Variations in health within Australia

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1 CHAPTER 3 PR E PA G WHY IS THIS IMPRTANT? There are various population groups within Australia who do not experience the same level of health as the rest of the population. Understanding the health status of these groups enables government and non-government organisations to allocate resources to those areas that require improvement. Determinants of health can be used to provide an insight into why there is variation in the health status among various population groups in Australia. FS Variations in health within Australia TE D KEy KNWLEDGE 1.3 Variations in the health status of population groups in Australia, including males and females, higher and lower socioeconomic status groups, rural and remote populations and Indigenous populations (pages ) U N C R R EC KEy SKILLS Use and interpret data to compare the health status of selected population groups in Australia (pages , 118, , ). Use the determinants of health to explain differences in the health status of Australians and between population groups (pages , 118, , , ). The harsh physical environment provides just a few of the challenges facing different population groups in Australia. 96 UNIT 3 Australia s health c03variationsinhealthwithinaustralia.indd 96 8 June :34 PM

2 KEY TERM DEFINITINS U N C R R EC TE D PA G E PR FS chronic kidney disease (CKD) the gradual, permanent loss of kidney function. Kidneys filter the blood and, if CKD progresses, the function of the kidneys may have to be carried out artificially (called dialysis) colonisation the settlement of Australia by Europeans in 1788 foetal alcohol spectrum disorder a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. Problems that may occur in babies exposed to alcohol before birth include low birth weight, distinctive facial features, heart defects, behavioural problems and intellectual disability Indigenous Australians Australians of Aboriginal or Torres Strait Islander origin perinatal mortality rate death occurring in the foetus or infant between the twenty-second week of pregnancy and seven days after birth Syndrome X (also called metabolic syndrome) when a person exhibits a range of factors that increase their risk of cardiovascular disease and type 2 diabetes. Examples of the factors include abdominal obesity, high cholesterol and insulin resistance c03variationsinhealthwithinaustralia.indd 97 8 June :34 PM

3 3.1 Variations in health within Australia KEY CNCEPT The variations in health status as experienced by Indigenous Australians and the determinants that explain the differences elesson: Aboriginal renal patients being turned away Searchlight ID: eles-0217 The determinants of health provide a basis to analyse the differences in health status experienced by different population groups. Now that the determinants have been examined, the specific differences experienced and the reasons for them can be investigated. With all the improvements that have occurred in education, technology and research in the past 100 years, the life expectancy of the Australian population has increased from approximately 57 years in 1901 to approximately 82 years in Unfortunately, these improvements in health have not been shared by the entire population. There are still population groups that have life expectancies significantly lower than the average. These include Indigenous people, males, people of low socioeconomic status (SES), and rural and remote populations. The health status of these groups is explored in the following section, along with an investigation of the determinants that contribute to these differences. Indigenous Australians Indigenous Australians make up 2.5 per cent of the Australian population and experience poorer health status than the rest of the population with regards to nearly all indicators. Variations in health status reported by the ABS and AIHW (2014) include: life expectancy that is about ten years less than the rest of the population. For the period , about two-thirds (65 per cent) of Indigenous deaths occurred before the age of 65, compared with 19 per cent of non-indigenous deaths an overall mortality rate that is nearly twice that of non-indigenous Australians, and five times as high among Indigenous people aged infant mortality rates that are two and a half times higher than the rest of the population being half as likely as non-indigenous Australians to report their health as excellent or very good burden of disease rates two to three times higher than the non-indigenous population death rates from injury three times higher than the non-indigenous population being 2.6 times more likely to experience a heart attack and 1.7 times more likely to experience a stroke compared to the rest of the population higher rates of cancer and lower survival rates five years after diagnosis compared to non-indigenous Australians high or very high levels of psychological distress experienced at three times the rate of the non-indigenous population rates of diabetes and high glucose levels more than three times higher than the rest of the population a rate of chronic kidney disease (also referred to as CKD, this is the long-term loss of kidney function) twice the rate of the rest of the population being almost twice as likely as non-indigenous people to report having asthma higher rates of dental decay and gum disease. Estimates of Indigenous life expectancy for were 69.1 years for men and 73.7 years for women (ABS, 2014). This represents a difference of about UNIT 3 Australia s health

4 and 9.5 years for males and females respectively when compared with the rest of the population. Even though there have been some significant improvements in recent years with regards to Indigenous mortality rates, Indigenous Australians are more likely to die at every lifespan stage and at younger ages than the non-indigenous population. In fact, approximately 65 per cent of Indigenous Australians die before their sixty-fifth birthday compared to just under 20 per cent for the non-indigenous population (see figure 3.1). Per cent Indigenous Non-Indigenous Determinants of health The reasons for the comparatively low health status of Indigenous Australians compared with the rest of the population are varied and complex. However, there are a range of identifiable determinants that adversely affect the health status of Indigenous Australians. Biological determinants There are many biological determinants that contribute to variations in health status of Indigenous Australians compared to non-indigenous Australians. These include: body weight, in particular, overweight and obesity hypertension impaired glucose regulation low birth weight. Indigenous Australians have higher rates of obesity across all ages, which increases the risk of suffering from chronic conditions such as cardiovascular disease, diabetes mellitus and osteoarthritis. The obesity rate among Indigenous adults is one and a half times higher than in the non-indigenous population. Being obese is linked to Syndrome X, a major problem in the Indigenous population (see figure 3.2). Indigenous Australians are also 1.2 times more likely to report hypertension, a risk factor for stroke and heart disease. As well as experiencing higher rates of obesity and hypertension, Indigenous Australians also experience higher rates of impaired glucose regulation. Indigenous Australians experience diabetes and high blood glucose levels at rates 3.2 times higher than the rest of the population. They are also more likely to develop diabetes at a younger age and die from it earlier than the non-indigenous population. Indigenous mothers are almost twice as likely to give birth to a baby with low birth weight when compared with non-indigenous Australians. Low birth weight is associated with a range of short- and long-term negative health outcomes, including foetal and neonatal death and morbidity, inhibited growth and brain development, and the development of chronic diseases later in life. f live births to Aboriginal elesson: Ear disease rife in Qld Indigenous communities Searchlight ID: eles-0218 FIgURE 3.1 Age distribution of deaths among Indigenous and non-indigenous Australians, Source: Adapted from Australian Institute of Health and Welfare Mortality and life expectancy of Indigenous Australians: 2008 to Cat. no. AIHW 140. Canberra: AIHW. Variations in health within Australia CHAPTER 3 99

5 3.1 Variations in health within Australia FS or Torres Strait Islander mothers in 2012, 11.8 per cent were classified as low birth weight, compared with 6.0 per cent for live-born babies of non-indigenous mothers. Babies of Indigenous mothers were also more likely to be premature (13.3 per cent), compared with babies of non-indigenous mothers (8 per cent). In 2012, the perinatal mortality rate for babies born to Indigenous mothers (14.9 deaths per 1000 live births) was significantly higher than that for babies born to non-indigenous mothers (9.4 per 1000 births). Syndrome X or metabolic syndrome High blood pressure Type 2 diabetes Renal failure leading to dialysis or transplantation Premature death Syndrome X gives an increase of six times the average rate of premature death. U N C R R EC FIgURE 3.2 Syndrome X, or metabolic syndrome, has a profound effect on the health of Indigenous people. Source: Australian Medical Association Report Card Series 2005 Aboriginal and Torres Strait Islander Health, AMA, Strokes TE D Heart disease heart failure/ heart attacks PA G E PR The Australian Aboriginal and Torres Strait Islander population is being decimated not by a single disease but a collection of diseases, which have been named collectively as Syndrome X, or the metabolic syndrome. This syndrome is the combination of several unhealthy factors including abdominal fat, low levels of good cholesterol (high-density lipoprotein or HDL), high levels of triglycerides (a bad blood fat), high blood pressure and high blood sugar with high insulin levels meaning that the body is resistant to the effects of insulin. Syndrome X isn t a disease in itself. It is the name for a collection of simultaneously occurring conditions that cause an increased risk of disorders such as diabetes and heart disease. FIgURE 3.3 Having a good birth weight increases the chance of optimal health in later life. 100 UNIT 3 Australia s health c03variationsinhealthwithinaustralia.indd June :34 PM

