Determinants of health for First Nations people

Health is related to an individual’s environment and circumstances such as where they live, their education level, income and living conditions along with their access to and use of health services (WHO 2017). For Aboriginal and Torres Strait Islander (First Nations) people, factors such as cultural identity, family and kinship, country and caring for country, knowledge and beliefs, language and participation in cultural activities and access to traditional lands are also key determinants of health and wellbeing (AIHW 2023). These factors are interrelated and combine to affect the health of individuals and broader communities.

An overview of determinants of health for First Nations people is provided on this page. For more information, see the Aboriginal and Torres Strait Islander Health Performance Framework (HPF) (Tier 2). The HPF covers a range of measures of the determinants of health, including community, socio-economic, environmental, and health risk factors.

Historical context, culture and family connections

Colonisation has had a devastating impact on First Nations communities and culture. Violence and epidemic disease caused an immediate loss of life, and the occupation of land by settlers and the restriction of First Nations people to ‘reserves’ disrupted their ability to support themselves. Together with the forcible removal of First Nations children from their families and communities, First Nations people have suffered ongoing inter-generational trauma. These factors are recognised as having a fundamental impact on the disadvantage and poor physical and mental health of indigenous peoples worldwide, through social systems that maintain disparities (see for example, ANU 2020; Paradies 2016; Paradies and Cunningham 2012).

For First Nations people, cultural identity and participation in cultural activities, access to traditional lands along with connection to family and kinship, are recognised as protective factors and can positively influence overall health and wellbeing (AIHW 2023). Based on the Australian Bureau of Statistics (ABS) Aboriginal and Torres Strait Islander Health Survey 2018–19, an estimated 74% of First Nations people aged 18 and over (357,800 people) recognised an area as a homeland/traditional country, 65% (314,200 people) identified with a tribal group, language, clan, mission or regional group, and 27% (130,500 people) lived on their homeland (AIHW and NIAA 2020). See also Profile of First Nations people.

The importance of culture is recognised in the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 which sets the policy direction for the health and wellbeing of First Nations people. The plan notes that implementation across each priority area will need a holistic approach that considers the cultural determinants across the life-course. For example, it notes that to ensure the health and wellbeing of First Nations people, contemporary housing must embed culturally-responsive design, including consideration of kinship, family and community living arrangements (Department of Health 2021).

Family connections are affected by child removal, family violence, incarceration and the pervasive effects of intergenerational poverty (Dudgeon et al. 2021).

Contact with the child protection and criminal justice systems

Experience of maltreatment during childhood has serious and long-term impacts on social and emotional wellbeing and health (Emerson et al. 2015). The experience of child welfare policies by First Nations people has historically been traumatic, in particular, the policy of forcible removal of children from their families (see also Profile of First Nations people).

The majority of First Nations children are being raised in safe environments. However, First Nations children are over-represented in all aspects of the child protection system, reflecting a history of trauma and stressors which have impacted parents and communities.

The reasons for the overrepresentation of First Nations children in child protection systems are complex. They include the intergenerational effects of previous separations from family and culture and the legacy of past policies of forced removal of children from their families, known as the Stolen Generations (AIHW 2019; HREOC 1997).

First Nations people experience contact with the criminal justice system – as both offenders and victims – at much higher rates than non-Indigenous Australians. Detention and imprisonment compounds existing social and economic disadvantage and affects families and the broader community. 

Data on the child protection and criminal justice systems show that:

• In 2021–22, 57,975 First Nations children came into contact with the child protection system (a rate of 170 per 1,000 population) – of these 13,553 children were the subjects of substantiated maltreatment (see glossary). The rate of substantiated maltreatment in First Nations children was 7 times as high as in non-Indigenous children (39.8 compared with 5.7 per 1,000 population).
• 24,610 First Nations children were on care and protection orders at 30 June 2022. The rate of care and protection orders was nearly 11 times as high for First Nations children as for non-Indigenous children (71.9 compared with 6.8 per 1,000 children). 
• The rate of community supervision for First Nations people aged 10–17 in 2021–22 was 94 young people per 10,000 population, 17 times the rate for non-Indigenous young people (5.4 per 10,000 population).
• The rate of First Nations youth in detention on an average day in 2021–22 was 24 times as high as for non-Indigenous youth (28.3 compared with 1.2 per 10,000 population). 
• As at 30 June 2022, 12,902 First Nations adults were in prison at a rate of 2,330 per 100,000 population, with 78% having experienced prior adult imprisonment. First Nations prisoners made up 32% of all prisoners (AIHW & NIAA 2024a, 2024b).

The Aboriginal and Torres Strait Islander Health Performance Framework has detailed information on contact with the criminal justice system and child protection among First Nations people. See Measure 2.11 Contact with the criminal justice system and Measure 2.12 Child protection.

