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Indigenous health

Household infrastructure in Aboriginal communities and the implications for health improvement

Ross S Bailie and Myfanwy J Runcie
Med J Aust 2001; 175 (7): 363-366.

Indigenous Health

Household infrastructure in Aboriginal communities and the implications for health improvement

Ross S Bailie and Myfanwy J Runcie

MJA 2001; 175: 363-366

Abstract - Methods - Results - Discussion - Competing Interests - Acknowledgements - References - Authors' details -
- - More articles on Aboriginal health


Abstract

Objective: To evaluate housing survey data, describe the state of household infrastructure in Aboriginal communities in the Northern Territory (NT), and to discuss implications for health improvement for people in these communities.
Design: Quantitative analysis of survey data and qualitative analysis of the survey process.
Setting: All NT houses funded for repairs and maintenance through the Indigenous Housing Authority of the Northern Territory (IHANT).
Main outcome measure: Status of infrastructure necessary for four key "healthy living practices" (washing people, washing clothes and bedding, waste removal, and food storage and preparation).
Results: 3906 houses (79% of all houses funded by IHANT) were surveyed. Infrastructure components most frequently identified as not functional or not present were those required for the storage and preparation of food (62% not functional). The facilities required for personal hygiene and safe removal of human waste were not functional in 45%-46% of houses.
Conclusions: These findings highlight the significance of absent or non-functioning household infrastructure as a potential contributory factor in the poor nutritional status and high rates of respiratory, skin and gastrointestinal infections in Indigenous communities. The environmental health and housing survey in the NT is an important tool for monitoring progress on addressing a key underlying determinant of the health of Indigenous people, and potentially for facilitating research aimed at gaining an improved understanding of the relationship of the household environment to health in Indigenous communities.

The most significant improvements in health in industrialised countries over the past two centuries have been attributed to improvements in living and working conditions. Adequate and safe water supply, sanitation, housing, nutritious food, waste disposal, drainage and crowding have all been shown to influence health.1,2 A number of Australian studies have described the inadequacy of housing and the association between the poor living environment and poor health in the Indigenous population.3-6

The National Aboriginal Health Strategy, through the establishment of the Health Infrastructure Priorities Projects in 1993 and 1994 and the Environmental Health Program in 1996, provided for large-scale infrastructure development in communities where this would have maximal impact on health. Projects included ensuring adequate water supply, sanitation, housing and drainage, providing internal roads, and dust management.7 The Indigenous Housing Authority of the Northern Territory (IHANT) was established to ensure a coherent housing strategy, with a specific mandate to facilitate planning and allocation of housing programs and to increase Aboriginal consultation, self-determination and self-management. The NT Government Environmental Health Task Group has published Environmental Health Standards for remote communities in the NT that define a minimum set of functional components of household infrastructure for the building and maintenance of houses.8 These standards are based in part on work done in central Australia by the HealthHabitat group in defining a set of "healthy living practices".

As the program manager for IHANT, the NT Department of Local Government introduced an annual Environmental Health Survey (EHS) in 1998. Important points in the background to the survey are presented in Box 1. The Menzies School of Health Research was contracted to evaluate the first round of survey data, with a view to advising on improvement in the conduct of the survey and reporting on the current status of housing in the NT.9 We report the findings of this evaluation.


Methods

The survey methods are described in detail in the survey evaluation report.9

Briefly, the survey aimed to cover all houses funded by IHANT, and included all communities in the NT, including remote settlements and communities near or within the boundaries of towns and major centres. Surveys were conducted primarily by environmental health officers of Territory Health Services or community development officers of the Department of Local Government. A number of surveys were also conducted by Aboriginal environmental health workers or other community workers under the direction of the environmental health officers and community development officers, with the intention of ultimately handing over responsibility for the survey to community housing organisations.

The survey form included components of infrastructure specified as essential in the Environmental Health Standards,8 with each component scored according to its presence or absence, and, if present, its condition and the level of maintenance required to render it fully functional. The data were entered into a database managed by the Department of Local Government.  

