due to injury and poisoning were the third highest cause of deaths, at twice the rate of non‑Indigenous Australians in 2014–2018
was the leading cause of injury-related hospitalisation for Indigenous Australians in Remote areas, July 2015 to June 2017
Indigenous Australians were 1.7 times as likely as non‑Indigenous Australians to be hospitalised for injury and poisoning between July 2015 and June 2017
Why is it important?
For Aboriginal and Torres Strait Islander peoples, external causes (injury and poisoning) is currently the third highest cause of deaths, and death rates are more than twice as high as rates for non-Indigenous Australians. Intentional self-harm is the leading cause of death from external causes followed by transport accidents (see measures 1.23 Leading causes of mortality and 1.18 Social and emotional wellbeing) (MacRae et al. 2013).
Injuries can cause long-term disability and disadvantage including reduced opportunities in education and employment, communication impairment and burden on caregivers (Stephens et al. 2014). Evidence shows that acquired brain injury leading to cognitive impairment is associated with contact with the criminal justice system (Haysom et al. 2014). Injury is a significant health issue for Indigenous Australians and rates of injury for specific causes are many times those for non-Indigenous Australians (AIHW 2019a). Indigenous Australian children suffer a disproportionately high burden of unintentional injury (Möller et al. 2017).
Burden of disease
Injuries were the second leading cause (15%) of disease burden for Indigenous Australians in 2011, behind mental and substance use disorders (19%) but were the leading cause of the total fatal burden (24%). Injuries accounted for 14% of the gap in health outcomes between Indigenous and non‑Indigenous Australians in 2011. Overall, injury burden among males (19%) was nearly twice as high as among females (10%). Most of the injury burden (84%) was due to early death, predominantly among males and those aged 15–44 (common causes of injury deaths include falls, intentional self-harm and transport accidents).
Suicide and self-inflicted injuries accounted for 30% of the total injury-related burden for Indigenous Australians, followed by road traffic injuries of motor vehicle occupants (16.5%) (AIHW 2016).
What does the data tell us?
Death rates for injury and poisoning
In 2014–2018, injury and poisoning was the third leading cause of death for Indigenous Australians, after neoplasms (including cancer—23%) and circulatory diseases (23%), accounting for 15% of deaths in the five jurisdictions combined with Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory).
Injury and poisoning death rates for Indigenous males were twice the rate for Indigenous females (Table D1.23.1). The death rate for injury and poisoning for Indigenous Australians has not changed significantly from 1998 to 2018 (Table D1.23.19).
In 2014–2018, among Indigenous Australians, the most common causes of deaths from injury and poisoning were suicide (796 deaths), transport accidents (418 deaths), accidental poisoning (369 deaths) and assault (183 deaths) (Table D1.03.1).
For Indigenous children aged 1–4, injury and poisoning accounted for half (50%) of all deaths (Table D1.23.3). The most common causes of death due to injury and poisoning for Indigenous children aged 0–4 were accidental drowning (25 deaths, 37% of deaths due to injury and poisoning) and transport accidents (23 deaths, 34%) (Table D1.23.11).
After adjusting for differences in the age structure between the two populations, Indigenous Australians died from injury and poisoning at twice the rate as for non Indigenous Australians (78 compared with 40 per 100,000). Indigenous Australians died from intentional self-harm at 1.9 times the rate for non-Indigenous Australians (24 and 12 per 100,000, respectively). For transport accidents, the rate for Indigenous Australians was 2.4 times the rate for non-Indigenous Australians (14 and 6 per 100,000, respectively). Intentional self-harm and transport accidents accounted for 48% of all deaths due to injury and poisoning for Indigenous Australians and 44% for non-Indigenous Australians. Indigenous Australians died from assault at 6.4 times the rate for non-Indigenous Australians (5.8 and 0.9 per 100,000) (Table D1.03.1, Figure 1.03.1). Over the period 2010–11 to 2014–15, 63% of transport-related fatal injuries among Indigenous Australians involved car occupants and 24% involved pedestrians (AIHW 2019b).
Figure 1.03.1: Age-standardised death rates for external causes (injury and poisoning), by Indigenous status and sex, 2014–2018
Hospitalisations due to injury reflect hospital attendances for the condition, rather than the extent of the problem in the community.
