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Tier 1 - Health status and outcomes

1.22 All causes age-standardised death rates

Key facts

Why is it important?

The age-standardised mortality rate provides a summary measure of the overall health status of a population. However, it has well-known limitations, there may be delays for many years before improvements in health status lead to reductions in mortality, and mortality statistics do not reflect the burden of illness in a population for diseases that do not necessarily result in death. These include arthritis and depression. Despite these limitations, mortality rates are a useful measure with which to compare the overall health status of different populations and to monitor changes in overall health status of populations over time. The all-causes mortality rate for Aboriginal and Torres Strait Islander peoples is 1.6 times that for non-Indigenous Australians, indicating that the overall health status of Indigenous Australians is worse than that of non-Indigenous Australians.

The recently established National Agreement on Closing the Gap has identified the importance of making sure Indigenous Australians enjoy long and healthy lives. This includes specific outcomes, targets and indicators to direct policy attention and monitor progress in areas such as life expectancy, all-cause mortality and the leading causes of death. Reporting arrangements for the new agreement are being established. The data presented in this report predates the establishment of the Agreement.

Findings

What does the data tell us?

During the period 2014–2018, 14,734 deaths were identified as deaths of Indigenous Australians in the five jurisdictions with Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory).

After adjusting for differences in age structure between the two populations, the death rate for Indigenous Australians was 1.6 times the rate for non‑Indigenous Australians (917 compared with 567 deaths per 100,000, respectively) (Table D1.22.3).

Between 1998 and 2018, there was a significant reduction by 32% in death rates for Indigenous Australians, after adjusting for differences in age structure between the two populations. Over this period, there was also a significant decrease, by 19%, in death rates for non-Indigenous Australians. Most of the decline for Indigenous Australians occurred between 1998 and 2006 (a 27% decrease), and there was a slower rate of decline from 2006 to 2018 (by 10%) (both changes were statistically significant). The reduction in death rates for Indigenous Australians should however be interpreted with caution as it was likely impacted by the increased propensity for people to identify as Indigenous in the census.

These changes resulted in the gap between the two populations decreasing significantly by 49% from 1998 to 2018. Most of this improvement was seen between 1998 and 2006, when the gap narrowed significantly by 42%. Over the period 2006 to 2018, the gap continued to narrow by 8% but this was not a significant change (Table D1.22.5, Figure 1.22.1).

Figure 1.22.1: Age-standardised death rates, by Indigenous status, NSW, Qld, WA, SA and NT, 1998–2018

This line chart shows that for Indigenous Australians, the mortality rate was decreased from 1,357 per 100,000 in 1998 to 927 per 100,000 in 2018, and for non-Indigenous Australians it decreased from 700 to 539 per 100,000.

Source: Table D1.22.5. AIHW and ABS analysis of the ABS Causes of Death Collection.

By age and sex

Indigenous Australians were more likely to die at a younger age than non‑Indigenous Australians, with 62% of the deaths of Indigenous Australians occurring before age 65 compared with 18% of the deaths of non‑Indigenous Australians in 2014–2018.

Death rates for Indigenous males were higher than Indigenous females across all age groups. The relative difference peaked in the 15–34 age group, with the rates for Indigenous males 1.8 times the rates for Indigenous females (Table D1.22.2).

The distribution of deaths by age differed for Indigenous males and females with a higher proportion of male deaths than female deaths in all age groups from age 15 to 65. The proportion of deaths for Indigenous males peaked in the 45–69 age group with around half (49%) of male deaths occurring between these ages. For Indigenous people 65 and over, the proportion of deaths for females was higher than males, 45% and 32%, respectively (Table D1.22.1, Figure 1.22.2).

Figure 1.22.2: Age distribution of deaths, by sex and Indigenous status, NSW, Qld, WA, SA and the NT, 2014–2018

This figure has two bar charts, one for Indigenous and one for non-Indigenous Australians, showing the distribution of deaths for males and females by five-year age groups. The first bar chart shows that for Indigenous males, deaths peaked between 45 to 69 years, with at least 9% of deaths occurring each five-year age group in this range. For Indigenous females, around 10% of deaths occurred in each five-year age group between 55 and 69 as well as in the 85 and over age group. For non-Indigenous Australians, 32% of deaths for males and 50% of deaths for females were at age 85 or over.

Source: Table D1.22.1. AIHW and ABS analysis of the ABS Causes of Death Collection.