6 Behavioural determinants The behavioural determinants that contribute to differences in health status between Indigenous and non-indigenous Australians include: higher rates of tobacco smoking including during pregnancy (known as maternal smoking) higher rates of alcohol consumption and illicit drug use lower rates of physical activity poor dietary intake unsafe sexual practices lower vaccination rates. Indigenous Australians are more likely to smoke cigarettes than their non- Indigenous counterparts including when pregnant (see table 3.1). This contributes to the higher rates of cancers, cardiovascular disease, respiratory disease and low birth weight babies experienced by Indigenous Australians. Alcohol misuse is more common in Indigenous Australians than non-indigenous Australians (see table 3.1). This is despite the fact that more Indigenous Australians abstain from drinking alcohol compared with the non-indigenous population. Alcohol abuse is linked to obesity, type 2 diabetes, cardiovascular disease, liver disease and injuries, and may contribute to the higher rates of these conditions among the Indigenous population. TAblE 3.1 Percentage of Indigenous and non-indigenous people displaying selected risk factors, including the Indigenous to non-indigenous ratio Behavioural risk factor Total Indigenous (%) Total non-indigenous (%) Indigenous to non-indigenous ratio Current smoker : 1 Maternal smoker : 1 Risky alcohol consumption single occasion (a) : 1 Risky alcohol consumption lifetime risk : 1 (a) Consumed alcohol at risky levels for short-term harm at least monthly Source: AIHW National Drug Strategy Household Survey detailed report: Drug statistics series no. 28. Cat. no. PHE 183. Canberra: AIHW and Hilder L, Zhichao Z, Parker M, Jahan S, Chambers GM Australia s mothers and babies Perinatal statistics series no. 30. Cat. no. PER 69. Canberra: AIHW. Data from the 2013 National Drug Strategy Household Survey reports that illicit drug use in Australia is more widespread among the Indigenous population than the non-indigenous population, with 24.1 per cent reporting recent use of an illicit drug compared with 14.2 per cent among non-indigenous people. There is no reliable national data on petrol sniffing, but case studies indicate that the practice continues to be a major problem in some Indigenous communities. Drug use is associated with higher rates of blood-borne infections, low birth weight babies, malnutrition, mental illness and injury. Physical activity levels are lower than in the non- Indigenous population. Lack of physical activity increases the chance of becoming obese, which in turn is a risk factor for health conditions such as diabetes and cardiovascular disease. Indigenous people s diet has changed significantly since colonisation. The traditional diet was high in fibre and protein and low in saturated fats. The current diet of many Indigenous Australians includes processed carbohydrates and saturated fats. Such a diet, coupled with physical inactivity, has increased the risk of obesity, cardiovascular diseases, some cancers and diabetes mellitus. FIgURE 3.4 Food that formed the traditional Indigenous diet, such as this kangaroo meat, is high in protein and low in fat. This is in stark contrast to many of the foods introduced by European settlers. Variations in health within Australia CHAPTER 3 101

7 3.1 Variations in health within Australia Indigenous people suffer from higher rates of STI than other Australians, suggesting that more Indigenous Australians participate in unsafe sexual practices. The rates for most STIs are higher for the Indigenous population with some STIs, such as gonorrhoea, being much higher (14 times the rate when compared to non- Indigenous Australians) (UNSW, 2014). According to Immunise Australia (2015), between 2012 and 2014 about five per cent fewer one year olds were fully vaccinated in the Indigenous population compared to non-indigenous one year olds. Not being vaccinated increases the risk of numerous infectious diseases, including measles, mumps and whooping cough, which affects morbidity and mortality figures. Physical environment determinants The physical environment determinants that contribute to variations in health status for Indigenous Australians include: poorer quality and overcrowded housing poorer quality water and sanitation systems poorer infrastructure, including poorer road quality lack of access to recreational and health care facilities. In 2008, 28.2 per cent of houses in Indigenous Australian communities required major repair or replacement. These dwellings posed many risks to the health of Indigenous Australians, including increased risk of injury, disease and mental health problems. Much of the housing in Indigenous Australian communities is substandard with regards to shelter, drinking water and sanitation. Twelve per cent of Indigenous Australians were reported to be living in overcrowded housing in 2011 which places a strain on bathroom, kitchen and laundry facilities. This strain can lead to unhygienic living conditions and increased risk of infections and mental health issues. Most Australians have access to one of the cleanest and most reliable water supplies in the world, but the 2006 Community Housing and Infrastructure Needs Survey (the most recent data available) found that 48 of the 148 Indigenous communities (about people) that were tested had drinking water supplies that failed testing at least once in the 12 months before the survey. f the people covered in the survey, 59 per cent (about forty-eight thousand, five hundred people) also reported experiencing an interruption to their water supply in the previous 12 months. Sewerage systems are also inadequate in many Indigenous communities. In 2006, 40 per cent of Indigenous communities (about thirty thousand people) experienced a sewerage leak or overflow. Lack of clean water and sanitation has been shown to increase the risk of infectious diseases including gastroenteritis, diarrhoea, dysentery and cholera, and can be particularly dangerous for children, who are likely to experience repeated infections. Increased morbidity and mortality rates can also be attributed to a lack of clean water and sanitation in Indigenous communities. Indigenous Australians living in rural and remote areas are less likely to have access to a fluoridated water supply, which contributes to the higher rates of dental decay in those areas. The Indigenous population has lower levels of access to, and use of, health services and resources such as Medicare-funded services, the Pharmaceutical Benefits Scheme (PBS, subsidised medication) and private GPs. About 26 per cent of Indigenous Australians live in remote areas, compared to 2 per cent of the rest of the population, which makes service delivery and access to services more difficult for many. As a result, conditions may go undiagnosed or untreated, which may limit treatment options and increase morbidity and mortality rates. Indigenous Australians living in rural and remote areas are exposed to aspects of the physical environment that can increase the risk of injuries and deaths from road crashes, including unsealed roads and poorer lighting at night. 102 UNIT 3 Australia s health

8 Indigenous Australians living in remote areas may lack access to recreational facilities, which can contribute to sedentary lifestyles. This can further increase the risk of obesity, cardiovascular disease and type 2 diabetes. Social determinants A range of social determinants contribute to the variations in health status experienced between Indigenous and non-indigenous Australians, including: lower levels of education and income higher unemployment rates social exclusion, including discrimination food insecurity early life experiences access to health care. Indigenous Australians are more likely to experience low socioeconomic status than other Australians. According to the Australian Institute of Health and Welfare (2010), Indigenous Australians reported lower incomes, poorer education achievements and lower rates of home ownership than other Australians. In , Indigenous Australians were more than four times as likely to be unemployed (18.9 per cent compared with 4.3 per cent). There is a relationship between unemployment and a range of variations in health status, including reduced overall feelings of wellbeing and increased rates of cardiovascular disease, mental health problems and lung cancer. Lower socioeconomic status also places Indigenous Australians at greater risk of behaviours such as smoking and alcohol misuse, which further contribute to obesity, diabetes, cardiovascular disease and lung cancer. According to an Australian Labor Party report (2007), there is no community more social[ly] excluded than Australia s Indigenous people. Social exclusion has been an issue for Indigenous Australians since European settlement and this has generated a sense of alienation that is not easily rectified. In a report by the WH ( Solid facts ), social exclusion also results from racism, discrimination and unemployment. Racial discrimination complaints still form more than 10 per cent of all complaints received by anti-discrimination bodies in NSW, Queensland, SA, WA and NT, many of which involve Indigenous Australians. Social exclusion contributes to a range of physical and mental health problems and to the higher rates of morbidity and mortality experienced by Indigenous Australians. Indigenous Australians are significantly (3.4 times) more likely to report food insecurity compared with those in the general population in major cities (AIHW, 2008). Early life experiences including maternal tobacco, alcohol and drug use are thought to contribute to variations in health status between Indigenous and non- Indigenous Australians, including higher rates of: low birth weight babies some infections among infants foetal alcohol spectrum disorder under-five mortality cardiovascular disease type 2 diabetes. Cultural barriers contribute to the decreased rate of many Indigenous Australians accessing Western medicine. Many Indigenous people feel Western medicine is culturally inappropriate and associate hospitals with death. As a result, many conditions go unchecked for extended periods of time, which can increase morbidity and mortality rates, and reduce life expectancy. Figure 3.5 is a summary of determinants affecting the health of Indigenous Australians. Education is linked to socioeconomic status and better health outcomes. People who receive more formal education are more likely to have better health as they get older. Indigenous people have lower educational outcomes than non-indigenous Australians: 45.4 per cent of Indigenous people who started year 7 finished year 12 compared to 77.3 per cent of the non- Indigenous population (ABS, Australian schools statistics, 2009). Variations in health within Australia CHAPTER 3 103

