Elsevier

The Lancet

Volume 391, Issue 10122, 24 February–2 March 2018, Pages 766-782
The Lancet

Articles
Health and wellbeing of Indigenous adolescents in Australia: a systematic synthesis of population data

https://doi.org/10.1016/S0140-6736(17)32141-4Get rights and content

Summary

Background

Indigenous populations have high rates of disease and premature mortality. Most Indigenous communities are young, and adolescence (age 10–24 years) provides great opportunities for population health gain. However, the absence of a comprehensive account of Indigenous adolescents' health has been a barrier to effective policy. We aimed to report a national health profile for Indigenous adolescents in Australia.

Methods

We undertook a systematic synthesis of population data to report the health and wellbeing of Indigenous adolescents in Australia. A reporting framework for Indigenous adolescent health in Australia was defined to measure health outcomes, health risks, and sociocultural determinants. Available data (primary data from national surveys and administrative datasets, and available published data) were mapped against the defined reporting framework, and the quality graded, with the highest quality data selected to report a health profile for Indigenous adolescents. Comparison with non-Indigenous adolescents was made where possible, and estimates (disaggregated by age, sex, and remoteness) were reported as relative risks. A national advisory group (six Indigenous young people, three Indigenous adult community members, three researchers, three policy makers, and two service providers, all aged ≥16 years) provided input about the reporting framework, interpretation of findings, and policy recommendations.

Findings

Data were available for 184 (79%) of 234 elements of the reporting framework. All-cause mortality for Indigenous adolescents (70 per 100 000) was more than twice that of non-Indigenous adolescents, with about 60% of deaths due to intentional self-harm and road traffic injury. 80% of all deaths among Indigenous adolescents were considered as potentially avoidable in the current health system. Communicable diseases (particularly sexually transmitted infections) were leading contributors to morbidity. Almost a third of Indigenous adolescents aged 18–24 years reported high levels of psychological distress (twice the non-Indigenous rate). There was an excess burden of mental disorders and substance use, alongside emerging type 2 diabetes and ischaemic heart disease. Additionally, there were excess intentional and unintentional injuries. Many aspects of this health profile differed markedly from that of non-Indigenous adolescents: rates of acute rheumatic fever, pneumococcal infection, gonorrhoea, and type 2 diabetes resulting in admission to hospital were ten times higher; rates of assault and childbirth in those aged 15–19 years were five times higher; whereas rates of eating disorders, melanoma and other skin cancers, and anaphylaxis were significantly lower. Risks for future ill-health were common; 43% of 15–24 year olds were current tobacco smokers and about 45% had high body mass (overweight or obese). Disadvantage across sociocultural health determinants also emerged, particularly around education.

Interpretation

Despite Australia's adolescents having one of the best health profiles globally, Indigenous adolescents have largely been left behind. Adequate responses will require intersectoral actions, including a health system responsive to the needs of Indigenous adolescents. Without a specific focus on adolescents, Australia will not redress Indigenous health inequalities.

Funding

Australia's National Health and Medical Research Council, Sidney Myer Foundation, and the Murdoch Children's Research Institute.

Introduction

Health inequities arise from the social and material circumstances in which people grow, live, work, and age, and the systems put in place to deal with ill health.1 Nowhere is this concept more powerfully illustrated than for Indigenous peoples. Gaps in life expectancy between Indigenous and non-Indigenous populations range from a decade to more than two decades.2 The underlying determinants are complex: colonisation; forced separation from land, community, family, and culture; racism; and intergenerational poverty have played a role in many settings.3, 4 Economic development and urbanisation are typically drivers of improved population health, but they can also accentuate inequities and social marginalisation experienced by Indigenous people.5