When the rates per 100,000 population are examined, the rate of deaths was higher for Indigenous Australians across all age groups compared with rates for non-Indigenous Australians. The largest relative difference in death rates between Indigenous and non-Indigenous Australians was among those aged 35–44, where the death rate for Indigenous Australians was 3.7 times the rate of non‑Indigenous Australians (367 per 100,000 and 99 per 100,000 respectively) (Table, 1.22.2, Figure 1.22.3).

Figure 1.22.3: All causes age-specific death rates, by age and Indigenous status, 2014–2018

This bar chart shows that the death rate  per 100,000 for Indigenous Australians was higher than for non-Indigenous in all age groups. The death rate for infants less than 1 year old was 632 per 100,000 for Indigenous Australians, compared with 307 for non-Indigenous Australians. The lowest death rates were for those aged 5 to 14, for Indigenous Australians a rate of 17 per 100,000 and for non-Indigenous Australians 8 per 100,000. Death rates then increased with age. For Indigenous Australians aged 75 and over, the death rate was 7,251 per 100,000 compared with 6,541 per 100,000 for non-Indigenous Australians.

Source: D1.22.2. AIHW and ABS analysis of the ABS Causes of Death Collection.

By remoteness

From 2001 to 2018, after adjusting for differences in the age structure between the Indigenous and non-Indigenous populations, the death rate for Indigenous Australians in Remote areas decreased significantly by 31%. This resulted in the gap between Indigenous and non-Indigenous Australians in Remote areas narrowing significantly by 36%. Significant decreases in death rates in Remote areas for Indigenous Australians occurred in all age groups, except among those aged 75 and over (Table D1.22.4, Figure 1.22.4).

Figure 1.22.4: Age-standardised death rates in Remote areas, by Indigenous status, 2001 to 2018

This line chart shows that in Remote areas, the rate of deaths decreased from 1,886 to 1,281 per 100,000 for Indigenous Australians, and from 645 to 517 for non-Indigenous Australians.

Source: Table D1.22.4. AIHW and ABS analysis of the ABS Causes of Death Collection.

Over the shorter-term period of 2011 to 2018, the death rate for Indigenous Australians living in Non-remote areas increased significantly by 14%. In Remote areas the death rate for Indigenous Australians did not change significantly over the same period (Table 1.22.11 Figure 1.22.5).

In Non-remote areas, there was a significant widening of 159% in the gap in death rates between the two populations over the same period, due to a significant increase in the death rate for Indigenous Australians and a significant decrease of 7.8% for non‑Indigenous Australians.

The gap between Indigenous and non-Indigenous Australians in Remote areas narrowed by 12%, but it was not a statistically signficantly change. This was due to a 10% decrease in the death rates for Indigenous Australians (not significant) and a significant decrease of 7.9% for non-Indigenous Australians over the period (Table D1.22.11, Figure 1.22.5).

Among Indigenous Australians in Non-remote areas, those aged 45–54 were the only age group who had a significant change over the period (an increase of 29%). In Remote areas, significant decreases in death rates for Indigenous Australians were seen for those aged 5–44 (Table D1.22.11).

Figure 1.22.5: Age-standardised death rates, by remoteness and Indigenous status, 2011 to 2018

This figure shows two line charts, one for non-remote areas and one for remote areas. The first line chart shows that in non-remote areas, for Indigenous Australians the death rate increased from 722 per 100,000 in 2011 to 796 per 100,000 in 2018, and in remote areas, it decreased from 1,341 to 1,281 per 100,000. For non-Indigenous Australians the death rate decreased in non-remote and remote areas.

Source: Table D1.22.11. AIHW and ABS analysis of the ABS Causes of Death Collection.

By jurisdiction

In 2014–2018, after adjusting for differences in the age structure between the two populations, the death rate for Indigenous Australians was lowest in New South Wales (690 deaths per 100,000) and highest in the Northern Territory (1,465 per 100,000) (Table D1.22.3).

Potential years of life lost (PYLL)

Potential years of life lost (PYLL) is the number of additional years a person would have been expected to live had they not died before the age of 75.

Based on the sum of years of life lost due to premature mortality, the largest gap between Indigenous and non-Indigenous Australians was in the 50–54 age group (128 per 1,000) and the smallest gap was in the 5–9 age group (5.6 per 1,000). The difference in rates of PYLL for Indigenous and non-Indigenous males peaked in the 45–49 age group (166 per 1,000), while for females it was in the 60–64 age group (114 per 1,000) (Table D1.22.8, Figure 1.22.6).