9 3.1 Variations in health within Australia FS Higher rates of smoking, alcohol and drug misuse Lower levels of physical activity High fat diet High rates of unsafe sexual practices Lower immunisation rates E Social Poor quality housing vercrowded housing Lack of geographical access to health care and recreation facilities Poor infrastructure in some remote areas, such as poor quality roads, and poor quality water supply and sanitation facilities PR Physical environment Low socioeconomic status Social exclusion Higher rates of food insecurity Cultural barriers to accessing health care R R Car crash tragedy: the hidden Indigenous toll U N C Aborigines and Torres Strait Islanders are three times more likely to die in vehicle accidents than other Australians, with crashes causing more Indigenous deaths than any other type of injury, apart from suicide. While violence in Indigenous communities often sparks media and political attention, a recent forum on Indigenous safety was told 26.3 per cent of all fatal injuries to Aborigines and Torres Strait Islanders were transport related. Suicide claims 26.4 per cent. Figures presented at the forum from an Australian Institute of Health and Welfare report also revealed that for every Indigenous people, 135 are seriously injured in transport incidents each year. This compared with a rate of 85 per among the non-indigenous population. A leading Aboriginal health researcher said several factors contributed to the high death and injury rate 104 verweight/obesity Hypertension Impaired glucose regulation Low birth weight Behavioural EC Case study By Deborah Gough TE D FIgURE 3.5 Summary of the determinants of health contributing to the health status of Indigenous Australians Biological PA G Life expectancy about ten years less than other Australians Higher mortality rates in each age group Infant mortality 1.5 times higher than the rest of the population Half as likely to rate health as excellent or very good Burden of disease rates 2 3 times higher than the non-indigenous population Injury death rates three Health status times higher than that experienced by non-indigenous people Higher rates of chronic conditions including cancer, arthritis, asthma and cardiovascular disease High or very high levels of psychological distress experienced at 3 times the rate of the non-indigenous population Diabetes/high glucose rates 3.5 times higher than the rest of the population Chronic kidney disease rates 2 times higher than the rest of the population Higher rate of dental decay and gum disease including the distance to the nearest medical centre and the fact that people driving on private property, including native title land, did not have to wear seatbelts, be licensed, adhere to basic road rules or observe speed limits. The report also found that Indigenous pedestrians were five times more likely to be fatally injured in a transport accident than other Australians. This may be due, in part, to remote communities having poor street lighting and no footpaths. The institute study by Flinders University researchers Geoff Henley and James Harrison looked at four years of data to 2007 for fatalities and five years of data to 2008 for serious injuries. The Indigenous Road Safety Forum, held earlier this month in New South Wales, resolved to call for the National Road Safety Council to introduce uniform road rules between the states, to make baby capsules more easily available in remote areas and to introduce pre-licence programs with basic road safety messages in Indigenous communities. UNIT 3 Australia s health c03variationsinhealthwithinaustralia.indd June :34 PM

10 A researcher for the Flinders Aboriginal Health Research Unit, in South Australia, Yvonne Helps, said road conditions and the distance from health services and hospitals had an impact. She also said drivers on private land often travelled much faster and were required to cover vast distances. Fatigue can be an issue, Mrs Helps said. There is a lot of pressure, particularly from elders on young people to drive to funerals, even if a driver might not be licensed or know how to drive. Case study review 1 (a) Identify the two leading causes of injury death among Indigenous Australians. (b) What percentage of injury deaths do these two causes contribute to? 2 Compare the morbidity rate due to injuries between Indigenous and non-indigenous Australians. 3 Discuss the determinants that may account for the differences in injury deaths between Indigenous and non-indigenous Australians. 4 Explain why those driving on private property may be more likely to be injured compared with those driving on public roads. 5 (a) How many times more likely were Indigenous pedestrians to be fatally injured? (b) Discuss reasons that may account for this difference. 6 Discuss ways that physical, social and mental health may be affected for: (a) a person injured in a car crash (b) the family of someone fatally injured in a car crash. TEST your knowledge 1 (a) Based on figure 3.1, approximately what percentage of deaths occurred in the under 65s for: the Indigenous population the non-indigenous population? (b) Suggest two reasons that might account for this difference. 2 What is the life expectancy for male and female Indigenous people? 3 (a) What is the Indigenous to non-indigenous ratio for diabetes? (b) What does this number mean? 4 List three diseases that Indigenous people suffer from more compared to non-indigenous people. 5 (a) According to table 3.1, what ratio of Indigenous people smoke compared with non-indigenous people? (b) List the variations in health status this difference may lead to. She said Aboriginal mothers often held babies in the front seat because they did not want them to be scared in the back seat, but the safety message was slowly being heard. When you point out the number of funerals they are going to and why, they begin to see the need to change, she said. Sunday Age (Melbourne) 28 November (a) Explain what is meant by Syndrome X. (b) Suggest two ways that someone could reduce their chances of developing Syndrome X. APPlY your knowledge 7 Which of the risk factors listed in table 3.1 pose the greatest risk to: (a) Indigenous people? Why? (b) non-indigenous people? Why? 8 List two conditions that someone with Syndrome X may be at a greater risk of developing. 9 How could not finishing school lead to poor health outcomes? Draw a flowchart to illustrate. 10 List the examples of determinants of health and explain how each could contribute to the following variations in health status: (a) higher rates of death from injuries in Indigenous people (b) higher rates of infant mortality in Indigenous people (c) higher rates of cardiovascular disease in Indigenous people (d) higher rates of diabetes in Indigenous people. (continued) Variations in health within Australia CHAPTER 3 105

11 3.1 Variations in health within Australia 11 (a) How many Indigenous Australians were unemployed in compared with non- Indigenous Australians? (b) Make a list of the factors that could contribute to this difference. 12 Draw a flowchart that illustrates how poor housing could lead to poor health. 13 Use the Indigenous health success links in the Resources section of your ebookplus to find the weblink and questions for this activity. 14 Use the Better Indigenous health links in the Resources section of your ebookplus to find the weblink and questions for this activity. 106 UNIT 3 Australia s health

12 3.2 Variations in health status: males and females KEY CNCEPT The variations in health status as experienced by male and female Australians and the determinants that explain the differences Males and females The health status of males in Australia has always been below the health status of females. There have been some improvements in recent decades, but males are still not expected to live as long as females and experience a range of conditions at higher rates than their female counterparts. Although the life expectancy for males has been steadily increasing, they are still more likely to die at every lifespan stage. A male baby born in 2013 is expected to have a lifespan about four years shorter than a female baby born at the same time. According to the Australian Bureau of Statistics, males: have higher rates of injury than females. The male death rate from injury is about twice the female death rate from injury have higher rates of deaths due to suicide, road trauma and violence suffer higher rates of cancer. By age 75, one in three males and one in four females will have been diagnosed with some form of cancer. Males are also more likely to develop melanoma (by age 75, one in 22 males and one in 33 females have been diagnosed with melanoma) (AIHW, Cancer in Australia, an overview, 2012). have higher rates of diabetes (6 per cent of males compared with 4 per cent of females) are more likely to be diagnosed with cardiovascular disease and mortality rates due to these conditions are also higher when compared with females (185.6 and deaths per people respectively). TAblE 3.2 Leading causes of death as a percentage of all deaths, 2012 Rank Cause Males Females % of all male deaths Rank Cause % of all female deaths 1 Coronary heart disease Coronary heart disease Lung cancer Dementia and Alzheimer s 9.6 disease 3 Cerebrovascular diseases (including stroke) Cerebrovascular diseases (including stroke) Chronic obstructive pulmonary disease 5 Dementia and Alzheimer s disease Lung cancer Chronic obstructive pulmonary disease 6 Prostate cancer Breast cancer Blood cancers (including leukaemia) Diseases of the urinary system 8 Colorectal cancer Diabetes Diabetes Heart failure Intentional self-harm Colorectal cancer 2.5 * See interest box. Source: Adapted from ABS, Causes of death, Australia, FIgURE 3.6 Males are more likely to be injured at every lifespan stage and experience higher rates of injury. Chronic obstructive pulmonary disease (CPD) is an umbrella term for a number of conditions that restrict the airways and therefore make breathing difficult. The two most common forms of CPD are emphysema and bronchitis. Variations in health within Australia CHAPTER 3 107

13 3.2 Variations in health status: males and females Unit 3 AS 1 Topic 4 Concept 1 Per cent Do more Variations of health status between males and females The types of long-term conditions suffered are similar for both males and females, although there are some areas where males fare better than females: males experience lower rates of osteoporosis (see figure 3.7); 85 per cent of all osteoperosis cases occur in females males experience lower rates of arthritis than females (11.8 per cent of males compared to 17.7 per cent of females) males report slightly fewer cases of long-term mental and behavioural problems: 12 per cent of males compared with 15.1 per cent of females in Males Females Proportion of persons with osteoporosis, years and over Age group (years) Note: Based on self-reports of having a doctor s diagnosis of osteoporosis FIgURE 3.7 Prevalence of osteoporosis, by age group, Source: ABS, Australian Health Survey: first results, Determinants of health A range of factors contribute to the variations in health status experienced by males and females. Biological determinants The biological determinants that contribute to the variations in health status experienced by males when compared to females include: increased body weight hypertension genetics, including sex and hormones. Although the numbers of obese males and females are the same (27.5 per cent), the number of overweight individuals is much higher in the male population (42.2 per cent of males compared with 28.2 per cent of females). Males are more likely to experience hypertension until they are in the age group. From this age group onwards, females are more likely to experience hypertension. Across all age groups, 23.4 per cent of males experience hypertension compared to 19.5 per cent of females. Males tend to store more fat around their abdomen, which is associated with greater health risks, especially cardiovascular disease. Cardiovascular disease is more common in males in almost all countries and cultures around the world. At this stage, research is still being conducted to ascertain the exact genetic difference that leads to this variation. 108 UNIT 3 Australia s health

