Good health is related to a complex set of factors that include health risk factors, access to and use of health services, environmental factors, and an individual’s own health capabilities or endowments. Systematic differences in these factors between individuals and subgroups of society are related to their socioeconomic position, including differences in education, employment and income. These socioeconomic differences are called the social determinants of health that are behind the observed differences in health outcomes (see Social determinants of health and Health across socioeconomic groups).

Broadly, social determinants are the circumstances in which people grow, live, work and age (WHO 2008). They can be measured by indicators that reflect an individual’s own personal situation—such as their income, education, employment, and levels of social support and social inclusion; or their external natural environment—such as the levels of air pollution and hazardous materials they are exposed to in the areas they live in.

Early life experiences, housing conditions, transportation and access to health services are other commonly accepted social determinants of health (Wilkinson & Marmot eds 2003). Most of these social determinants are closely related; for example, higher levels of education usually lead to better employment prospects and higher incomes, and that leads to healthier housing conditions.

For Aboriginal and Torres Strait Islander people, the social determinants of health also include factors such as cultural identity, family, participation in cultural activities and access to traditional lands. Factors related to Indigenous community functioning are also important determinants of Indigenous health and wellbeing (AIHW 2017). See Profile of Indigenous Australians for more information on cultural connectedness.

The importance of social determinants in understanding and addressing the health gap between Indigenous and non-Indigenous Australians, along with differences in health outcomes within the Indigenous population, is well established. This page presents examples of the relationship between selected social determinants and self-assessed health status, and selected health risk factors. The focus is primarily on how these social determinants help to explain differences in health risk factors and outcomes within the Indigenous population.

Social determinants and the health gap

Studies have shown the importance of social determinants in understanding and addressing the health gap (differences in the average values of many health indicators between Indigenous Australians and non-Indigenous Australians) (AHMAC 2017; AIHW 2018; Booth & Carroll 2008; Marmot 2011).

Estimating impact of social determinants on the Indigenous health gap

The AIHW quantified the role of social determinants behind the average health gap between Indigenous and non-Indigenous Australians using a composite measure of health. The analysis relates to data on people aged 15–64 from the ABS 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey (Indigenous data), and comparable data from the ABS 2011–12 Australian Health Survey (non-Indigenous component).

In these data 28% of Indigenous adults were assessed to be in good health, based on the composite health measure, compared with 54% of non-Indigenous adults, leading to an average gap of 26 percentage points.

The results of the statistical analyses showed that more than half (53%) of this health gap between Indigenous and non-Indigenous working-age adults can be accounted for by:

  • a set of 5 selected social determinants (contributed 34% of the gap): employment and hours worked, highest non-school qualification, level of schooling completed, housing adequacy and household income
  • a set of 6 ‘health risk factors’ (contributed 19% of the gap): binge drinking, high blood pressure, overweight and obesity status, inadequate fruit and vegetable consumption, insufficient physical exercise, and smoking.

Household income differences alone contributed almost 14% of the overall health gap, followed by differences in employment and hours worked (12%), and level of schooling completed (8.7%). Among the health risk factors, the key component was the difference in smoking status between Indigenous and non-Indigenous Australians (which contributed to 10% of the health gap).

The 47% of the health gap that remained unexplained after accounting for the selected social determinants and health risk factors can be related to other variables not able to be included in the analysis, which include differences in access to health services.

For more information, see ‘Chapter 6.7 Size and sources of the Indigenous health gap’ in Australia’s health 2018.

Differences in social determinants can also account for a large part of the differences in health status within the Indigenous population. For instance, Indigenous Australians who are not employed and those with lower levels of education in general, have poorer health than employed Indigenous Australians and those with higher education levels. Also, Indigenous Australians who are not employed, and those with lower levels of education, are more likely to smoke which also contributes to their poorer health.

Self-assessed health

Indigenous Australian adults were more likely to report very good or excellent health if they lived in higher socioeconomic areas, were employed, or had completed a higher level of educational attainment at school.

Figure 1 shows differences in health status among Indigenous Australians by selected social determinants in 2018–19.

Among Indigenous Australian adults who were employed:

  • 54% reported having very good or excellent health, compared with 37% among those who were not employed (ABS 2019b).