Injury and poisoning was the second leading cause of hospitalisation for Indigenous Australians, after dialysis (Table D1.02.5). From July 2015 to June 2017, there were 68,343 (43 per 1,000) hospitalisations due to injury and poisoning for Indigenous Australians. After adjusting for differences in the age structure between the two populations, Indigenous Australians were 1.7 times as likely as non-Indigenous Australians to be hospitalised for injury and poisoning (50 per 1,000 and 29 per 1,000, respectively) (Table D1.03.3).
For Indigenous Australians aged 35–44, the hospitalisation rate for injury and poisoning was 3 times the rate for non-Indigenous Australians (64 and 21 per 1,000, respectively). For both Indigenous and non-Indigenous Australians, rates were highest for those aged over 65, reflecting the higher number of falls among older people (Table D1.03.2, Figure 1.03.2).
Figure 1.03.2: Age-specific hospitalisation rates for a principal diagnosis of injury and poisoning, by Indigenous status and sex, Australia, July 2015 to June 2017
After adjusting for differences in the age structure between the two populations, the hospitalisation rate due to assault was higher for Indigenous males (8 times as high) and Indigenous females (25 times as high) than for non-Indigenous males and females (Table D1.03.7).
Rates of hospitalisation due to assault for Indigenous Australians were highest in Remote areas (25 per 1,000) and Very remote areas (24 per 1,000), and lowest in Inner regional areas (3.1 per 1,000) (Table D2.10.6; see measure 2.10 Community safety). Indigenous Australians are also more likely to be subjected to subsequent admissions into hospital as a result of interpersonal violence than Other Australians (people who have declared they are non‑Indigenous and those whose Indigenous status is unknown)) (Berry et al. 2009; Meuleners et al. 2008).
For Indigenous Australians living in Non-remote areas, falls were the first reported external cause of hospitalisation for both same-day and overnight hospitalisations (3 and 8 per 1,000). In Remote areas, the leading cause was assault (10 and 14 per 1,000, respectively) (Table D1.03.17).
Between 2011–12 and 2015–16, Indigenous Australians (27%) sustained a greater proportion of injuries to the head compared with non-Indigenous Australians (18%). The rate of injury to the head for Indigenous females was 12 times the rate for non-Indigenous females (119 cases per 100,000). For Indigenous males aged 25–44, the rate of injury to the head was 4 times the rate for non-Indigenous males of the same age (316 cases per 100,000). The only other notable difference between Indigenous and non-Indigenous Australians was that a smaller proportion of Indigenous Australians had injuries to the hip and thigh, 4% and 9%, respectively (AIHW 2019a).
Between 2004–05 and 2016–17, hospitalisation rates for injury and poisoning for Indigenous Australians increased by 53% in the six jurisdictions combined with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory). Rates increased faster for Indigenous Australians compared with non-Indigenous Australians, resulting in a widening in the gap (12 per 1,000 in 2004–05 and 23 per 1,000 in 2016–17, respectively) (Table D1.03.5, Figure 1.03.3).
Figure 1.03.3: Age-standardised hospitalisation rates for a principal diagnosis of injury and poisoning, by Indigenous status, NSW, Vic, Qld, WA, SA and NT, 2004–05 to 2016–17
For Indigenous males, falls were the leading cause of hospitalisation due to injury and poisoning (21%) followed by assault (16%). For Indigenous females, assault was the leading cause (22%), followed by falls (20%) (Table D1.03.7, Figure 1.03.4). For Indigenous females, rates of non-fatal hospitalisation for family violence-related assaults were 31 times the rate for non-Indigenous females (6.5 compared with 0.2 per 1,000) (see measure 2.10 Community safety). Hospitalisations for intentional self-harm represented 11% of hospitalisations of Indigenous females, nearly twice as high as for Indigenous males (6%) (Figure 1.03.4).
Figure 1.03.4: First reported external causes for hospitalisations for a principal diagnosis of injury and poisoning and other consequences for Indigenous Australians, by sex, July 2015 to June 2017
After adjusting for differences in age structure, hospitalisation rates varied across jurisdictions, with the highest rates in the Northern Territory and Western Australia (88 and 62 per 1,000, respectively), and lowest in Tasmania (20 per 1,000) (Table D1.03.3, Figure 1.03.5).