14 Declining amounts of oestrogen at menopause have been shown to accelerate the loss of bone density and therefore contribute to higher rates of osteoperosis among females over the age of 60. The debate continues with regards to the protective nature of oestrogen in relation to heart disease. Behavioural determinants The behavioural determinants that contribute to differences in health status between males and females include: higher rates of tobacco smoking risky alcohol consumption poor dietary intake being less likely to access health care being less likely to take notice of health promotion messages being more likely to engage in risk taking behaviour. Tobacco smoking is a leading risk factor for preventable death in Australia. Males used to smoke at much higher rates than females and although more males still smoke when compared to females (18.3 per cent of males and 14.7 per cent of females) the rates are much closer than they were previously. Smoking increases the risk of cardiovascular disease, respiratory problems and many forms of cancer. Compared to females, males are about twice as likely to consume alcohol at levels that put them at risk of harm both in the short and long term. Short-term risks include violence and injuries, which males experience at higher rates than females. Long-term risks of alcohol consumption include weight gain, cardiovascular disease, diabetes and some cancers. Both short- and long-term risks contribute to the higher rates of premature mortality experienced by males. Males tend to have less healthy diets than females. Males are more likely to eat saturated fat and less likely to eat fruit and vegetables. These trends contribute to the higher rates of overweight and hypertension among males. Males are less likely to visit doctors and take care with their health. Many Australian males still tend to have a more casual attitude with regards to checkups and visiting doctors when they feel unwell. As a result, many conditions in males are not detected until late stages where treatment options may be limited. This can increase the burden of disease among males and may contribute to their lower life expectancy. Males are less likely to take notice of health promotion messages and as a result are less likely to get skin checks for skin cancer, screening for prostate cancer and general checkups from their GP. This contributes to increased rates of morbidity and mortality for many conditions among males. Males are more likely to take unnecessary risks throughout their lives, such as speeding in a car and diving off structures into water. They are also more likely to take risks while under the influence of alcohol, which contributes to the higher rate of injury deaths experienced by males (see figure 3.9). Deaths per FIgURE 3.8 Males are less likely to take notice of health promotion messages. Source: ABS, Causes of death, various years Male Female Year FIgURE 3.9 Trends in death rates for injury and poisoning, Variations in health within Australia CHAPTER 3 109

15 3.2 Variations in health status: males and females FIgURE 3.10 Jobs such as mining involve a certain amount of risk. Physical environment determinants The work environment is the main physical environment determinant that contributes to differences in health status between males and females. Males are more likely to work in industries such as trades, farming and mining. The physical environments associated with these occupations can increase the risk of serious injury and death. These workplaces often involve the use of heavy machinery and tools, and exposure to hazardous substances such as chemicals and asbestos. As a result, males are more likely to be injured or killed at work. f the 190 work-related deaths recorded in 2013, 176 (92 per cent) involved male workers. The fatality rate for male workers was 10 times the rate for female workers. Males are more likely to work outside and therefore have increased exposure to UV rays. This could explain the higher rates of melanoma and other skin cancers in males. Males are also more likely to work in transport, which can lead to extended periods of time on public roads. This increases the risk of injury and death associated with road trauma. Social determinants A range of social determinants contribute to the variations in health status experienced by males compared to females, including: impacts of unemployment higher socioeconomic status being less likely to care for children gender. The effects of unemployment can be particularly influential on the health of males. Males have traditionally been the breadwinners of the family and many males feel it is their duty to provide material resources for the family. An inability to do this can make males feel inadequate and stressed, which affects mental health. Males who are unemployed experience greater rates of morbidity and mortality compared to unemployed females. Specifically, rates of obesity, cardiovascular disease and suicide are higher for unemployed males. 110 UNIT 3 Australia s health

16 Case study National men s health plan a first; suicide prevention study a priority By Jewel Topsfield A national men s health policy will be developed for the first time in Australia, after alarming statistics reveal that men are three times more likely than women to commit suicide. More than 90% of people who die from AIDS are men, as are 74% who die from transport accidents and 69% who die from cancer of the oesophagus, according to a discussion paper released yesterday. Health Minister Nicola Roxon said men s health was too often overlooked, with women expected to live 4.8 years longer than men. Men s health deserves attention. ver the next 12 months, the Government will develop a comprehensive men s health policy, she said. As an initial down payment, the Government would spend $ on a national suicide prevention study and $ to encourage men to see their GP, she said. f the suicide funding, $ would go to building industry organisation Incolink, in Victoria, to undertake a program for apprentices aimed at preventing suicide. The men s health policy will also focus on groups with greater health problems, such as Aborigines and Torres Strait Islanders and men from rural areas. The health of Indigenous men is significantly worse than for any other group in Australia, with an average life expectancy of only 59 years, some 20 years less than non-indigenous Australian males, she said. The discussion paper, Setting the Scene, said the kinship system had ensured, historically, that Aboriginal and Torres Strait Islander men had clearly defined responsibilities and obligations. FIgURE 3.11 The suicide rate among male farmers is higher than the national average. Aboriginal and Torres Strait Islander men have been displaced, and do not have the confidence, opportunity or facilities available to help them improve their health, it said. It also said the suicide rate among male farmers was about twice the national average and rural men often did physically demanding and potentially hazardous work on their own in isolated areas. Cultural factors and beliefs also contribute to differences such as rural men who are overweight believing that being a big bloke is an advantage and sign of strength. The discussion paper said many of the risk factors that caused chronic illnesses remained high among men, including smoking, physical inactivity, poor diet and alcohol misuse. Men were over-represented in deaths from lung cancer, emphysema and liver diseases. Australian men have the second highest rate of bowel cancer in the world, after New Zealand. The national men s health policy is expected to be completed next year, with consultation to take place in each state and territory. Source: The Age, 9 June Case study review 1 How many times more likely are men to commit suicide? 2 Suggest reasons why men are more likely to commit suicide. 3 Why might farmers be more likely to commit suicide? 4 List three causes of death where men are over-represented. 5 Develop a strategy that would encourage men to visit their GP. 6 What benefits to health could be achieved by regularly visiting a GP? Variations in health within Australia CHAPTER 3 111

17 3.2 Variations in health status: males and females According to the ABS (2014), males employed on a full-time basis earn higher incomes on average than females employed full time ($ per week compared to $ per week). As a result, males often have a higher socioeconomic status than females, especially those who are single parents. Low socioeconomic status is associated with lower health status. Males are less likely to be carers of children. This means that some men have more opportunities for adult contact than some women. Women who provide fulltime care may experience a form of social isolation, which can impact their mental health. Females who don t get the opportunity to communicate with people their own age may bottle up problems and issues, which can impact their mental health. Gender relates to the aspects of life that are traditionally considered to be masculine or feminine and is an example of a social determinant. Some aspects of gender can be detrimental to the health of males. Examples include: occupations. Physically laborious jobs are generally considered to be masculine. This can increase the risk of injury in the workplace for males undertaking these jobs sports. Contact sports such as Australian Rules Football and Rugby League are generally considered to be masculine sports. These sports can increase the risk of injuries among males accessing health care. According to the Australian Institute of Health and Welfare (2011), males may be less likely to access health care than females as a result of social norms and values associated with a traditional view of masculinity selfreliance, suppression of emotion and perseverance in the face of pain or discomfort. The media also play a role in defining masculinity and femininity. For example, many researchers have indicated that the way the media represent beauty, especially of females, has contributed to increasing rates of eating disorders and the greater proportion of eating disorders among females compared to males. Female beauty is often portrayed by thin models, whereas male beauty is often portrayed by muscular individuals. These representations may have an effect on eating and exercise patterns, particularly among male and female youth. Peer pressure can have differing impacts on males compared to females. Males may encourage traditional stereotypes among their peers when in groups with other males. This can include the use of violence to resolve conflicts, risk-taking behaviour and risky alcohol consumption. These behaviours increase the risk of injury among males. FIgURE 3.12 Gender stereotypes, such as different sports being considered masculine or feminine, can affect the type and risk of injuries males and females experience. 112 UNIT 3 Australia s health