Among Indigenous Australian adults who had a Year 12 or equivalent level of school qualification:

  • 54% reported being in very good or excellent health, compared with 38% among those who had only a Year 10 or lower level of school qualification (ABS 2019b).

The difference in the proportions reporting excellent or very good health on 2 other socio-economic determinants defined at the household level (that is, whether the actual house that is lived in is of an acceptable standard or not, and the socioeconomic ranking of the region the household is in) are also shown in Figure 1.

See Indigenous health and wellbeing for more information on the health of Indigenous Australians.
 

This chart shows the percentage of Indigenous Australians aged 15 and over who report excellent or very good self-assessed health, classified by 4 different examples of the social determinants of health. These 4 determinants are employment status, Year 12 attainment, housing standard and socio-economic ranking of the region the household is in.

The proportion of Indigenous Australians who report excellent or very good self-assessed health is higher for those in the more favourable socio-economic category on each of these four variables. For instance, 54% reported having very good or excellent health among the employed, compared with 37% among those not employed. Also, 54% reported being in very good or excellent health among those with Year 12 or equivalent qualifications, compared with 38% among those with only Year 10 or lower level of school qualification.

Health risk factors

Broadly, Indigenous Australians who are more advantaged across social and economic measures are more likely to have a lower prevalence of health risk factors.

Figure 2 shows the relationship between 2 selected risk factors (smoking and adequate physical activity) among Indigenous Australians based on their level of school education, and among those who were employed compared with those who were not employed.

In 2018–19, among Indigenous Australian adults aged 18 and over, the proportion who did not smoke was higher among those:

  • who were employed compared with those not employed (including those not in the labour force) (66% compared with 48%, respectively)
  • who had completed Year 12 or equivalent, compared with those with a Year 10 or lower level of school qualification (71% compared with 49%, respectively) (ABS 2019a).

Similarly, in 2018–19 the proportion of Indigenous Australian adults that met the guidelines for weekly physical activity was higher among those employed (15%) than among those not employed (8.4%), and higher among those who had completed Year 12 or equivalent (15%) than those with Year 10 or below (9.1%) level of schooling (ABS 2019a).

See also Health risk factors among Indigenous Australians.
 

This chart shows the percentage of Indigenous Australians aged 18 and over who do not smoke and who have met the weekly physical activity guidelines, classified by school education level and employment status.

The proportion of Indigenous Australian adults who did not smoke was higher among those who were employed (66%) compared with those not employed (48%). Similarly, the proportion of Indigenous Australian adults who met the guidelines for weekly physical activity was higher among those who had completed Year 12 or equivalent (15%) compared with those with Year 10 or below (9.1%) level of schooling.

Where do I go for more information?

For more information on social determinants and Indigenous health, see:

Visit Indigenous Australians for more on this topic.

References

ABS (Australian Bureau of Statistics) 2019a. National Aboriginal and Torres Strait Islander Health Survey, 2018–19. cat. no. 4715.0. Canberra: ABS.

ABS 2019b. National Aboriginal and Torres Strait Islander Health Survey, 2018­–19. Expanded Confidentialised Unit Record File, DataLab. Findings based on use of ABS Microdata. Canberra: ABS.

AHMAC (Australian Health Ministers’ Advisory Council) 2017. Aboriginal and Torres Strait Islander Health Performance Framework 2017 report. Canberra: AHMAC.

AIHW (Australian Institute of Health and Welfare) 2017. Australia’s welfare 2017. Australia's welfare series no. 13. Cat. no. AUS 214. Canberra: AIHW.

AIHW 2018. Australia’s health 2018. Australia's health series no. 16. Cat. no. AUS 221. Canberra: AIHW.

Booth A & Carroll N 2008. Economic status and the Indigenous/non-Indigenous health gap. Economic Letters 99(3):604–606.

Marmot, M. 2011. Social determinants and the health of Indigenous Australians. Medical Journal of Australia 194(10):512–513.

WHO (World Health Organization) Commission on Social Determinants of Health 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: WHO.

Wilkinson R & Marmot M eds. 2003. The social determinants of health: the solid facts. 2nd edn. Copenhagen: World Health Organization Europe.