Socio-economic and environmental factors

Education, employment and income

A person’s educational qualifications can influence their health status and health outcomes. Specifically, higher levels of education can directly impact a person’s health through a greater understanding and application of health information, in addition to better prospects for employment and income which can help people access good quality housing, healthy food and health care services. 

Levels of educational attainment among First Nations people have improved substantially over the past decade. Based on data from the ABS Census of Population and Housing, between 2011 and 2021:

• the proportion of First Nations people aged 20–24 who had attained at least a Year 12 or equivalent qualification increased from 52% to 68% 
• the proportion of First Nations adults aged 20–64 whose highest level of education was Certificate III to Advanced Diploma increased from 24% to 34%, and the proportion whose highest level was a Bachelor Degree or above increased from 6.6% to 9.8% (AIHW and NIAA 2023b, 2023c).

In 2021, the employment rate – the number of employed people as a proportion of the working age population – was 56% for First Nations people aged 25–64. Between 2011 and 2016 the employment rate for First Nations people changed little; however, between 2016 and 2021, the employment rate for First Nations people aged 25–64 increased by 4.7 percentage points (51.0% to 55.7%). The proportion of First Nations people aged 25–64 who were employed was higher in non-remote areas than remote areas, and among those with higher levels of educational qualification (AIHW and NIAA 2023d).

The employment rate remains considerably lower among First Nations people than non-Indigenous Australians (56% compared with 78%) (AIHW and NIAA 2023d). 

An adequate income is fundamental to being able to live a healthy life – it gives a person greater access to nutritious food, better housing, health and other services, as well as a greater ability for social participation (Galobardes et al. 2006). Based on AIHW analysis of the Census of Population and Housing 2021:

• More than 1 in 3 (35%) First Nations adults lived in households with equivalised gross household incomes (which adjust for differences in income based on differences in household sizes) in the bottom 20% of incomes nationally.
• The average (median) weekly equivalised household income of First Nations adults was highest among those living in Major cities ($982/week) and lowest among those living in Very remote areas ($459/week) (AIHW and NIAA 2023e).

The Aboriginal and Torres Strait Islander Health Performance Framework has detailed information on education, employment and income among First Nations people. See Measure 2.04 Literacy and numeracy, Measure 2.05 Education outcomes for young people, Measure 2.06 Educational participation and attainment of adults, Measure 2.07 employment, Measure 2.08 Income and Measure 2.09 Index of disadvantage.

Housing

Adequate housing – that is, housing that provides space for all members of the household and is in good structural condition with adequate working facilities – is essential to good health. Housing that is overcrowded or lacks facilities for washing and cleaning, increases the risk of infectious disease (Ware 2013).

First Nations people have less access to affordable or secure housing than other Australians and are considerably more likely to live in overcrowded conditions, or to experience homelessness (AIHW 2019). While there have been improvements in overcrowding, home ownership and a reduction in homelessness, there is a continued need for public policy that aims to ensure access to affordable, safe and sustainable housing for First Nations people (AIHW and NIAA 2023a).

According to the ABS Census of Population and Housing, in 2021, 81% of First Nations people lived in appropriately sized (not overcrowded) housing (569,400 people). This was an increase from 75% in 2011 (AIHW and NIAA 2023a).

Functional housing encompasses basic facilities, infrastructure, and habitability. Poorly maintained infrastructure and inadequate basic facilities can lead to the spread of infectious and bacterial diseases. In 2018–19:

• 1 in 3 (33%) First Nations households were living in housing with one or more major structural problems, such as major cracks in walls or floors, sinking or moving foundations, or major electrical or plumbing problems. This was a similar proportion to 2012–13
• the proportion of First Nations households living in housing with major structural problems was highest for those living in Remote and Very remote areas (41% and 50% respectively, compared with between 27% and 35% in non-remote areas) (AIHW and NIAA 2022). 

The Aboriginal and Torres Strait Islander Health Performance Framework has detailed information on housing among First Nations people. See Measure 2.01 Housing and Measure 2.02 Access to functional housing with utilities.

Health risk factors

Health risk factors, including overweight and obesity, alcohol consumption, smoking, dietary behaviours and insufficient physical activity, increase the likelihood of a person developing a chronic disease, or interfere with the management of existing conditions. Many health risk factors are preventable and modifiable and significant reduction is associated with improved health outcomes.

Overweight and obesity

A poorer quality diet – lacking in important nutrients and high in processed food – can contribute to obesity. Diet can be affected by what foods are affordable and readily available. For example, fresh fruit and vegetables can be difficult to access by people with low incomes and in more remote areas (Thurber et al. 2017).

Excess weight is a major risk factor for many diseases, such as cardiovascular disease, type 2 diabetes, kidney disease, some musculoskeletal conditions, and cancers. In 2018–19, 71% (381,800) of First Nations people aged 15 and over were overweight or obese (Figure 1). This was higher than in 2012–13 (66%). The rise was driven by an increase in non-remote areas (ABS 2013, 2019).