18 Health status Higher rates of overweight Higher rates of hypertension Genetics (sex, hormones and fat deposition) Males Workplace environments, including: exposure to building sites, farms, mines, heavy machinery, tools and hazardous substances outdoor work increased time on roads PR Life expectancy around four years less than females Higher chance of death at each lifespan stage Higher rates of injury than females Higher rates of deaths due to suicide, road trauma and violence Higher rates of cardiovascular disease and many types of cancer Higher rates of diabetes Lower rates of osteoporosis Lower rates of mental and behavioural problems Physical environment Social PA G E Behavioural More males smoke Males are more likely to consume alcohol at risky levels Males eat less healthy diets Males are less likely to visit doctors Males are not as likely to take notice of health promotion messages Males take more risks FS Biological TE D Males often experience pronounced impacts of unemployment Males often have higher socioeconomic status (especially in single parent households) Gender roles and representations can have negative impacts on males Peer pressure may be more likely to negatively affect male behaviour EC FIgURE 3.13 Summary of the determinants of health contributing to the health status of males R TEST your knowledge U N C R 1 What is the difference in life expectancy between males and females? 2 List two conditions that females are more likely to report suffering from. 3 (a) Identify two trends shown in figure 3.7. (b) Provide possible reasons for these trends. 4 (a) Identify two trends shown in figure 3.9. (b) Explain possible reasons for these trends. 5 Explain why males may experience more detrimental effects on their health than females when unemployed. APPlY your knowledge 6 Provide three reasons that might account for the higher death rates due to injuries in males. 7 What sort of short-term consequences would males be more likely to suffer from as a result of alcohol consumption? 8 Males are more likely to be overweight or obese. Which conditions does this put males at higher risk of developing? 9 Why might males suffer fewer deaths from Alzheimer s disease and dementia than females? 10 Which differences in determinants of health may explain the following? (a) Males have higher rates of diabetes. (b) Males experience higher rates of cancer. (c) Females report higher rates of long-term mental and behavioural problems. 11 Suggest reasons for the following statements. (a) According to the AIHW, smoking rates for males and females are fairly similar (20 per cent of males, 16 per cent of females), yet the rate of lung cancer is much higher for males. (b) The death rate for prostate cancer is higher than the rate for breast cancer, yet breast cancer tends to get more funding. 12 Why might the rates of lung cancer deaths have fallen for males yet increased for females? Variations in health within Australia CHAPTER 3 c03variationsinhealthwithinaustralia.indd June :34 PM

19 3.3 Variations in health status: socioeconomic status groups KEY CNCEPT The variations in health status as experienced by higher and lower socioeconomic groups in Australia and the determinants that explain the differences verall lower health and wellbeing Low socioeconomic status FIgURE 3.14 The social gradient FIgURE 3.15 Potentially avoidable mortality rates, by sex and socioeconomic status, Source: AIHW Mortality inequalities in Australia Key differences in health status Higher and lower socioeconomic status groups People in the highest socioeconomic status (SES) groups tend to have more choices and resources available to them and therefore enjoy better health outcomes. People with the lowest socioeconomic status are at the other end of the spectrum. Health and wellbeing tend to improve for each step taken towards the highest socioeconomic status level (see figure 3.14). People living in lower socioeconomic status groups have: lower life expectancy (life expectancy is around three years lower for the most disadvantaged groups) mortality rates 1.3 times higher than the higher socioeconomic status groups higher infant mortality rates higher rates of disability higher mortality rates from cardiovascular disease, lung cancer, type 2 diabetes, respiratory diseases and injuries more potentially avoidable deaths (see figure 3.15). Potentially avoidable deaths are deaths that might have been avoided through prevention, or through treatment, within the current health system. Examples include deaths due to road traffic accidents, lung cancer, diabetes and skin cancer (AIHW 2014). Deaths per population (Lowest: SES) verall higher health and wellbeing High socioeconomic status The effect of socioeconomic status on health is known as the social gradient of health. Those at the top of the social gradient experience better health outcomes than those further down the gradient, as shown in figure Males Females (highest SES) 114 UNIT 3 Australia s health

20 Low socioeconomic status groups also experience higher rates of morbidity relating to a range of conditions (see figure 3.16), specifically: higher rates of cardiovascular disease twice the rate of type 2 diabetes higher rates of mental and behavioural problems higher rates of arthritis higher rates of mental and behavioural problems higher rates of asthma and chronic obstructive pulmonary disease (CPD). Asthma Arthritis Heart, stroke and vascular disease Chronic obstructive pulmonary disease Diabetes (type 2) Mental and behavioural problems Per cent Determinants of health Lowest SES group Highest SES group People from low socioeconomic status groups tend to have poorer health as they experience higher levels of risk factors with regards to most indicators. Biological determinants The biological determinants that contribute to the variations in health status among low socioeconomic groups compared to the rest of the population include higher rates of: overweight/obesity hypertension impaired glucose regulation low birth weight babies. besity rates are higher for those in low socioeconomic status groups. As socioeconomic disadvantage increases, so does the rate of overweight /obesity (see figure 3.17). This contributes to lower life expectancy largely due to the increased rates of death from cardiovascular disease and diabetes. Rates of hypertension are higher among low socioeconomic status groups, which contributes to the higher rates of cardiovascular disease experienced by this group. Rates of impaired glucose regulation are also higher among low socioeconomic status groups. This contributes to higher rates of type 2 diabetes. People experiencing socioeconomic disadvantage are more likely to give birth to low birth weight babies. Babies born into low socioeconomic status families in 2011 were 30 per cent more likely to have a low birth weight compared with those of high socioeconomic status (7.2 per cent compared with 5.4 per cent respectively). This contributes to higher rates of under-five mortality, infection and disability among low socioeconomic groups. FIgURE 3.16 Prevalence of morbidity relating to a range of conditions across socioeconomic groups Source: ABS, Australian Health Survey elesson: The socioeconomically disadvantaged Searchlight ID: eles-1055 Variations in health within Australia CHAPTER 3 115

21 3.3 Variations in health status: socioeconomic status groups FIgURE 3.17 Prevalence of overweight/obesity by socioeconomic status Source: ABS, Australian Health Survey Per cent Group 5 (lowest socioeconomic status) Group 4 Group 3 Socioeconomic group 60.5 Group Group 1 (highest socioeconomic status) Behavioural determinants The behavioural determinants that contribute to differences in health status experienced by low socioeconomic status groups include: high rates of tobacco smoking (including maternal smoking) low levels of physical activity poor dietary intake (including lower rates of breastfeeding). People from low socioeconomic status groups are more than twice as likely to smoke compared with the most socioeconomically advantaged (see figure 3.18). This contributes to higher mortality and morbidity from respiratory diseases, cardiovascular diseases and lung cancers. According to the AIHW (2012), mothers in the lowest socioeconomic status groups were more than four times as likely to have smoked in pregnancy than those in the highest socioeconomic status groups (23 per cent and 5 per cent respectively). This contributes to higher rates of respiratory conditions such as asthma and low birth weight among babies born to mothers living in low socioeconomic environments. People with a low socioeconomic status are more likely to be physically inactive (see figure 3.18). Those with less than 12 years of schooling are nearly twice as likely to be sedentary compared with those with tertiary education, which increases the risk of a range of conditions such as obesity, diabetes, cardiovascular disease and some cancers. Per cent Socioeconomic group 51.8 Insufficient physical activity Current smoker FIgURE 3.18 Prevalence of daily smoking and insufficient physical activity by socioeconomic group, Source: ABS, Australian Health Survey (lowest SES) (highest SES) UNIT 3 Australia s health

22 People in low socioeconomic status groups are less likely to consume fruit and vegetables. This may partly explain the higher rates of obesity, cardiovascular disease and type 2 diabetes experienced by these groups. Women from low socioeconomic status groups are less likely to breastfeed their babies when compared with women from higher socioeconomic status groups. Breastfeeding is another aspect of dietary behaviour that can have benefits for both the mother and the baby. As well as the nutritional and economic benefits, it also helps the baby to reach their genetic potential and provides antibodies that can reduce the risk of infection for the infant and therefore reduce morbidity and mortality rates. Physical environment determinants Suburbs where socioeconomic disadvantage is greater are often the suburbs with the highest number of fast food outlets. Fast food is generally higher in fat, salt and sugar than other options (see the case study on page 115). Living in close proximity to such venues may increase the likelihood of people consuming these foods. People in low socioeconomic status groups are often less educated about healthy eating and may be more likely to be influenced by marketing. People of low socioeconomic status may not be able to afford high quality housing. As a result, they may experience: overcrowding, which can put strain on sanitation facilities, resulting in an increased rate of infection. vercrowding can also result in increased rates of psychological distress inadequate cooking facilities, which can contribute to a reliance on processed foods. This can contribute to obesity, cardiovascular disease, type 2 diabetes and some cancers an unsafe physical environment. If there are hazards around the home, the risk of injury may be increased closer proximity to industrial sites. This can increase the level of noise pollution, which can contribute to anxiety and stress. People living in socioeconomic disadvantage are more likely to work in jobs that have dangerous working environments, such as factories and manufacturing plants, and involve exposure to toxic substances and heavy machinery. This may contribute to higher rates of illness and injury. As smoking rates are higher among low socioeconomic groups, children and nonsmoking adults in these groups have an increased risk of exposure to environmental tobacco smoke. This increases the risk of respiratory diseases such as asthma and other conditions including cancer and cardiovascular disease. According to AIHW data (2012), children living in households in the lowest SES areas were four times as likely as those in the highest SES areas to be exposed to tobacco smoke in the home (12 per cent compared with 3 per cent). According to the 2010 General Social Survey (ABS), people living in areas with the highest SES were more likely to feel safe or very safe at home alone both during the day and at night (88%) than those living in the lowest SES areas (72 per cent). Those living in areas with the highest SES were more likely to report feeling safe or very safe (71 per cent) walking in their local area at night than those living in areas with the lowest SES (41 per cent). Lower feelings of safety in the home and neighbourhood can increase anxiety and stress, and contribute to higher rates of mental health issues among low socioeconomic status groups. Social determinants A range of social determinants contributes to the variations in health status experienced by low socioeconomic groups, including: lower levels of education Unit 3 AS 1 Topic 4 See more The social gradient of health Concept 2 Variations in health within Australia CHAPTER 3 117