Figure 1.22.6: The gap in potential years of life lost before age 75 years (PYLL) per 1,000 population between Indigenous and non-Indigenous Australians, by age and sex, 2014–2018

This bar chart shows that overall the gap in potential years of life lost before age 75 years per 1,000 population between Indigenous and non-Indigenous Australians was 55 for males and 41 for females. The largest gap between Indigenous and non-Indigenous males was in the 45-49 age group (166), followed by the 50-54 age group (159). The largest gap between Indigenous and non-Indigenous females was in the 60-64 age group (114), followed by 55-59 age group (111).

Note: PYLL is the number of additional years a person would have lived had they not died before age 75 years. The gap is the difference between the PYLL rate per 1,000 for Indigenous and non-Indigenous Australian populations.

Source: Table D1.22.8. AIHW and ABS analysis of the ABS Causes of Death Collection.

International comparisons

Death rates are also available for other countries where indigenous people share a similar history, such as New Zealand and the United States. In New Zealand in 2017, the age-standardised death rate for the Māori population was 1.7 times the rate of other New Zealanders (942 and 565 per 100,000, respectively) (Table D1.22.7). In the United States, the mortality rate for American Indians and Alaska Natives was 1.5 times the rate of non-Hispanic whites during the period 1999–2009 (Espey et al. 2014).

Caution must be used in comparing Australian data with data for other countries due to variations in data quality, methods applied for addressing data quality issues and definitions for identifying Indigenous peoples.

What do research and evaluations tell us?

Hoy et al (2017) analysed deaths among the Tiwi people on Bathurst and Melville Islands off the coast of the Northern Territory between 1960 and 2010. The study illustrated the epidemiological transition of these communities with improvements in preventable infant deaths leading to changes in the demographic and mortality profile of the population over time. High numbers of infant deaths in the 1960s from diarrhoea, respiratory disease and failure to thrive shifted to deaths in older age groups from chronic lung disease, cardiovascular disease and renal failure. The study also illustrated the Barker Hypothesis, showing that many children with low birthweight who were once at greater risk of early death are surviving to adulthood but with enhanced susceptibility to chronic disease. Improvements in birthweights and in the prevention and management of chronic disease will lead to continued improvements in mortality. The study also showed a concerning pattern of deaths among 15-45 year olds from non-natural causes such as accidents, suicide, and homicide from the mid-1980s and peaking in the early 2000s, suggesting that improvements in socioeconomic determinants as well as health services for these age groups is needed (Hoy et al. 2017).

The quality of Indigenous status identification in mortality data is only of sufficient quality to publish rates for New South Wales, Queensland, Western Australia, South Australia and the Northern Territory. Changes in Indigenous status identification in data sets make it difficult to distinguish between changes in outcomes and changes in data quality, and therefore hinders drawing conclusions from the available data. Incorrect or inconsistent collection of Indigenous status can lead to undercounting of Indigenous deaths. The Australian Institute of Health and Welfare has produced guidelines to improve the consistent collection of Indigenous status information across health data sets (AIHW 2010). Internationally, research has found that the reliability of self-identification of Indigenous status, while largely a dependable method, is impacted by issues such as internalised racism and the effects of historic policies and practices. It is also difficult to confirm the Indigenous status of a person if they die without third-party identification and this is further complicated by people moving between states or regions and away from place of birth (Freemantle et al. 2015).

A significant amount of research that utilises data linkage techniques demonstrates the value of linked datasets for improving the quality of Indigenous statistics. Data linkage is particularly important for time series reporting, and this benefits from improvements from increased identification by Indigenous Australians and changes in collection methodology (AIHW 2012; Christensen et al. 2014; Draper et al. 2009; Lawrence et al. 2012; Taylor et al. 2012).

Implications

The mortality rate of Indigenous Australians decreased during the period 1998 and 2018. However, it is clear that progress since 2006 has slowed, and in more recent years has plateaued. This is a significant concern for policy and efforts to close the gap which had sought greater improvement over the past decade. Much more effort is required to further improve the health status of Indigenous Australians. This is described in more detail in the issue-specific measures across the three tiers of the Aboriginal and Torres Strait Islander Health Performance Framework and in the Policies and strategies section.

In particular, continued and enhanced efforts are needed to address the factors that influence maternal and child health, social and emotional wellbeing, and chronic disease. Timely and appropriate access to primary health care is critical to improve prevention, screening, detection and management of chronic disease in order to reduce mortality from causes that are sensitive to population health interventions and medical care. More regional and local data would assist in identifying areas of greatest need.

