The health and wellbeing of
Aboriginal people in prison: findings
from The NSW Inmate Health
Survey
Indigenous Allied Health Australia National Conference
November 2012
Jude Page
Project Manager, Aboriginal Health
Acknowledgements
• 2009 Inmate Health Survey (IHS), Investigators:
Devon Indig, Libby Topp, Elizabeth McEntyre, Bronwen
Ross, Peter Kemp, Denise Monkley, Martin McNamara,
Robyn Rosina, Stephen Allnut, David Greenberg, and
Edouard Tursan D’Espaignet.
• IHS Aboriginal Health Report, Authors: Devon Indig,
Elizabeth McEntyre, Jude Page and Bronwen Ross.
• Funding: NSW Health: (Mental Health and Drug and
Alcohol Office, Centre for Epidemiology and Research,
Centre for Health Protection) and Justice Health
Overview
• Background – to imprisonment
– to the survey
• Methodology
• Results
- Social Determinants
- Risk Behaviours
- Chronic diseases
- Infectious Diseases
• Conclusions
International Incarceration Rates, 2008
United States
756
Russia
629
Cuba
531
South Africa
335
Israel
326
Thailand
257
New Zealand
185
United Kingdom
153
Australia
129
China
119
Canada
116
Germany
89
Indonesia
58
India
33
0
100
200
300
400
500
600
700
800
Rate per 100,000 population
Source: World Prison Population List (eight edition), December 2008. Kings College London.
Note: Australia is cited in this report using ABS figures as 129 per 100,000 for 30/6/2008; however ABS reports Australia as having 168
per 100,000 at 30/6/2008 in its Prisoners in Australia publication (cat 4517.0), 2009. Note: This data may include both adults and
juveniles in some countries.
Adult Incarceration Rate by State 2009
Australia
175
658
NT
WA
261
204
NSW
QLD
168
SA
155
TAS
140
VIC
104
ACT
75
0
100
200
300
400
Rate per 100,000 population
Source: ABS Prisoners in Australia, 2009. ABS Cat no 4517.0
.
500
600
700
Adult Incarceration Rate by State and
Indigenous Status, 2009
131
Australia
2310
NT
161
WA
159
NSW
156
2104
4075
2591
QLD
125
SA
121
TAS
126
VIC
99
1733
2597
578
1159
66
ACT
966
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Rate per 100,000 population
Indigenous
Source: ABS Prisoners in Australia, 2009. ABS Cat no 4517.0
Non-Indigenous
Background to imprisonment
Individual factors
• Effects of colonization
• Social determinants of
health (housing ,education,
employment, poverty etc)
• Mental health, disabilities
• Other risk factors
Structural factors
• Laws and policies
• Policing
• Sentencing
• Bail laws & conditions
• Access to health & support
services
• Availability of diversion
options
Change in Aboriginal Custodial Population,
NSW 1998-2012
1998
2009
2012
7824
11160
9624
94
92
93.5
6.2
7.7
6.5
Aboriginal Male (%)
13.5
21
22
Aboriginal Female
(%)
20
28
30
Custodial Population
Male (%)
Female (%)
SOURCE
CS NSW Inmate
Census
Source: NSW Inmate Census 2009, CSNSW 2012, Offender population report, CSNSW 30 September 2012.
Totals include full-time inmates and period detainees.
Nationally 71% increase in Indigenous imprisonment between 2001 and
2009, compared to 25% increase for non Indigenous prisoners
(ABS, 2009)
Risk factors for Aboriginal prosecution &
imprisonment
Major risk
 High risk alcohol consumption
 Illicit drug use (Weatherburn, et. al 2006, NATSIS)
Increase risk
 Not completing year 12, unemployment, overcrowded
housing, homelessness, being removed from family as child
(incl. stolen generations)
 Breach of bail conditions
 Violent offences (assault, robbery)
Impact of colonisation on Aboriginal health today. Modified from Mathews5
Cunningham, C. et al. BMJ 2003;327:403-404
Copyright ©2003 BMJ Publishing Group Ltd.
Research Methods
• The Aboriginal Health Report is the first report of the
health of Aboriginal adults in NSW prisons.