23 3.3 Variations in health status: socioeconomic status groups FIgURE 3.19 Education comes in many forms and is relate to health outcomes. lower incomes lower status jobs lower levels of health literacy higher rates of unemployment higher rates of social exclusion higher rates of food insecurity lack of access to health care lower levels of private health insurance membership. People in low socioeconomic status groups have lower educational attainment, lower incomes and jobs with lower social status. These factors are all interrelated and all influence the lower health status experienced by these groups, including lower life expectancy, higher morbidity rates and higher mortality rates. Health literacy relates to a person s ability to find, understand and apply health information. It involves knowledge of factors such as bodily functions, signs of poor health, and where and how to seek the required information. According to the AIHW (2012), those in low SES groups have lower health literacy rates than the higher SES groups; 55 per cent of the population in the highest SES group had at least an adequate level of health literacy compared with 26 per cent of those in the lowest group. People experiencing socioeconomic disadvantage are more likely to be unemployed. As already explored, they are also more likely to experience poor health. Poor health can lead to unemployment, creating a cycle between unemployment and poor health. There is a relationship between unemployment, risk-taking behaviours and impacts on health (see figure 3.20). Socioeconomic disadvantage can also lead to social exclusion. Those who are socially excluded experience poorer physical and mental health than those who are socially connected. People living with socioeconomic disadvantage are more likely to experience food insecurity. Lack of financial resources can lead to an inability to afford nutritious foods. Higher rates of obesity and lower rates of fruit and vegetable consumption are often the product of food insecurity, which can contribute to higher rates of obesity, cardiovascular disease, diabetes and some types of cancer. Fair/poor health Two or more long-term conditions Core activity limitation or schooling/employment restriction High/very high psychological distress Current daily smoking Risky/high-risk alcohol consumption Sedentary Unemployed* Employed FIgURE 3.20 Prevalence of healthrelated factors by employment status, people aged years, Source: AIHW analysis of NHS verweight/obese *Data are for people unemployed 6 months or more. Per cent 118 UNIT 3 Australia s health

24 People from low socioeconomic status groups are also less likely to access preventative health services such as Breastscreen and cervical screens. This can lead to health conditions going undiagnosed. As a result, fewer treatment options are available once a diagnosis is made, contributing to higher rates of mortality. Those with low socioeconomic status are less likely to have private health insurance, with 75.7 per cent of the most disadvantaged not having private health insurance, compared with 28.8 per cent of the most advantaged. This can contribute to psychological distress and extend waiting times for surgery, which can increase rates of morbidity and mortality. Case study ur epicentres of fast food By Brigid Connell MELBURNE S fast-food outlets are booming across suburbs that are home to some of the city s most obese and overweight residents. But wealthy suburbs with extensive bike paths and recreation facilities have largely been left alone by the fast-food giants, which are instead concentrated in suburbs of lower socio-economic status with poorer health statistics and less opportunity to exercise. And an extra 100 stores of the major chains have popped up across Melbourne over the past 10 years. Nutrition experts have called for local councils to be given the power to refuse a fast-food building permit on health and wellbeing grounds, not just for traffic congestion or building design. Frankston was revealed as the fast-food capital outside the CBD, with 15 major outlets including six McDonald s stores in a Sunday Herald Sun survey that mapped the number of McDonald s, KFC, Red Rooster and Hungry Jack s in each suburb over the past 10 years. Six of the top 10 Melbourne local government areas with the largest proportion of obese or overweight residents each housed between 15 and 26 outlets of these fast-food chains. Monash University s head of nutrition and dietetics, Professor Helen Truby, said residents in lower socio-economic suburbs faced more barriers to healthy living. We know that there is less infrastructure for recreation in low socio-economic areas and we know that if the facilities are there such as walking tracks and bike paths people are more likely to be more active and take part in opportunistic exercise, Prof Truby said. It s a multitude of factors that build up into one big problem in these areas. It s high housing density, lack of public transport, more fast-food outlets, less recreation infrastructure and lack of availability of fresh food. Prof. Truby said councils needed the power to veto fast-food applications to help their communities make the best health choices. The survey found that the four big brands increased their reach from 270 stores in 2001 to 370 across Melbourne this year. McDonald s had the biggest increase with 39 new stores staking claim in new areas such as Rosebud, Point Cook, Abbotsford and Roxburgh Park with KFC building 35 new sites. Red Rooster added three extra stores in this decade. Areas with the lowest numbers of major fastfood outlets such as Bayside, Boroondara and Stonnington also had the largest proportion of women who were not overweight or obese. Source: Sunday Herald Sun, 24 June Case study review 1 (a) Why might fast-food outlets target socioeconomically disadvantaged areas? (b) Suggest ways of decreasing fast-food consumption in these areas. 2 What are the multitude of factors that contribute to those in low socioeconomic areas and poor health? Explain how each of these factors could contribute to variations in health status. Variations in health within Australia CHAPTER 3 119

25 3.3 Variations in health status: socioeconomic status groups Low socioeconomic status Behavioural Social PR Physical environment Greater exposure to fast-food outlets More likely to live in poor quality housing More likely to work in dangerous working environments Higher rates of exposure to environmental tobacco smoke More likely to live in neighbourhoods with more violence E Life expectancy is around three years lower for the most disadvantaged groups Higher death rates More avoidable deaths Higher infant mortality rates Higher rates of diabetes Higher rates of coronary heart disease Almost twice the rate of mental and behavioural problems Higher prevalence and mortality rates from lung cancer Higher rates of asthma and CPD Higher rates of arthritis Higher rates of mental and behavioural problems More likely to smoke, including during pregnancy Lower levels of physical activity Less likely to consume fruit and vegetables Less likely to breastfeed PA G Health status Higher obesity rates Higher rates of hypertension Higher glucose intolerance levels Higher rates of lower birth weight babies FS Biological More likely to be unemployed Lower education levels, including health literacy Higher rates of social exclusion More likely to experience food insecurity Less likely to access preventive health services Lower levels of private health insurance EC TE D FIgURE 3.21 Summary of the determinants of health contributing to the health status of low socioeconomic status groups R TEST your knowledge U N C R 1 Identify the three components that determine socioeconomic status. 2 Identify three differences in health status between low and high socioeconomic status groups. 3 What relationship exists between socioeconomic status and health status? 4 Identify two trends from figure 3.15 and suggest possible reasons for the trends. 5 From figure 3.16, which condition shows the biggest difference between high and low socioeconomic status? 6 Explain the differences in rates of overweight / obesity for lowest and highest quintiles of socioeconomic advantage as shown in figure APPlY your knowledge 7 Which risk factor is higher for employed people compared with unemployed people according to figure 3.20? Which determinants of health may influence this trend? Making reference to the determinants of health, discuss why people from lower socioeconomic status groups are more likely to suffer from mental and behavioural problems. 9 Select two examples of determinants of health from each category as presented in figure 3.21 and discuss the likely impact on health status for each one. 10 utline two possible effects on the physical, social and mental health of a child growing up in a low socioeconomic status family. 11 Suggest possible reasons why people from lower socioeconomic status groups may experience higher rates of infant mortality. 12 Many health services (such as screening for breast and cervical cancers) are available free through Medicare, yet people from low socioeconomic status groups are less likely to use them. Suggest possible reasons for this. 13 People who are born into low socioeconomic status families are more likely to belong to low socioeconomic status groups later in life. Draw a cycle diagram illustrating how this may occur. UNIT 3 Australia s health c03variationsinhealthwithinaustralia.indd June :34 PM

