap; according to the burden of disease report, they account for 61% of cardiovascular disease, 62% of diabetes, 64% of cancers, 83% of mental disorders and 66% of chronic respiratory disorders within the overall all Indigenous health gap.2 Urban Indigenous people experience considerable health disadvantage relative to their non-Aboriginal counterparts25-29 and may experience particular challenges relating to dislocation, racism and disempowerment.30-34

There are, however, some studies in progress that may provide more detailed information about the health of urban Indigenous people. For example: the Study of Environment on Aboriginal Resilience and Child Health (SEARCH) is a long-term study of urban Indigenous children attending four Aboriginal medical services in New South Wales;35 the Antecedents of Renal Disease in Aboriginal Children and Young Adults (ARDAC) is a study of children and kidney disease;36 the Gudaga Study is based on a birth cohort in south-west Sydney;37 the Kanyini Vascular Collaboration is engaging with Indigenous patients at high cardiovascular disease risk;38 DRUID is a large-scale study of urban Indigenous people in Darwin;39,40 and recent studies have been undertaken at Derbarl Yerrigan Health Service in Perth.20,25 All of these studies and others will provide important information in the coming years.

Nonetheless, there is an urgent need to increase the amount and quality of information about the health needs of urban Indigenous people and about strategies to address them if the Australian Government’s goal of closing the gap in Indigenous health by 2020 is to be achieved. The commitment to closing the total mortality gap within a generation, the mortality gap for children aged under 5 years in the next decade, as well as yet another challenge — that of reducing the gap in disability-adjusted life-years — will require a better understanding of the strategies that are most likely to be effective in improving the health of Indigenous people in urban areas.