Evaluation and data analysis

The design and conduct of the survey were examined through documentary evidence (held by the Department of Local Government); interviews with the project manager, field officers and database operators; and examination of the database. The data within the database were checked for data entry errors and completeness. Errors were corrected and a subset of the data containing observations for houses with entries in most data fields was downloaded and analysed using SPSS statistical software.10

The proportions of houses for which each infrastructure component specified on the survey form was adequately functional (required no or minor repairs only), was not functional (required major repairs or replacement), was not present or for which data on that component were missing were calculated.

Of the nine healthy living practices described by Pholeros et al,4 four that are directly dependent on components of household infrastructure examined in this survey were identified. These were washing people, washing clothes and bedding, waste removal, and food storage and preparation. A set of infrastructure components required to allow the effective conduct of each of these four healthy living practices was defined, and the four healthy living practices were expanded to six for the purpose of the analysis, as shown in Box 2. The proportion of houses which had all the infrastructure components required for each practice recorded as functioning was calculated, both overall and for individual communities with 10 or more houses included in the survey.

Ethical approval

This article is based on data collected primarily for the purposes of housing management and planning rather than for research. No individuals or communities are identified, so there are no issues relating to confidentiality or privacy that require ethical approval for publication.


Results

Complete data were recorded for 3906 (79%) of a total 4936 houses funded by IHANT.

A number of inadequacies in survey conduct and quality control were found. These stemmed primarily from a lack of or inadequate protocols for the conduct of the survey and from inadequate training of surveyors. These inadequacies resulted in inconsistencies in identifying the most appropriate respondent for the survey, and in questioning, inspection and testing of infrastructure components, and may have restricted the survey coverage.9

The components of infrastructure most frequently identified as not functional or not present were the kitchen bench, the stove top and the oven (26%, 41%, and 42%, respectively) (Box 3).

The cold water taps and supply to the kitchen sink, shower and laundry were clearly identified as functional in between 76% and 81% of houses. In the bathroom, 30% of houses were identified as having no functioning cold water taps, and 32% as having no functional basin.

Hot water taps were functional in the laundry in 68% of houses, and in the shower in 74%. However, the hot water service was functional in only 62% of houses, not functional in 11% of houses and absent altogether in 14%.

Electricity supply to switches, power points and lights was functional in different rooms for 72%-79% of houses.

Between 63% and 78% of houses had the general structure of the kitchen, laundry, bathroom, bedroom, main toilet, exterior doors and windows and house exterior recorded as functional and not a threat to safety. The general structure was least commonly identified as functional or safe in kitchens.

Forty-two per cent of houses were clearly identified as having a functioning refrigerator, 19% had functioning air-conditioning or evaporative cooling and 41% had a functioning washing machine. Thirty-three per cent had a functional fence around the boundary.

The proportion of surveyed houses for which the components required to effectively conduct each of the six key "healthy living practices" ranged between 38% and 69%. Those components required for preparing and storing food were least likely to all be in a functional state and those required for removal of rubbish were most likely to be available (Box 2).

The proportion of houses that had functioning infrastructure for conducting each of the healthy living practices varied widely between communities. In some communities, and for some healthy living practices, none of the surveyed houses had the required infrastructure functioning, whereas in other communities all of the surveyed houses had the required infrastructure functioning (Box 2).

In 13% of all communities where 10 or more houses were surveyed, more than 50% of surveyed houses had the functional amenities to allow all six of the key healthy living practices (Box 4). In 44% of communities 50% of surveyed houses had functional infrastructure components necessary for three or less of the healthy living practices.


Discussion

Our analysis of the survey data describes for the first time the poor state of household infrastructure in Indigenous communities at a detailed level and across a wide jurisdiction. The findings confirm the poor state of housing previously described at a more localised level.4,5,11 Certain types of infrastructure are commonly in a poor state of repair, most notably the facilities for storage and preparation of food. This is of particular concern in light of the high rates of gastrointestinal infection, undernutrition and obesity in children and obesity in adults,12-14 the associated high rates of "lifestyle"-related disease among people living in these communities, and the now widely accepted evidence of the role of fetal nutrition in the development of chronic disease in adulthood.15 (We recognise that lifestyle is strongly determined by the social, cultural and physical environment.)