26 3.4 Variations in health status: rural and remote populations KEY CNCEPT The variations in health status as experienced by Australians living in rural and remote areas and the determinants that explain the differences Rural and remote populations The rural and remote landscape in Australia poses many challenges for its inhabitants. As well as factors influenced by the remoteness in which some people live, such as access to services and social isolation, many people in rural and remote areas also experience challenges from the natural environment, such as drought, bushfires and floods. verall, people in rural and remote areas experience worse health outcomes than their urban counterparts. Many people who live in rural and remote areas are of Indigenous background (26 per cent of those in remote areas are Indigenous) and are also more likely to be of lower socioeconomic status. This means that many of the health concerns for people of indigenous and low socioeconomic status are carried over to the rural and remote population. Classifying people based on geographical location is difficult in Australia as a result of the various landscapes and characteristics of this vast country. For the sake of this course, the urban population relates to those in major cities (Melbourne and Geelong), the rural population relates to those in or near regional centres (such as Bendigo and Ballarat) and the remote population includes those in remote and very remote areas (such as Genoa and Murrayville; note that, unlike other states, Victoria contains no very remote areas). Basically anyone living outside the major cities is considered rural and remote. As this definition encompasses many different groups, the variation of health status within the rural and remote population group is considerable. Using this classification, about one-third of Australia s population lives in rural and remote areas (AIHW, 2008). FIgURE 3.22 nly small areas of Victoria are considered remote. Source: AIHW, Rural, regional and remote health indicators of health status and determinants of health, March Walkenie Wentworth Dimboola Kingston S.E. Rural and remote populations experience the following health differences when compared to their urban counterparts: lower life expectancy (life expectancy decreases as the level of remoteness increases: one to two years less for rural areas and up to seven years less for remote areas) higher mortality rates higher rates of preventable cancers (lung and melanoma and detectable cancers, such as cervical cancer) higher death rates from cardiovascular disease higher rates of coronary heart disease higher rates of avoidable deaths higher rates of injury higher rates of diabetes higher rates of dental decay. Balranald Very remote Australia Remote Australia uter regional Australia N Griffith km Eden Lakes Entrance Inner regional Australia Major cities of Australia Variations in health within Australia CHAPTER 3 121

27 3.4 Variations in health status: rural and remote populations elesson: Heart disease hits hardest in rural areas Searchlight ID: eles-0216 Determinants of health A number of determinants or factors contribute to poorer health outcomes due to the location in which people live. People in rural and remote areas experience a range of environmental risk factors as well as higher rates of many biological and behavioural risk factors. Biological determinants The biological determinants that contribute to the variations in health status experienced by those living in rural and remote areas include higher rates of: overweight and obesity high blood cholesterol low birth weight babies hypertension. verweight and obesity levels are higher in rural and remote areas (about 10 per cent higher than in major cities). This puts people in rural and remote areas at higher risk of developing type 2 diabetes and cardiovascular disease. Rural and remote populations are 10 per cent more likely to experience high blood cholesterol. This contributes to the higher rates of cardiovascular disease, including hypertension, experienced by the rural and remote population. The percentage of low birth weight infants is higher in remote and very remote areas (about 8.4 per cent) compared with rates for those in major cities (6.0 per cent in 2009). This may in part be attributable to higher maternal smoking rates. People living in rural and remote areas experience higher rates of hypertension (1.2 times the rate of those in major cities). This increases the risk of cardiovascular disease and contributes to the higher burden of disease seen in these areas. Behavioural determinants The behavioural determinants that contribute to differences in health status for those living in rural and remote areas include: higher rates of tobacco smoking (including during pregnancy) higher rates of alcohol consumption lower levels of physical activity. FIgURE 3.23 Rural and remote Australia poses many challenges for its inhabitants. The natural environment is one of the challenges. 122 UNIT 3 Australia s health

28 People in rural and remote populations are more likely to smoke tobacco about twenty-one per cent compared with 15 per cent in urban areas. This increases the risk of diseases associated with tobacco smoking such as cancers, and cardiovascular and respiratory diseases. According to AIHW data (2012), about onethird (36 per cent) of mothers in very remote areas who gave birth in 2009 smoked during pregnancy three times the percentage in major cities (11 per cent). This contributes to higher rates of low birth weight babies and babies with asthma. Rural and remote populations are more likely to consume alcohol at risky levels in both the short and long term than those living in major cities. This may contribute to higher levels of overweight/obesity and diseases associated with excessive alcohol consumption, such as liver and cardiovascular diseases. It also increases the risk of injuries associated with risk-taking behaviour while under the influence of alcohol. Those in rural and remote areas are more likely to be sedentary compared to those in major cities (ABS, 2014), contributing to variations in health status including higher rates of overweight/obesity, cardiovascular disease and type 2 diabetes, and lower life expectancy. Physical environment determinants Factors within the physical environment that contribute to variations in health status for people living in rural and remote areas include: poorer road quality poorly lit roads greater driving distances and higher speed limits reduced proximity to resources such as health care, transport, recreation facilities, supermarkets and employment greater exposure to harsh climates and the effects of climate change less access to fluoridated water more dangerous working environments. In rural and remote areas, roads are generally in poorer condition, driving times and distances are longer, wildlife is more likely to cross the path of vehicles, roads may be poorly lit at night, and speed limits are often higher. All of these factors contribute to higher mortality and morbidity rates in these areas. Proximity to resources is a significant challenge for many in rural and remote areas. The location of health services, recreation facilities, transport and employment in relation to where people live may make it difficult for people in rural and remote areas to access these resources. This can contribute to a range of issues such as food insecurity, low socioeconomic status, unemployment, increased risk of morbidity and mortality, and lower life expectancy. People living in rural and remote areas may experience greater hardship with regards to climates. Drought, floods and fires can disrupt farmers and lead to unstable income. This in turn lowers socioeconomic status and increases stress levels. Climate change is also predicted to have a greater impact on those living in rural and remote areas compared to those in major cities (Climate Commission, 2011). Increased frequency of natural disasters such as fires, floods and droughts can affect physical, social and mental health. The relative isolation of those in remote areas can particularly reduce access to support services to deal with climate change. Many communities in remote areas do not have access to mains water supplies from towns or cities, which is often fluoridated. Non-fluoridated water supplies can increase dental health issues such as dental caries. Common occupations in rural and remote areas include farming, mining and fishing. All of these industries have certain risks associated with the physical environments in which they occur. According to the AIHW (2005), an undersupply of work may mean that workers accept working conditions that are more hazardous. Variations in health within Australia CHAPTER 3 123

29 3.4 Variations in health status: rural and remote populations Many jobs in rural and remote areas are based outdoors, which can increase UV exposure and increase the incidence of skin cancer. Geographical isolation also contributes to social isolation (a social determinant), which is explored in the next section. Social determinants The social determinants that contribute to variations in health status among people living in rural and remote areas include: lower incomes higher rates of unemployment less access to health care higher levels of social isolation food insecurity. People in rural and remote areas are more likely to rely on social security payments than those in major cities, which indicates that more people struggle financially in rural and remote areas. This can impact on access to an adequate food supply and health care. People in rural and remote areas experience higher rates of unemployment compared with those in major cities. Unemployment is one aspect that results in people from rural and remote areas experiencing lower socioeconomic status, which in turn contributes to lower health status, including higher rates of cardiovascular disease, diabetes, respiratory disease, injury and overall mortality. In rural and remote areas, it is much more difficult to access health care professionals. According to the Australian Bureau of Statistics (2014), in 2011 the proportion of GPs in major cities was twice that of remote areas (227.8 compared to per ), and considerably higher than the ratio of GPs in rural areas (144.9 per ). This further reduces access to GPs for those in rural and remote areas, and contributes to higher morbidity and mortality rates. In addition, if specialist health services are required or hospitalisation is needed, family members often have to take time off work to transport those who are ill to these services. This adds additional costs and increases the level of stress and anxiety experienced. FIgURE 3.24 For many Australians in remote areas, the Royal Flying Doctor Service is the only access they have to emergency medical care. Source: Royal Flying Doctor Service of Australia, Central perations Inc. 124 UNIT 3 Australia s health

30 People in rural and remote areas are 1.2 times more likely to experience food insecurity than their city counterparts. This is largely due to lack of access and high costs. Transporting food to remote areas adds significant costs, particularly to fresh foods. This can lead to the consumption of more processed food items, which often have high levels of fat, salt and/or sugar. This can contribute to higher rates of obesity, diabetes and cardiovascular disease. People in rural and remote areas often have higher rates of community participation and feel like they are part of a community, but they may still be socially isolated due to geographic distances. Social isolation results from a lack of contact with other people such as family, neighbours and friends. Social isolation contributes to higher rates of mental illness, as the individual may experience feelings of loneliness and have no-one to talk to in times of trouble. Case study Rural and remote health falling behind Cardiovascular diseases contribute to alarming rates of premature death in rural and remote areas of Victoria. According to experts, differences in health status between those in rural and remote areas and those in major cities occur partially as the result of a lack of preventative health services and treatment options. Factors that increase the risk of cardiovascular disease including high blood pressure, cholesterol problems, obesity and depression have also been found in significantly higher rates in rural populations compared to their city counterparts. The Healthy Hearts program, coordinated by the Baker IDI Heart and Diabetes Institute, provides a screening service for those in rural and remote Victoria. After screening 1500 people, results indicated that around 50% of those who presented for health checks had hypertension and nearly 70% were carrying excess fat around the abdominal area. In addition to the high rates of biological risk factors, some participants had not sought health care in over 10 years. Those at increased risk were also less likely to receive medication, access health services and experience social support. The combination of these factors also Case study review 1 What percentage of those screened had hypertension? 2 What is the difference in rates of new prescriptions for males in rural and remote areas compared to those in metropolitan areas? 3 Suggest two reasons that make it difficult for people in remote areas to access health services. 4 How else could people in rural and remote areas be supported with regards to achieving better health outcomes? acted to increase the risk of premature death in rural and remote areas. Researchers from the School of Rural Health at Melbourne University found that males in rural and remote areas were less likely to utilise drugs used to treat cardiovascular disease. The rate of new prescriptions for cholesterol-lowering drugs was 286 per males in cities, 147 in rural areas and 10 in remote areas. Source: The Age, 19 August FIgURE 3.25 Getting access to emergency services can be particularly difficult in rural and especially remote areas. Variations in health within Australia CHAPTER 3 125