The gap in PYLL Lost for each age group illustrates the need for policy attention to improve child health and the causes of mortality among younger to middle-aged adults, particularly preventable mortality from chronic disease, and suicide.

The new National Agreement on Closing the Gap has been developed in partnership between all Australian governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations. This new Agreement outlines a better way of working, with governments working in genuine partnership with Indigenous Australians to get better outcomes. The National Agreement sets out ambitious targets and new Priority Reforms that will change the way governments work to improve life outcomes experienced by Indigenous Australians. The National Agreement specifically outlines the following outcomes and targets to direct policy attention and monitor progress:

  • Outcome 1 – Aboriginal and Torres Strait Islander people enjoy long and healthy lives.
    • Target – Close the Gap in life expectancy within a generation, by 2031.
  • Outcome 2 – Aboriginal and Torres Strait Islander children are born healthy and strong
    • Target – By 2031, increase the proportion of Aboriginal and Torres Strait Islander babies with a healthy birthweight to 91 per cent.
  • Outcome 14 – Aboriginal and Torres Strait Islander people enjoy high levels of social and emotional wellbeing.
    • Target – Significant and sustained reduction in suicide of Aboriginal and Torres Strait Islander people towards zero.
  • As stated in the Summary report, mortality rates over the period 1998 to 2006 may be less reliable than rates since 2006 as the reliability of the population estimates used in the statistics lessens the further away the time series moves from the 2016 Census upon which they are based (PM&C 2020). This may have the effect of overstating the early improvements in Indigenous mortality rates, while the more recent trends, based on more reliable data, indicate little progress has been made.
  • The time series analysis spanning 1998 to 2018 reflects the extent of the data that is available for both numerators and denominators. The time series from 2006 is chosen to reflect the baseline year for the target to close the gap in life expectancy, for which age-standardised mortality is a supporting indicator. It also serves as a suitable basis for comparing the time series before and after 2006 to explore the impact of data quality issues relating to the population estimates. This can be explored using the data tables available on this website.

Monitoring changes in mortality over time is very important, and improving Indigenous identification is essential in order to improve the accuracy of Indigenous mortality and life expectancy estimates across the states and territories.

Analysis of mortality rates by remoteness illustrates the stark disadvantage experienced by Indigenous Australians in remote areas. However, recent increases in Indigenous mortality in non-remote areas needs further unpacking.

The policy context is at Policies and strategies.

References

  • AIHW (Australian Institute of Health and Welfare) 2010. National best practice guidelines for collecting Indigenous status in health data sets. Canberra: AIHW.
  • AIHW 2012. An enhanced mortality database for estimating Indigenous life expectancy: A feasibility study.
  • Christensen D, Davis G, Draper G, Mitrou F, McKeown S, Lawrence D et al. 2014. Evidence for the use of an algorithm in resolving inconsistent and missing Indigenous status in administrative data collections. Australian Journal of Social Issues 49:423-43.
  • Draper G, Somerford P, Pilkington A & Thompson S 2009. What is the impact of missing Indigenous status on mortality estimates? An assessment using record linkage in Western Australia. Australian and New Zealand journal of public health 33:325-31.
  • Espey DK, Jim MA, Cobb N, Bartholomew M, Becker T, Haverkamp D et al. 2014. Leading causes of death and all-cause mortality in American Indians and Alaska Natives. The American Journal of Public Health 104 Suppl 3:S303-11.
  • Freemantle J, Ring I, Arambula Solomon TG, Gachupin FC, Smylie J, Cutler TL et al. 2015. Indigenous mortality (revealed): the invisible illuminated. American journal of public health 105:644-52.
  • Hoy WE, Mott SA & McLeod BJ 2017. Transformation of mortality in a remote Australian Aboriginal community: a retrospective observational study. BMJ Open 7:e016094.
  • Lawrence D, Christensen D, Mitrou F, Draper G, Davis G, McKeown S et al. 2012. Adjusting for under-identification of Aboriginal and/or Torres Strait Islander births in time series produced from birth records: Using record linkage of survey data and administrative data sources. BMC medical research methodology 12:90.
  • PM&C (Department of the Prime Minister and Cabinet) 2020. Closing the Gap Report 2020.
  • Taylor LK, Bentley J, Hunt J, Madden R, McKeown S, Brandt P et al. 2012. Enhanced reporting of deaths among Aboriginal and Torres Strait Islander peoples using linked administrative health datasets. BMC medical research methodology 12:91.

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