Responses to Indigenous health have largely mirrored global health policies in that they have predominantly focused on maternal and child health and communicable diseases, with a more recent focus on chronic illness. There have been some notable successes. In Australia, for example, under-five mortality among Indigenous Australians has declined by 33% between 1998 and 2014.6 However, overall life expectancy for Indigenous Australians (69·1 years for men and 73·7 years for women, which are about 10 years less than for non-Indigenous Australians) has improved little.6, 7 A focus on adolescents has remained largely at the margins of Indigenous health policy.8 Yet adolescence is increasingly recognised as a life phase in which the foundations for later life health and that of the next generation are established.8, 9

Research in context

Evidence before this study

Adolescence is now understood as a developmental stage in which investments in health bring a triple dividend of reduced death and disability during these years, healthier trajectories across the life-course, and the best possible start for the next generation. Many Indigenous communities have a large burden of disease, high rates of premature mortality, and poor health in early childhood. Yet there has been no comprehensive account of the health of Indigenous adolescents in Australia or in other countries. We had previously systematically reviewed health-related literature including all studies of individual health outcomes and risks for Indigenous adolescents in Australia over a 15-year period. The methodological quality of each study was graded and the focus mapped against the burden of disease reporting framework. We identified 360 publications that focused predominantly on sexually transmitted infections, oral health, and substance use, a mismatch with modelled burden of disease where mental health and injury were prominent. A simple synthesis of the published literature would therefore be unlikely to provide an adequate profile of health. We did an updated search in English on July 1, 2017, with PubMed using the broad search terms “(Aborigin* OR Indigenous)” AND “(youth OR young OR adol*)”. We did not identify a published health profile of Indigenous adolescents in any setting.

Added value of this study

This study provides the first comprehensive profile of Indigenous adolescent health in Australia. Priority areas of health need (spanning health outcomes, health risks, and sociocultural determinants) were identified to inform policy. The reported indicators provide a baseline for monitoring of progress and a framework for setting policy and service delivery priorities. Identified data gaps inform a research agenda. Although the focus of the study is Indigenous adolescents in Australia, the findings and approach used might inform the development of relevant Indigenous adolescent health policies in other countries that share similar health profiles.

Implications of all the available evidence

The health profile of Indigenous adolescents differs markedly from that of non-Indigenous Australian adolescents, with high rates of communicable, nutritional, and reproductive diseases; non-communicable diseases; and injuries. Policies and programmes designed for the broader Australian population might be inadequate to address the health needs of Indigenous adolescents. The early onset of health risks, high adolescent birth rates, and heavy disease burden suggest that without a priority focus on adolescents, Australia will not redress Indigenous health inequalities.

A sound understanding of the health problems, risks, and their determinants is a prerequisite for effective policy. In this paper, we report the first such national health profile for Aboriginal and Torres Strait Islander (Indigenous) adolescents in Australia (10–24 years old), an age range that encompasses many of the biological, neurocognitive, and social role transitions that define adolescence.9

Section snippets

Overview of the study

We undertook a systematic synthesis of population data to report the health and wellbeing of Indigenous adolescents in Australia. In the absence of available indicators for Indigenous adolescent health, we first defined a reporting framework. Elements of the reporting framework were defined by considering public health, policy, and stakeholder relevance. Against each element of the reporting framework, we then systematically identified, graded, and selected the best available data to report a

Results

The reporting framework consisted of 234 specific outcomes, risks, or determinants across three domains: 145 related to health outcomes, 22 to health risks, and 67 to sociocultural determinants (table 2). Except for some of the non-communicable diseases, data for health outcomes were largely drawn from administrative datasets. Health risk data were sourced from national surveys and were limited in coverage for young adolescents. Data coverage was poorest for the sociocultural determinants. Data

Discussion

Despite Australia's adolescents having one of the best health profiles globally, Indigenous adolescents have largely been left behind.8 Their high rates of communicable diseases, combined with poor sexual and reproductive health, and nutritional disorders are more typical of adolescents in low-income countries.8 Yet non-communicable diseases also contribute a disproportionate burden of morbidity and mortality in Indigenous adolescents, as do intentional and unintentional injuries. As such,

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