Figure 1.03.5: Age-standardised hospitalisation rates for a principal diagnosis of injury and poisoning, by Indigenous status and jurisdiction, Australia, July 2015 to June 2017
The highest hospitalisation rates for injury and poisoning were for Indigenous Australians living in Remote areas (85 per 1,000), and lowest in Inner regional areas (37 per 1,000, respectively) (Table D1.03.4).
In 2015–16, at least 40–50% of Indigenous Australians with all-cause hospitalised injury were living in the most disadvantaged socioeconomic areas. Socio-Economic Indexes for Areas (SEIFA) is a set of indexes that rank geographic areas in Australia according to relative socio-economic advantage and disadvantage (ABS 2016). Indigenous Australians are not distributed evenly across socioeconomic groups examined, which will affect the patterns seen (AIHW 2019c). In 2016, 33% of the Indigenous population lived in areas that were in the most disadvantaged decile (most disadvantaged 10% of areas), based on the SEIFA Index of Relative Socio-economic Advantage and Disadvantage (Table D2.09.1, Figure 1.03.6) (see measure 2.09 Index of disadvantage).
Figure 1.03.6: Population distribution by SEIFA advantage/disadvantage deciles, by Indigenous status, 2016
General Practitioner reported data
According to the Bettering the Evaluation and Care of Health (2015–16) survey, injuries accounted for 4.5% of all problems managed by general practitioners (GP) for Indigenous patients. After adjusting for differences in the age structure between the two populations, the rate of injuries managed per 1,000 GP encounters was similar for Indigenous and Other Australian patients (70 and 66 per 1,000 encounters respectively). Injuries most commonly managed by a GP for Indigenous Australians were musculoskeletal injuries (38 per 1,000 encounters) and skin injuries (26 per 1,000 encounters). Although assault/harmful event accounted for only 0.2% of all problems managed by GPs for Indigenous patients, the rate was 4.4 times as high as for Other Australian patients (2.5 and 0.6 per 1,000 encounters respectively) (Table D1.03.8).
Findings from ABS survey data
Based on the 2012–13 Aboriginal and Torres Strait Islander Health Survey, 19% of Indigenous Australians had experienced injuries in the four weeks prior to the survey, with falls (45%) and hitting or being hit by something (19%) being the most common events causing injury. The main types of injuries were open wounds (35%) and bruising (28%). Action was taken by 46% of those injured and of those who were treated, 11% of those aged 15 and over were injured while under the influence of alcohol or other drugs. Of those with a long-term health condition, 27% reported that it was as a result of injury or an accident (Table D1.03.9). After adjusting for differences in the age structure between the two populations, Indigenous Australians aged 15 and over experienced stress due to a serious accident at a rate 1.8 times as high as for non-Indigenous Australians (6.7% and 3.8%, respectively) (ABS 2013).
What do research and evaluations tell us?
Mortality, hospital and survey data can be unpacked further to understand factors and characteristics associated with the high burden of injury for Indigenous Australians. Finer disaggregation by age, sex, remoteness, and specific causes by the research community can shed light on where targeted interventions could be effective such as around social and emotional wellbeing, road safety, alcohol use, and violence.
- Across the period from 2011–12 to 2014–15 the three most frequent external causes of death for Indigenous Australians were suicide (33% of all injury deaths), transport crashes (20%) and unintentional poisoning by pharmaceuticals (14%). For both sexes, 8 in 10 suicide deaths occurred between the ages of 15 and 44. For children aged 5–14, suicide rates for Indigenous boys and girls were 9 and 7 times as high (respectively) as for non-Indigenous boys and girls (AIHW 2020).
- Indigenous Australians were 3.1 times as likely as non-Indigenous Australians to experience a fatal injury as a car occupant. In general, rates of fatal and serious land transport injury increase with remoteness (Henley & Harrison 2019). A number of factors contribute to the higher rates of injury in remote areas, where higher proportions of Indigenous than non-Indigenous Australians live. Risk factors include greater distances travelled, higher speed limits, poor condition of roads, poor availability of transport services, greater diversity in vehicle condition and delay in accessing medical treatment (Thomson et al. 2009).
- Alcohol and substance use is a known factor in suicide (Robinson et al. 2011), transport accidents (Fitts et al. 2017; West R. et al. 2014b) as well as assault (Mitchell 2011) (see measures 2.16 Risky consumption of alcohol and 2.17 Drug and other substance use).