The Aboriginal and Torres Strait Islander Health Performance Framework has detailed information on overweight and obesity among First Nations people. See Measure 2.22 Overweight and Obesity.

Alcohol consumption

Between 2001 and 2018–19, there was an increase in the proportion of First Nations people aged 18 and over reporting that they ‘had not consumed alcohol in the last 12 months or have never consumed alcohol’, from 19% to 26% (ABS 2019).

In 2018–19, based on data from the National Aboriginal and Torres Strait Islander Survey, a greater proportion (37%) of First Nations people aged 18 and over in remote areas reported that they did not consume alcohol in the last 12 months or have never consumed alcohol, than First Nations adults in non-remote areas (23%) (ABS 2019).

Harmful use of alcohol is a problem for the Australian community as a whole. Long-term excessive alcohol consumption is associated with a variety of adverse health and social consequences (AIHW and NIAA 2023g). High levels of alcohol consumption can increase the risk of lifetime harm. Exceeding alcohol risk guidelines can contribute to the risk of cancer, chronic liver disease and cardiovascular disease, among other health outcomes (NHMRC 2020).

In 2018–19, about 1 in 5 (20% or 97,100) First Nations adults reported drinking alcohol at levels exceeding the lifetime risk guideline in the previous week (Figure 1). This was the same as in 2012–13 (ABS 2019). In this survey, exceeding the guidelines was defined as consuming more than two standard drinks per day on average in the last week. This was based on the National Health and Medical Research Council (NHMRC) 2009 guidelines that applied at the time of the survey. Note that in December 2020, the National Health and Medical Research Council (NHMRC) released updated alcohol guidelines, advising consumption of no more than ten standard drinks a week to reduce the lifetime risk of harm from alcohol-related disease or injury.

The Aboriginal and Torres Strait Islander Health Performance Framework has detailed on alcohol consumption among First Nations people. See Measure 2.16 Risky alcohol consumption.

Tobacco smoking

Smoking is a major risk factor for cardiovascular disease, cancer, and respiratory disease (AIHW 2022). The proportion of First Nations people aged 15 and over who smoke every day has fallen substantially over the past decade. In 2018–19, 37% of First Nations people aged 15 and over (about 200,400) smoked every day (Figure 1), compared with 45% in 2008 (AIHW and NIAA 2023f). The largest falls in daily smoking rates have occurred among younger First Nations people.

In 2018–19, 85% of First Nations people aged 15–17 reported that they had never smoked, compared with 72% in 2008. The decline in daily smoking rates among First Nations adults occurred in non-remote areas – there was no significant change over this period in daily smoking rates among First Nations adults in remote areas (AIHW and NIAA 2023f).

The Aboriginal and Torres Strait Islander Health Performance Framework has detailed on tobacco smoking and second-hand smoking among First Nations people. See Measure 2.15 Tobacco use and Measure 2.03 Environmental tobacco smoke.

The health gap

Although there have been improvements in a range of health and social indicators for First Nations people, substantial disparities remain in many health outcomes between First Nations and non-Indigenous Australians. This is referred to as the ‘health gap’.

AIHW analysis of ABS health survey data from 2017 to 2019 estimated that just under 3 in 10 (29%) First Nations adults aged 18–64 were in ‘good health’, using a composite measure based on a number of survey questions, compared with 51% of non-Indigenous Australians. After accounting for the differences in average age, sex, marital status, remoteness and state/territory between First Nations and non-Indigenous survey respondents, the health gap between First Nations and non-Indigenous was 24.0 percentage points – a decrease from 26.9 percentage points in 2011–13.

Analysis of data for 2017–19 showed that an estimated 35% of the health gap was explained by social determinants, and a further 30% by selected health risk factors (Figure 2).

Around 35% of the gap was left unexplained by this analysis. This unexplained component of the health gap reflects the fact that the available data sources do not provide a complete picture of the differences in health between First Nations people and non-Indigenous Australians, and includes possible effects due to factors that may contribute to good health but which are not available in the survey data analysed. For example, these factors may include access affordable and culturally appropriate health care services, connection to country and language, and effects of structural disadvantage and racism.

For more information, see Australia’s health 2024: data insights article Size and sources of the health gap for Australia's First Nations people 2017–2019.

Figure 2: Contribution of individual social determinants and health risk factors to the adjusted health gap between First Nations people and non-Indigenous Australians aged 18–64, 2017–19

Where do I go for more information?

For more information, see:

• Aboriginal and Torres Strait Islander Health Performance Framework
• Australian Bureau of Statistics National Aboriginal and Torres Strait Islander Health Survey, 2018–19 
• Australia's health 2024: data insights article ‘Size and sources of the health gap for Australia’s First Nations people 2017–2019’

For more information on this topic, see First Nations people.