Household infrastructure in Aboriginal communities and the
implications for health improvement
Ross S Bailie and Myfanwy J Runcie
MJA 2001; 175: 363-366
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Authors' details -
More articles on Aboriginal health
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
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
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
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
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
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
The survey methods are described in detail in the survey evaluation
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
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
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.
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.
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
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
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.
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
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
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
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.
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
- Lindheim R, Syme SL. Environments, people and health. Ann Rev
Public Health 1983; 4: 335-338.
World Bank. World Development Report: Investing in health. New
York: Oxford University Press, 1993.
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.
Pholeros P, Rainow S, Torzillo P. Housing for health: Towards a
healthy living environment for Cape York Communities. Newport
Beach: HealthHabitat; 1993.
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.
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.
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.
Northern Territory Government Environmental Health Task Group.
Environmental health standards for remote communities in the
Northern Territory. Darwin: Northern Territory Government,
Runcie M, Bailie R. Evaluation of environmental health survey data
— Indigenous housing. Darwin: Cooperative Research Centre for
Aboriginal and Tropical Health, 2000.
SPSS [computer program], version 10.0.5. Chicago: SPSS Inc,
Hardy B. Ramingining Manymak Wanga project report. Darwin:
Territory Health Services, 1998.
Cunningham J, Makerras D. Overweight and obesity: Indigenous
Australians. Canberra: Australian Bureau of Statistics, 1994.
Ruben A, Walker A. Malnutrition among rural Aboriginal children
in the Top End of the Northern Territory. Med J Aust 1995; 162:
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.
Harding JE. The nutritional basis of the fetal origins of adult
disease. Int J Epidemiol 2001; 30: 15-23.
Mathews JD. Historical, social and biological understanding is
needed to improve Aboriginal health. Rec Adv Microbiol 1997;
Housing and Infrastructure in Aboriginal and Torres Strait
Islander communities. Canberra: Australian Bureau of Statistics,
Strategic plan — 1996. Darwin: Indigenous Housing Authority of
the Northern Territory, 1996.
(Received 18 Apr, accepted 10 Aug, 2001)
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
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
||% Functioning in all
||Median % functioning
per community (range)*
||Shower hot tap; shower
cold tap; shower drainage; bathroom basin; bathroom hot tap; bathroom
||Laundry trough; laundry
hot tap; laundry cold tap
||Main toilet pan; main toilet
cistern; main toilet water supply; main toilet drainage
|Remove waste water
||Shower drainage; main toilet
|Remove waste rubbish
|Prepare and store food
||Kitchen cold tap; stove
top; oven; dry place for food storage; kitchen bench
|*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
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