The poor state of housing and access to adequate facilities for washing have been identified as key underlying factors in the high levels of morbidity and mortality from bacterial respiratory tract infections, and the significant contribution of such infections to the generally poor state of health of many Indigenous Australians.16

Providing sound household infrastructure is clearly important for improving the poor state of health among Indigenous people in Australia. The work of HealthHabitat in central Australia indicates that household infrastructure is used when it is available.4 However, providing a secure and good-quality food supply, and good hygienic and dietary behaviour, is also essential.

Although there were concerns about the lack of quality control in the conduct of the survey between different communities and regions, the high level of coverage (it might more correctly be referred to as a census) and the consistency in coding items as not present and missing data across regions9 allay these concerns to some extent. Further, the findings need to be seen as representing the best-case scenario in the NT, as the survey was intended to target permanent dwellings only. An estimated 1000 temporary dwellings (caravans, tin sheds, improvised dwellings) occupied by close to 4000 people17 would not have been included in this survey. This suggests that the level of functional infrastructure reported in this survey overestimates the level for all dwellings in the NT by about 25%.

Current infrastructure projects can be expected to contribute to improvements in health for the people they reach. However, projections indicate that, even with these projects, there will be significant unmet need for many years as population growth and aging housing stock tip the balance against the supply of new houses and repairs and maintenance to existing houses.18 Many more resources need to be committed if such projects are to influence health at the wider population level in the near future. The annual environmental health and housing survey introduced in the NT is an important tool for defining areas of greatest need, monitoring progress, and potentially for improving the understanding of the contribution of household infrastructure to a range of health, educational and social outcomes.


Competing interests

This article was based on an independent evaluation of a survey conducted under contract by the Menzies School of Health Research for the Northern Territory Department of Local Government. There was agreement at the start of the evaluation between the Department of Local Government and the evaluation team that the results of the evaluation could be the subject of articles published in the scientific literature. The authors have no conflict of interest in writing this article, and have not been subject to any undue influence. Opinions expressed are those of the authors and do not necessarily represent those of any employee of the NT Government.


Acknowledgements

Thanks to the Northern Territory Department of Local Government for its cooperation and funding of the work that led to this report. We acknowledge the decision of the Aboriginal Community Councils to agree to participate in the survey and the contribution of the many people involved in data collection and processing for the survey. We are grateful to a number of people for their cooperation in the survey evaluation, including Sallie Cairnduff, Graham Franklin, Steve Guthridge, Andrew Heath, Barbara Klessa, Esther Pearce, Phillipe Porigneaux, Danni Quickenden, Helen Secretary, Lynette Shields and Nicola Slaven.


