It has long been recognised that Indigenous people experience relatively high exposure to risk factors that are strongly associated with a variety of chronic, preventable and non-communicable diseases. While sometimes reported as ‘lifestyle’ factors, as in the case of smoking or alcohol consumption, not all health risks stem from behavioural decision making. Also important are more structural influences, such as living conditions and the means to improve nutrition.

The idea that Indigenous community housing should be designed, constructed and maintained to support healthy living practices is now firmly embedded in government policy. The National Indigenous Housing Guide includes a range of design and functionality guidelines aimed at ensuring access to adequate functional housing, clean water, and safe disposal of refuse and waste as a means of disease prevention (Commonwealth of Australia 1999). In the meantime, the reality of many Indigenous communities around the country remains a substantial backlog of need in the provision of healthy housing and infrastructure. Difficulty in overcoming this need is compounded by populations that are not only growing rapidly in size, but are also increasingly dispersed in distribution.

Using census-derived normative measures of overcrowding, it has been calculated that 14 865 Indigenous households in non-improvised dwellings (16% of the total) were overcrowded in 1996 (Jones 1999). In addition, 1883 Indigenous families and 1310 individual Indigenous adults were recorded in improvised dwellings. Overall, this translates into almost 35 000 additional bedrooms required to eliminate overcrowding. At the same time, the 1999 CHINS revealed that 30 per cent of the 20 400 dwellings included in the survey required major repairs or replacement, thereby highlighting the persistent problem of depreciating stock and need for asset management. In addition, only 14 per cent of the 1291 communities in the survey were connected to town water supplies, with most dependent on bore water or alternative sources, especially the smaller communities of less than 50 persons. Even among the larger communities of more than 50 persons, almost half (44%) of those not connected to town supplies had no water treatment facility. This pattern of infrastructure provision is mirrored in sewerage systems, with only seven per cent of communities using a town system and the majority reliant on septic or other systems. A total of 69 small communities had no sewerage system.

It has long been recognised that poor diet and nutritional status are strongly associated with cardiovascular disease and diabetes, but malnutrition also forms part of the general complex of reduced resistance to infectious and other disease, and may engender its own morbidity profile, as in the form of osteoporosis, dental caries, gall bladder disease, nutritional anaemias, digestive tract disorders and diet-related cancers. It is also the case that nutritional disorders are relatively high among Indigenous populations. One recent study, for example, estimates that as much as 20 per cent of Aboriginal children in the Top End of the Northern Territory are malnourished (Ruben & Walker 1995).

Anthropometric measures, such as weight adjusted for height and age, can provide useful indicators of nutritional status and associated risk of long-term ill health. For example, underweight pregnant mothers often give birth to underweight babies, while being underweight in childhood (wasting) can lead to slower physical growth and failure to thrive. On the other hand, being overweight is a risk factor for a number of health conditions in adult life, such as diabetes and heart disease. The 1995 NHS provides information on self-reported height and weight for adults aged 18 years and over. This suggests that Indigenous adults were more likely than other adults to be obese (16% compared with 11%) and less likely to be of acceptable weight (29% compared with 42%). This observation is deliberately cautious because of the high non-response of Indigenous respondents to NHS questions on weight and height (22% compared with 9%). As for nutritional indicators for children, these are available for those aged between seven and 15 years from the NATSIS and have been analysed by Cunningham and Mackerras (1998). Compared with Australian standards, Indigenous children are more likely to be underweight or obese and less likely to be of acceptable weight. This is true of both sexes, although the discrepancies are greatest in rural areas and least in capital cities, especially in regard to wasting.

Tobacco smoking is a well-known risk factor for a number of major causes of mortality including heart disease, lung disease and cancers of various types. It has also been linked to low birthweight. According to the 1995 NHS, 51 per cent of Indigenous adults aged 18 years and over living in non-remote areas indicated that they currently smoked, compared with only 23 per cent of non-Indigenous adults. The size of this gap was similar for both males and females, although male smoking levels were generally higher. Excess alcohol consumption is also a major health risk factor and, although Indigenous adults are less likely than other adults to drink alcohol, they are more likely to do so at hazardous levels. Thus, the 1995 NHS reports that 51 per cent of Indigenous adults did not consume alcohol, compared with 44 per cent of all other adults. However, of those who consumed alcohol, 23 per cent of Indigenous people did so at medium to high levels of risk, compared with only 10 per cent of other adults.

Information is available via the 1999 CHINS on aspects of physical access to health services. This survey covered all discrete Indigenous communities (1291) across Australia embracing a population of 109 000, which approximated 27 per cent of the total estimated Indigenous population in 1999. While the majority of such communities are located in sparsely settled areas and are excluded from the NHS sample, the CHINS data do refer to a wider area than this, and therefore have some relevance to the interpretation of NHS results.

Many communities (69%) were located more than 100 kilometres from the nearest hospital, with smaller communities more likely than larger ones to be distant from hospitals. On a reported population basis, this comprised 54 per cent of the population in discrete communities—a total of 58 860 persons. While only 53 per cent of communities remote from hospitals had access to emergency air medical services, these tended to be the larger communities, and so 86 per cent of the population in such communities had access to emergency air medical services. Again, on a population basis, 90 per cent of the population in discrete communities were located within 25 kilometres of a first-aid clinic. However, lack of transport can impede service usage, and so the CHINS also measured the frequency with which health workers visited communities that were more than 10 kilometres from a hospital. This revealed that only nine per cent of such communities had daily access to a doctor, 54 per cent had weekly or fortnightly access, 22 per cent had access monthly or less frequently, and 15 per cent had no access. These data support the findings from case studies that indicate that a lack of physical access to health services remains a constraint on improved health outcomes (McDermott, Plant & Mooney 1996).