• A snapshot of Aboriginal people within a larger study of
Inmates in NSW Prisons
• Acknowledged as one of the world’s most
comprehensive assessments of prisoners’ health
Research Methods
• Random sample of 996 people (over-sample of women
and Aboriginal people)
• 31% identified as Aboriginal (312 people)
• Average age 35 years
• Exclusion criteria: non-English speaking, acute mental
illness, profound intellectual disability
• Computer-assisted telephone interviews
• Average interview length 73 minutes
• Response rate: 85%
Survey content
•
Physical health tests – physical measurements, blood
pressure, blood sample (blood borne viruses, blood
sugar, etc), urine sample (STIs, etc)
•
Physical health – prison history, demographics, health
status, disability, medications, asthma, diabetes,
exercise, injury, SF-12, diet, etc
•
Access to healthcare – in prison and community
•
Mental health & risk behaviours– psychiatric history,
suicide, self-harm, smoking, alcohol, drugs, tattoos,
sexual health
Healthcare access in community (ever),
Inmate Health Survey 2009
Aboriginal
Men (N=259)
Non-Aboriginal
Men (N=538)
Aboriginal
Women (N=53)
Non-Aboriginal
Women (N=146)
No health services
27%
12%
6%
4%
Hospital
45%
59%
62%
68%
GP
40%
69%
60%
87%
Medical centre
39%
41%
70%
58%
Community health
centre
25%
21%
36%
39%
Home nursing
5%
3%
23%
4%
Other
16%
7%
32%
19%
No school certificate by Aboriginality and sex,
Inmate Health Survey 1996, 2001 and 2009
80
73
70
66
58
60
60
50
47
46
43
48
43
39
40
20
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Unsettled accommodation/sleeping rough in 6 months prior to prison
by Aboriginality and sex, Inmate Health Survey 1996, 2001 and 2009
20
16
15
15
14
12
10
10
10
10
10
10
10
8
6
5
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Not working in 6 months prior to incarceration by Aboriginality and
sex, Inmate Health Survey 1996, 2001 and 2009
100
92
87
77
80
71
64
61
60
54
61
60
51
41
43
40
20
0
Aboriginal men
Non-Aboriginal men
1996
2001
Aboriginal women
2009
Non-Aboriginal women
On pension or benefit 6 months prior to imprisonment
by Aboriginality and sex, Inmate Health Survey 1996, 2001 and 2009
100
94
77
80
72
70
68
61
72
61
57
60
45
40
40
39
20
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Ever placed in care as a child by Aboriginality and sex,
Inmate Health Survey 2001 and 2009
60
46
45
40
40
34
27
22
20
20
15
0
Aboriginal men
Non-Aboriginal men
2001
Aboriginal women
2009
Non-Aboriginal women
Parents ever in prison (if known) by Aboriginality and sex,
Inmate Health Survey 2001 and 2009
40
36
31
29
30
27
20
11
13
12
10
10
0
Aboriginal men
Non-Aboriginal men
2001
Aboriginal women
2009
Non-Aboriginal women
Ever been in juvenile detention by Aboriginality and sex,
Inmate Health Survey 1996, 2001 and 2009
80
61
58
60
52
42
40
33
35
33
34
25
20
20
21
17
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Ever previously been in prison by Aboriginality and sex,
Inmate Health Survey 1996, 2001 and 2009
100
80
81
80
74
72
65
60
60
57
58
56
60
53
41
40
20
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Summary – Social determinants
 Aboriginal inmates had worse social determinants of health
than non-Aboriginal inmates:
 Nearly twice as likely to not complete Year 10
 More likely to be unemployed (often long-term) prior to
prison
 Nearly three times as likely to have had a parent in prison
 Twice as likely to have been placed in care as child
 Twice as likely to have ever been in juvenile detention
 More likely to have been in prison previously
Risk Behaviours
Current smoker by Aboriginality and sex,
Inmate Health Survey 1996, 2001 and 2009
100
92
88
80
78
81
83
81
77
76
68
73
71
76
60
40
20
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Like to quit smoking (among smokers) by Aboriginality and sex,
Inmate Health Survey 1996, 2001 and 2009
100
90
80
78
74
88
78
81
80
75
74
72
71
57
60
40
20
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Smoking characteristics
 Average Aboriginal inmates smoked at approximately
double the rate of Aboriginal people in the community
(85% vs 45%)
 A third of participants smoked by the time they were
aged 12.
 Aboriginal inmates smoked less cigarettes per day
(approximately 20% of Aboriginal inmates smoked 21+
per day compared to about 30% of non-Aboriginal
inmates)
Risky drinker by Aboriginality and sex,
Inmate Health Survey 1996, 2001 and 2009
80
73
63
60
58
56
48
44
42
40
40
49
37
34
22
20
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Drinking characteristics
 Over a third (35%) of Aboriginal women did not drink any
alcohol in the year before prison, compared to 31% nonAboriginal women.
