Household infrastructure in Aboriginal communities and the implications for health improvement

Abstract

The National Aboriginal Health Strategy, through the establishment of the Health Infrastructure Priorities Projects in 1993 and 1994 and the Environmental Health Program in 1996, provided for large-scale infrastructure development in communities where this would have maximal impact on health. Projects included ensuring adequate water supply, sanitation, housing and drainage, providing internal roads, and dust management.⁷ The Indigenous Housing Authority of the Northern Territory (IHANT) was established to ensure a coherent housing strategy, with a specific mandate to facilitate planning and allocation of housing programs and to increase Aboriginal consultation, self-determination and self-management. The NT Government Environmental Health Task Group has published Environmental Health Standards for remote communities in the NT that define a minimum set of functional components of household infrastructure for the building and maintenance of houses.⁸ These standards are based in part on work done in central Australia by the HealthHabitat group in defining a set of "healthy living practices".

As the program manager for IHANT, the NT Department of Local Government introduced an annual Environmental Health Survey (EHS) in 1998. Important points in the background to the survey are presented in Box 1. The Menzies School of Health Research was contracted to evaluate the first round of survey data, with a view to advising on improvement in the conduct of the survey and reporting on the current status of housing in the NT.⁹ We report the findings of this evaluation.

Methods

Briefly, the survey aimed to cover all houses funded by IHANT, and included all communities in the NT, including remote settlements and communities near or within the boundaries of towns and major centres. Surveys were conducted primarily by environmental health officers of Territory Health Services or community development officers of the Department of Local Government. A number of surveys were also conducted by Aboriginal environmental health workers or other community workers under the direction of the environmental health officers and community development officers, with the intention of ultimately handing over responsibility for the survey to community housing organisations.

The survey form included components of infrastructure specified as essential in the Environmental Health Standards,⁸ with each component scored according to its presence or absence, and, if present, its condition and the level of maintenance required to render it fully functional. The data were entered into a database managed by the Department of Local Government.  

Evaluation and data analysis

The proportions of houses for which each infrastructure component specified on the survey form was adequately functional (required no or minor repairs only), was not functional (required major repairs or replacement), was not present or for which data on that component were missing were calculated.

Of the nine healthy living practices described by Pholeros et al,⁴ four that are directly dependent on components of household infrastructure examined in this survey were identified. These were washing people, washing clothes and bedding, waste removal, and food storage and preparation. A set of infrastructure components required to allow the effective conduct of each of these four healthy living practices was defined, and the four healthy living practices were expanded to six for the purpose of the analysis, as shown in Box 2. The proportion of houses which had all the infrastructure components required for each practice recorded as functioning was calculated, both overall and for individual communities with 10 or more houses included in the survey.

Ethical approval

Results

A number of inadequacies in survey conduct and quality control were found. These stemmed primarily from a lack of or inadequate protocols for the conduct of the survey and from inadequate training of surveyors. These inadequacies resulted in inconsistencies in identifying the most appropriate respondent for the survey, and in questioning, inspection and testing of infrastructure components, and may have restricted the survey coverage.⁹

The components of infrastructure most frequently identified as not functional or not present were the kitchen bench, the stove top and the oven (26%, 41%, and 42%, respectively) (Box 3).

The cold water taps and supply to the kitchen sink, shower and laundry were clearly identified as functional in between 76% and 81% of houses. In the bathroom, 30% of houses were identified as having no functioning cold water taps, and 32% as having no functional basin.

Hot water taps were functional in the laundry in 68% of houses, and in the shower in 74%. However, the hot water service was functional in only 62% of houses, not functional in 11% of houses and absent altogether in 14%.

Electricity supply to switches, power points and lights was functional in different rooms for 72%-79% of houses.

Between 63% and 78% of houses had the general structure of the kitchen, laundry, bathroom, bedroom, main toilet, exterior doors and windows and house exterior recorded as functional and not a threat to safety. The general structure was least commonly identified as functional or safe in kitchens.

Forty-two per cent of houses were clearly identified as having a functioning refrigerator, 19% had functioning air-conditioning or evaporative cooling and 41% had a functioning washing machine. Thirty-three per cent had a functional fence around the boundary.

The proportion of surveyed houses for which the components required to effectively conduct each of the six key "healthy living practices" ranged between 38% and 69%. Those components required for preparing and storing food were least likely to all be in a functional state and those required for removal of rubbish were most likely to be available (Box 2).

The proportion of houses that had functioning infrastructure for conducting each of the healthy living practices varied widely between communities. In some communities, and for some healthy living practices, none of the surveyed houses had the required infrastructure functioning, whereas in other communities all of the surveyed houses had the required infrastructure functioning (Box 2).

In 13% of all communities where 10 or more houses were surveyed, more than 50% of surveyed houses had the functional amenities to allow all six of the key healthy living practices (Box 4). In 44% of communities 50% of surveyed houses had functional infrastructure components necessary for three or less of the healthy living practices.

Discussion

The poor state of housing and access to adequate facilities for washing have been identified as key underlying factors in the high levels of morbidity and mortality from bacterial respiratory tract infections, and the significant contribution of such infections to the generally poor state of health of many Indigenous Australians.¹⁶

Providing sound household infrastructure is clearly important for improving the poor state of health among Indigenous people in Australia. The work of HealthHabitat in central Australia indicates that household infrastructure is used when it is available.⁴ However, providing a secure and good-quality food supply, and good hygienic and dietary behaviour, is also essential.

Although there were concerns about the lack of quality control in the conduct of the survey between different communities and regions, the high level of coverage (it might more correctly be referred to as a census) and the consistency in coding items as not present and missing data across regions⁹ allay these concerns to some extent. Further, the findings need to be seen as representing the best-case scenario in the NT, as the survey was intended to target permanent dwellings only. An estimated 1000 temporary dwellings (caravans, tin sheds, improvised dwellings) occupied by close to 4000 people¹⁷ would not have been included in this survey. This suggests that the level of functional infrastructure reported in this survey overestimates the level for all dwellings in the NT by about 25%.

Current infrastructure projects can be expected to contribute to improvements in health for the people they reach. However, projections indicate that, even with these projects, there will be significant unmet need for many years as population growth and aging housing stock tip the balance against the supply of new houses and repairs and maintenance to existing houses.¹⁸ Many more resources need to be committed if such projects are to influence health at the wider population level in the near future. The annual environmental health and housing survey introduced in the NT is an important tool for defining areas of greatest need, monitoring progress, and potentially for improving the understanding of the contribution of household infrastructure to a range of health, educational and social outcomes.

Competing interests

Acknowledgements

References

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