References

  1. Lindheim R, Syme SL. Environments, people and health. Ann Rev Public Health 1983; 4: 335-338.
  2. World Bank. World Development Report: Investing in health. New York: Oxford University Press, 1993.
  3. Nganampa Health Council Inc, South Australian Health Commission, Aboriginal Health Organisation of South Australia. Report of Uwankara Palyanku Kanyintjaku: an environmental and public health review within the Anangu Pitjantjatjara Lands. Adelaide: Nganampa Health Council, 1987.
  4. Pholeros P, Rainow S, Torzillo P. Housing for health: Towards a healthy living environment for Cape York Communities. Newport Beach: HealthHabitat; 1993.
  5. Pormpuraaw Community Council, Apunipima Cape York Health Council, Centre for Appropriate Technology, HealthHabitat. Pormpuraaw housing for health project report: Towards a healthy living environment for Cape York Communities. Cairns: Apunipima Cape York Health Council, 1997.
  6. Torzillo P, Kerr C. Contemporary issues in Aboriginal public health. In: Trompf P, Reid J, editors. The health of Aboriginal Australians. Sydney: Harcourt Brace & Co, 1997.
  7. Guthridge S, Cairnduff S, Gollow P, et al. Structure, function and health: a review of the health impact of infrastructure change in remote Aboriginal communities of the Top End — final draft. Darwin: Territory Health Services, 2000.
  8. Northern Territory Government Environmental Health Task Group. Environmental health standards for remote communities in the Northern Territory. Darwin: Northern Territory Government, 1998/1999.
  9. Runcie M, Bailie R. Evaluation of environmental health survey data — Indigenous housing. Darwin: Cooperative Research Centre for Aboriginal and Tropical Health, 2000.
  10. SPSS [computer program], version 10.0.5. Chicago: SPSS Inc, 1999.
  11. Hardy B. Ramingining Manymak Wanga project report. Darwin: Territory Health Services, 1998.
  12. Cunningham J, Makerras D. Overweight and obesity: Indigenous Australians. Canberra: Australian Bureau of Statistics, 1994.
  13. Ruben A, Walker A. Malnutrition among rural Aboriginal children in the Top End of the Northern Territory. Med J Aust 1995; 162: 400-403.
  14. Muller SM, Priestly JR, McComb JR. Malnutrition among rural Aboriginal children in the Top End of the Northern Territory. Med J Aust 1995; 163: 445.
  15. Harding JE. The nutritional basis of the fetal origins of adult disease. Int J Epidemiol 2001; 30: 15-23.
  16. Mathews JD. Historical, social and biological understanding is needed to improve Aboriginal health. Rec Adv Microbiol 1997; 5: 257-334.
  17. Housing and Infrastructure in Aboriginal and Torres Strait Islander communities. Canberra: Australian Bureau of Statistics, 1999.
  18. Strategic plan — 1996. Darwin: Indigenous Housing Authority of the Northern Territory, 1996.

(Received 18 Apr, accepted 10 Aug, 2001)

Authors' details

Menzies School of Health Research and Flinders University Northern Territory Clinical School, Darwin, NT.
Ross S Bailie, MB ChB, FAFPHM, Associate Professor of Public Health.

CSIRO, Sustainable Ecosystems, Canberra, ACT.
Myfanwy J Runcie, PhD, Research Scientist.

Reprints will not be available from the authors. Correspondence: Professor R S Bailie,
Flinders University Northern Territory Clinical School, PO Box 41096, Casuarina, NT 0811
ross.bailieATmenzies.edu.au


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1: Background to the housing survey
  • The survey is the responsibility of the Indigenous Housing Authority of the Northern Territory (IHANT), the peak body for Indigenous housing issues in the NT.
  • The two elected Zone Commissioners and seven elected Regional Chairs of the Aboriginal and Torres Strait Islander Commission (ATSIC) have a majority on the IHANT Board to ensure appropriate Indigenous representation.
  • The housing survey's purpose is not just to document the condition of housing infrastructure, but to guide and monitor a substantial maintenance and building program.
  • Feedback of information and developing capacity at local and regional levels are key strategies in the program.
  • The survey aims to ensure the most appropriate use of funds and to improve health status.
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2: Percentage of surveyed houses for which the infrastructure components required to effectively conduct each of six "healthy living practices" were functional
Healthy living practice Infrastructure components % Functioning in all surveyed houses Median % functioning per community (range)*

Wash people Shower hot tap; shower cold tap; shower drainage; bathroom basin; bathroom hot tap; bathroom cold tap 54% 41% (6%-95%)
Wash clothes Laundry trough; laundry hot tap; laundry cold tap 68%     69% (14%-100%)
Functioning toilet Main toilet pan; main toilet cistern; main toilet water supply; main toilet drainage 55% 58% (7%-95%)
Remove waste water Shower drainage; main toilet drainage 61%    61% (9%-100%)
Remove waste rubbish Rubbish bin 69% 72% (0-100%)
Prepare and store food Kitchen cold tap; stove top; oven; dry place for food storage; kitchen bench 38% 33% (0-100%)

*Includes only those communities where at least 10 houses were surveyed.
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4: Funtionality ratings of 86 communities across the Northern Territory with 10 or more houses surveyed

Box 4

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Ross S Bailie
Myfanwy J Runcie