 Nearly half (44%) of Aboriginal men scored 20 or more
on the AUDIT, indicating alcohol dependence
 58% of Aboriginal men reported usually drinking 10 or
more drinks on a typical day (compared to 41% nonAboriginal men)
 40% of Aboriginal men reported they had 6 or more
drinks on a daily basis in the year before prison
(compared to 27% non-Aboriginal men)
Ever use illegal drugs by Aboriginality and sex,
Inmate Health Survey 1996, 2001 and 2009
100
96
89
92
88
88
84
80
79
76
73
81
74
67
60
40
20
0
Aboriginal men
Non-Aboriginal men
1996
2001
Aboriginal women
2009
Non-Aboriginal women
Type of drugs used,
Inmate Health Survey 2001 and 2009
Cannabis
81
75
41
Heroin
53
19
18
Other opiates
Amphetamines
51
Ice
57
42
11
Cocaine
40
2009
45
2001
Ecstasy
44
27
28
29
LSD/acid
Your
methadone/bup
Others
methadone/bup
23
24
16
17
25
Benzodiazepines
0
10
20
32
30
40
50
60
70
80
90
Ever inject drugs by Aboriginality and sex,
Inmate Health Survey 1996, 2001 and 2009
79
80
68
63
62
60
52
51
47
46
40
39
47
41
37
20
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Overweight or obesity (BMI 25+) by Aboriginality and sex,
Inmate Health Survey 1996, 2001 and 2009
80
66
60
57
55
51
52
55
51
47
46
45
41
40
34
20
0
Aboriginal men
Non-Aboriginal men
1996
Aboriginal women
2001
2009
Non-Aboriginal women
Ever been told by a doctor that you have asthma
by Aboriginality and sex, Inmate Health Survey 1996, 2001 and 2009
80
60
60
62
41
40
41
37
32
26
20
26
19
26
17
18
0
Aboriginal men
Non-Aboriginal men
1996
2001
Aboriginal women
2009
Non-Aboriginal women
Summary – Chronic Diseases
 Aboriginal inmates had high rates of chronic diseases than
non-Aboriginal inmates:
 Twice as likely to have diabetes
 Twice as likely to have ever had asthma (Aboriginal women)
 Aboriginal inmates had higher rates of infectious diseases
than non-Aboriginal inmates:
Chronic diseases characteristics
 Nearly all (91%) Aboriginal women were currently taking
medications, compared to 84% non-Aboriginal women
and two-thirds of both Aboriginal and non-Aboriginal men
 Over half of women (59% Aboriginal women and 54%
non-Aboriginal women) self-reported having 3 or more
health conditions compared to about 40% of both
Aboriginal and non-Aboriginal men
Infectious Diseases - Hepatitis C antibody
by Aboriginality and sex, Inmate Health Survey 1996, 2001 and 2009
100
80
76
72
64
60
61
54
42
40
36
42
39
35
30
24
20
0
Aboriginal men
Non-Aboriginal men
1996
2001
Aboriginal women
2009
Non-Aboriginal women
Hepatitis B core antibody
by Aboriginality and sex, Inmate Health Survey 1996, 2001 and 2009
80
58
60
52
45
42
40
36
35
33
31
24
20
28
26
17
0
Aboriginal men
Non-Aboriginal men
1996
2001
Aboriginal women
2009
Non-Aboriginal women
Summary – Infectious Diseases
 More likely to be Hepatitis C antibody positive
 But decreasing
 Twice as likely to be Hepatitis B core antibody positive
(Aboriginal men)
 But decreasing
 A third of Aboriginal men (32%) reported ever being
diagnosed with a sexually transmissible infection (30%) and
Aboriginal women (26%). NOTE: usually no symptoms
 Not decreasing
Infectious diseases characteristics
 One inmate tested positive to HIV antibody
 Aboriginal men - higher rates of testing for a blood borne
virus in prison (61% vs 47%) compared to non-Aboriginal
men.
 Aboriginal women - best knowledge of risk factors for
Hepatitis C transmission (54% correctly answered 3 risk
factors).
Conclusions
 Over representation of Aboriginal people in prisons
 Social determinants of health (poor educational attainment,
family displacement, unsettled accommodation) impact on
health
 Higher prevalence of risk factors for chronic diseases such
as smoking, risky drinking and illicit drug use
 Aboriginal inmates are more likely to have chronic and
infectious diseases, which start at a younger age
– mostly preventable
Where to from here?
 Utilising the evidence to inform policy and program
development and to seek enhanced funding and services
 Need for government to work more closely with Aboriginal
people to break the cycle of crime, disadvantage and poor
health
 Prison presents an opportunity to screen for chronic and
infectious diseases, provide treatment, health education and
strengthen self management
 Improving culturally responsive services to Aboriginal people
in custody and access to health care on return to community
What is our role?
 Reduce risk factors for poor health
 Treat effects of trauma
 Improve access to appropriate health care, support & follow
up
 Make the health care experience relevant and positive
 Include health promotion and understanding in each health
interaction (where appropriate)
 Model of health: patient centred, holistic
 Support healing & healthy communities
 Education, inclusion, opportunities
Tools
http://sydney.edu.au/medicine/addiction/indigenous/resources
Future research
Aboriginal Men in Custody Study
• Focus on experience of criminal justice system, resilience,
racism and mental health – using Inmate Health Survey
cohort
• Study of experiences of 125 men is being finalised
Thank you
Questions?
Jude.Page@justicehealth.nsw.gov.au
Tel (02) 8372 3076 | Mob 0400 237 272