- Indigenous Australian children are disproportionately affected with higher mortality and hospitalisation rates for some injury types. Evidence shows that family and community wellbeing were protective against child injury, with programs and services to support caregivers’ wellbeing leading to improvement in injury prevention for the child (Thurber et al. 2018) (see measure 1.13 Community functioning).
- Over the period 2014–18, the majority of Indigenous child (0–4) deaths were infants (less than 1 year old) and more than half of these deaths were due to perinatal conditions including pregnancy and birth. However, for Indigenous children aged 1–4 years, almost half of all deaths were due to accidents and injuries including transport accidents, drowning, other accidents and injuries (PM&C 2020).
- A recent study explored hospitalised injury rates in Indigenous Australian children and whether they have changed over time, compared with non-Indigenous children. The study used linked hospital data to construct cohorts of children born in New South Wales hospitals between 2003–07 and 2008–12. In both cohorts, falls were the leading cause of injury followed by burns and poisoning. While rates of injury in Indigenous children caused by burns, poisoning and traffic were lower in the later cohort compared with the early cohort, overall rates of hospitalisation caused by unintentional injury remained the same across the cohorts. Injury hospitalisation inequalities between Indigenous and non-Indigenous children remained similar across the period and the gap remains, with Indigenous children almost twice as likely to suffer unintentional injury as non-Indigenous children (Möller et al. 2019).
- A long-term study in the Northern Territory examined hospitalisations and deaths related to injury from 1997–2011. Across the period, the study found that hospitalisation rates in the Northern Territory were higher than the national average (70% higher in 2011). The Northern Territory Indigenous injury death rate was twice the Northern Territory non-Indigenous rate and 70% higher than the national Indigenous rate. Reasons for this are complex, but alcohol is considered to be a contributing factor, particularly in hospitalisations for assault (Foley et al. 2015).
Intentional and unintentional injuries are preventable. Effective injury prevention measures should identify causes and either remove them, or reduce exposure to them. A National Injury Prevention Strategy 2020–2030 is currently being developed and will outline the best ways to reduce the rate of injury across age groups (DoH). The Strategy identifies Aboriginal and Torres Strait Islander people as a priority population, along with people living in rural and remote areas, and people experiencing socioeconomic disadvantage.
The existing data can provide insight into some of the factors that are associated with the high rates of injury for Indigenous Australians such as age, sex and remoteness to assist in targeting prevention activities. This measure on injury and poisoning covers a broad range of policy, service delivery and health promotion issues such as suicide and self-harm, transport safety, accidental injury and community safety. Further research such as geospatial analysis, and data linkage of mortality, hospital and other health services data could provide new insights, and could highlight other contextual issues (including protective factors) specific to Indigenous Australians to inform targeted interventions.
Addressing the high rates of suicide among Indigenous Australians is an urgent priority receiving significant policy attention in recent years. Understanding the differences in the characteristics of suicide deaths and hospitalisation for self-harm among Indigenous Australian males and females compared to those for non-Indigenous Australian males and females is important for helping to target strategies that can prevent future suicide and self-harm.
Policy responses aimed at addressing injury prevention need to be evidence based, multi-dimensional, relevant and address systemic issues that reduce people's capacity to make health-enhancing choices (Anderson 2008; Berger et al. 2009; Berry et al. 2009). Alcohol and substance use have been found to be a factor in suicide and transport accidents as well as assault (Fitts et al. 2017; Mitchell 2011; Robinson et al. 2011; West C. et al. 2014a). Strategies to prevent injuries should address road safety, child car safety and alcohol abuse. In keeping with the holistic conceptualisation of health and wellbeing for Indigenous Australians, safety promotion and injury prevention activities should also address the social, cultural and geographic context in which Indigenous Australians live.
Over the past decade, efforts to reduce Indigenous child (0–4 years) mortality have focussed on reducing risk factors and improving maternal and child health particularly during pregnancy and infancy, as these factors have the most potential to impact child mortality rates. More research is needed to understand why improvements in health risk factors are not translating into stronger improvements in Indigenous child (0–4) mortality rates (PM&C 2020). The high proportion of injury related deaths among Indigenous 1–4 year olds may warrant more attention. Although these represent a much smaller contribution to the overall number of deaths among Indigenous 0–4 year olds they also represent an opportunity to address risks that are largely preventable such as transport accidents and drowning.
The policy context is at Policies and strategies.
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