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This volume outlines health issues, facts, strategies, and program resources that relate to factors with well established impacts on health status across the world - alcohol and other drugs, environmental health, and food and nutrition. We have included them because they have been identified as having a major impact on ill health and premature death among Aboriginal people in the Northern Territory.

The Aboriginal Health Policy (1996) provides a model for understanding the relationship between ill health, direct causative factors and underlying factors.


Underlying Factors* Direct Causative Factors Ill Health
Political, Cultural and Identity
History of European/Aboriginal contact

Loss of:
Own Culture, Lands & Identity, Law, Family Links, Power over, and responsibility for their own lives, meaningful activities
Food and Nutrition


Alcohol Abuse/Misuse

High levels of mental stress
Obesity, Diabetes, Hypertension, Heart Disease, Low Birthweight, Increased Damage caused by Infections.
Increased risk of Infections, Lung Damage, Respiratory Disease, Heart Disease, Cancer, Low Birthweight.
Violence, Accidents, Social Disruption, Hypertension, Liver Damage, STDs.
Demography and Geography
Small, dispersed, remote, multilingual, multitribal mobile communities
High cost & difficulties in providing services in remote communities
Environmental Health
Overcrowded housing
Inadequate standard of housing
Inadequate sewerage
Inadequate water supply
Poor hygiene
Trachoma & Eye Disease
Respiratory Diseases & Infections
Renal Diseases, Skin Sores & Infections
Education, Employment & Economic
Lack of relevant and culturally appropriate education
Lack of meaningful occupation/employment
Lack of relevant healht knowledge
Health Services
Late presentation/Diagnosis/Treatment
Under-utilisation of Health Services
High hospitalisation rates
More severe illness
More chronic illness

*Note that all the underlying factors impact on the direct causative factors.
Aboriginal Health Policy 1996:29

The model shows that health is related to a range of underlying factors, which underpin the direct causative factors which are the content of this Volume - and which, with the exception of relevant health knowledge, appear to be beyond the influence of health service providers. In fact, community health care workers can make an active contribution to these underlying health factors.

Life course

The model documents established evidence that the impact of underlying and direct causative factors begins before birth. We know that the foundations for health are laid down before birth, and continue to be built during the critical periods of infancy and early childhood development, and through childhood and adolescence. Good health in early adult life is the cumulative legacy of earlier life experiences to be valued, consolidated, and sustained through the years of increasing maturity.

A 'life course' approach is particularly relevant to a complex of chronic diseases - diabetes, cardiovascular and renal disease - that is increasing world-wide. Together with chronic respiratory disease, and injury, they are the main causes of the excess death and ill-health needing hospital admission, that are experienced by Aboriginal people in the Northern Territory compared with other NT citizens as a group. These problems are linked by a set of shared and compounding direct causative factors - alcohol, tobacco, environmental health, food and nutrition - whose influence begins in foetal life through their effects on developing organs and metabolic processes, continues across the years - and is amenable to intervention at every point along the life course.

Whole of life

The Aboriginal Health Policy model shows that these factors are related in turn, to underlying factors that are cultural, locational, social, and economic. Socioeconomic status has long been recognised as the most powerful determinant of health. It is a broad indicator with many associations, such as educational attainment, employment status, financial means, and where and how people live. This recognition is the basis for social policies which make it possible for families, children, young and older people, and other groups in our community who might otherwise be unfairly disadvantaged, to have the capacity to live a healthy life and participate to their full potential in a society that actively cares for its members.

The components that contribute to the association between health and socio-economic status are still being researched and clarified to see if there are interventions which could influence particular aspects and improve health, when changing their economic and social situation in the short term is just not possible.

Control of life

The model identifies a sense of power over, and responsibility for, one's life as an important underlying factor for health. Recent studies have provided evidence of an association between the socio-economic status of people and the degree of control that they feel they have over their lives; and further, that this sense of personal control directly impacts on physical health as well as mental and social health.

It appears that the experience of a low level of control over a prolonged period, particularly in the predicament of low control coupled with high demand to cope with problems, can cause persistently elevated levels of 'stress' hormones. While rapid production of these hormones can be vital in situations of acute stress, chronic elevation can generate biological harm - especially elevated blood sugar levels, cardiovascular disease, and their associated complications.

Besides material and knowledge based resources and assets, socio-economic status also then appears to reflect the capacity of people to resolve problems that confront them and their associated level of feelings of security or uncertainty, confidence or anxiety, dependency or self reliance, and control over their lives and their health.

This domain of 'control' is where all community health care workers can make a difference.

There is research evidence that developmental interventions which teach people to problem solve - even starting as early as pre-school children - can produce improvements in both their capacity to take action to solve problems, and in subsequent long term indicators of social function and socio-economic status itself, that are meaningful and lasting.

Providers of community care services may not be able to directly change people's socio-economic status, educational attainment, employment or financial status, but we can all work in ways that recognise and reinforce people's capacity to know what is needed and how to do it, and that strengthen their control and their confidence.

This volume sets out some facts and some options for action related to direct causative factors of ill-health which Aboriginal people have identified as important - alcohol and other drug misuse, proper food and nutrition, and a healthy environment. They are underpinned by the ways of working discussed in Volume I. These ways of working aim always to strengthen the capacity of people to have power over, and responsibility for, their own lives - which has been identified by Aboriginal people and in the literature, as critical underlying factors for health.

Shirley Hendy
Chief Health Officer
January 2000

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