31 3.4 Variations in health status: rural and remote populations Lower life expectancy (life expectancy decreases as level of remoteness increases: 1 2 years less for rural areas, up to 7 years less for remote areas) Higher mortality rates Higher rates of preventable cancers: lung and melanoma and detectable cancers (cervical) Higher death rates from cardiovascular disease Higher rates of coronary heart disease Higher rates of avoidable deaths, including deaths due to injury Higher rates of diabetes Higher rates of dental decay Physical environment Social E PA G Lower socioeconomic status Higher unemployment Higher rates of social isolation Higher rates of food insecurity Less access to health services FS Behavioural Rural and remote More likely to smoke tobacco More likely to drink alcohol at risky levels Lower levels of physical activity Poorer road quality Poorly lit roads Greater distances to drive Fewer public transport services Reduced proximity to health care services such as GPs and hospitals Reduced proximity to recreation facilities, supermarkets and employment Harsh climates Greater susceptibility to the effects of climate change Reduced access to fluoridated water More dangerous working environments including greater UV exposure PR Health status Higher rates of obesity Higher rates of low birth weight babies Higher rates of hypertension Higher rates of high blood cholesterol Biological EC TE D FIgURE 3.26 Summary of the determinants of health contributing to the health status of those living in rural and remote areas R TEST your knowledge U N C R 1 What is the difference between urban, rural and remote areas? 2 Approximately what percentage of Australians live in areas that would be classified as rural or remote? 3 List three health concerns of people living in rural and remote areas. 4 (a) Why are processed foods sometimes used or relied on to feed a family living in rural or remote areas? (b) What is the disadvantage of relying on processed foods? APPlY your knowledge 5 What role does the natural environment play with regards to the health of people living in rural and remote areas? 6 Would you expect the health of those living in rural Victoria to be better than those living in remote Western Australia? Justify your response How could access to GPs be improved for people in rural and remote areas? 8 Why is health care provision in rural and remote areas a constant challenge for countries such as Australia? 9 With a partner, brainstorm some ideas that could equalise the differences in health status between urban, rural and remote populations. 10 Discuss the examples of determinants of health that may contribute to higher rates of cardiovascular disease for people in rural and remote areas. 11 Use the Losing the farm links in the Resources section of your ebookplus to find the weblink and questions for this activity. 12 Use the utback Services links in the Resources section of your ebookplus to find the weblink and questions for this activity. 13 Use the Drought links in the Resources section of your ebookplus to find the weblink and questions for this activity. UNIT 3 Australia s health c03variationsinhealthwithinaustralia.indd June :34 PM

32 KEy SKILLS Variations in health within Australia KEY SKIll Use and interpret data to compare the health status of selected population groups in Australia Data can be presented in a range of different ways. Time should be taken to make sense of the data, and interpretation should be practised for data in various forms. The steps covered in the key skills section in chapter 1 should be followed regardless of the form the data takes. The following two graphs present information on hospital separations for Indigenous and non-indigenous Australians. The graphs essentially present the same information (hospitalisations) in two different ways. Figure 3.27 uses the total number of hospital separations for each group and figure 3.28 shows the rate of hospitalisations. Number of hospital separations Horizontal axis/units ❶ Vertical axis/units ❷ Non-Indigenous Indigenous FIgURE 3.27 Number of hospital separations by Indigenous status, ❸ Source: Adapted from ❹ Rate of hospitalisations per 1000 population Non-Indigenous Indigenous FIgURE 3.28 Rate per 1000 population of hospital separations by Indigenous status, Source: At first glance, figure 3.27 appears to show that Indigenous people are better off as they have much lower numbers of hospitalisations. There were about nine million hospitalisations for non-indigenous people compared to about four hundred thousand for Indigenous people. Figure 3.28 shows, however, that when the total number of people making up each group is taken into account (the population of non-indigenous Australians is much higher), Indigenous people experience much higher rates of hospitalisations. The rate for non-indigenous people is about four hundred hospitalisations per 1000 whereas for Indigenous Australians the rate is about nine-hundred and seventy hospitalisations per This difference could be missed unless the vertical axis on each graph is completely understood. ❶ Horizontal axis labels are Non-Indigenous and Indigenous. ❷ Vertical axis label is Number, with units representing numbers of separation in millions. ❸ Title of the graph ❹ Source provides important information about who has provided the research data. Variations in health within Australia CHAPTER 3 127

33 Key skills Variations in health within Australia FIgURE 3.29 Proportion of persons reporting diabetes or high sugar levels, by Indigenous status and age group, Source: ABS, Australian Aboriginal and Torres Strait Islander Health Survey: First Results, With this in mind, if the data from these two graphs were being analysed or discussed, the following conclusions could be drawn. Non-Indigenous Australians experience a much higher number of hospital isations compared to Indigenous Australians. There were about nine million hospitalisations among non-indigenous Australians compared to about four hundred thousand for non-indigenous Australians. Indigenous Australians are much more likely to be hospitalised, however. For every 1000 Indigenous Australians, about nine-hundred and seventy were hospitalised in compared to about four hundred for every 1000 non-indigenous Australians. PRACTISE the key skills 1 Identify two trends evident in figure Discuss the difference between Indigenous and non-indigenous people aged 55 and over experiencing diabetes or high blood glucose levels according to figure Per cent Indigenous Non-Indigenous and over Age group (years) KEY SKIll Use the determinants of health to explain differences in health status of Australians and between population groups An understanding of the differences in health status between population groups is the first step in reducing the inequalities that exist. The determinants that contribute to the variations must be examined so interventions can be put in place. The possible impacts on health status must be understood for each determinant. nce these are known, it is possible to identify the determinants that may contribute to differences in health status between groups. For example, if the higher rates of cardiovascular disease suffered by the lowest socioeconomic group were to be examined, the determinants of health that may have led to this difference would need to be discussed. First, brainstorm all of the determinants that contribute to differences in health status among low socioeconomic groups (see figure 3.30). nce a list of options has been created, the ones that contribute to cardiovascular disease can be used as the basis for discussion. Choose determinants that are easy to discuss in terms of their relationship to cardiovascular disease. 128 UNIT 3 Australia s health

34 Low socioeconomic status Social PR Physical environment Greater exposure to fast food outlets More likely to live in poor quality housing More likely to work in dangerous working environments Higher rates of exposure to environmental tobacco smoke More likely to live in neighbourhoods with more violence E Life expectancy is about three years lower for the most disadvantaged groups Higher death rates More avoidable deaths Higher infant mortality rates Higher rates of diabetes Higher rates of coronary heart disease Almost twice the rate of mental and behavioural problems Higher prevalence and mortality rates from lung cancer Behavioural More likely to smoke, including during pregnancy Lower levels of physical activity Less likely to consume fruit and vegetables Less likely to breastfeed PA G Health status Higher obesity rates Higher rates of hypertension Higher glucose intolerance levels Higher rates of low birth weight babies FS Biological More likely to be unemployed Lower education levels, including health literacy Higher rates of social exclusion More likely to experience food insecurity Less likely to access preventive health services Lower levels of private health insurance TE D FIgURE 3.30 Determinants of health contributing to variations in health status among low socioeconomic status groups U N C R R EC The second step in this process is to re-read the question. Can any determinants be used for the discussion or did the question specify that one determinant from each category had to be used? In this case, there were no specifications made so a general discussion of the determinants would suffice. It is recommended to include a range of factors even if the question did not specifically ask for this. Try to include at least one example of each determinant in the discussion. The conclusion can be drawn that there are numerous factors that could contribute to the differences in cardiovascular disease as experienced by those in low and high socioeconomic groups: Biological those in low socioeconomic status groups experience higher rates of obesity compared to those in high socioeconomic status groups. besity can place an added strain on the heart and can lead to blockages in the blood vessels, contributing to coronary heart disease. Behavioural tobacco smoking is higher in low socioeconomic status groups compared to high socioeconomic status groups, which can also lead to blocked blood vessels and increased rates of cardiovascular disease Physical environment closer proximity to fast food outlets in low socioeconomic neighbourhoods may increase the consumption of high fat and high energy foods, contributing to increased rates of obesity and cardiovascular disease compared to high socioeconomic status groups Social food insecurity may mean that low socioeconomic status groups rely on cheaper processed foods that can be high in fat, salt and sugar. This adds extra kilojoules to the diet and can contribute to higher rates of obesity, hypertension and cardiovascular disease compared to high socioeconomic status groups. Variations in health within Australia CHAPTER 3 c03variationsinhealthwithinaustralia.indd June :34 PM

35 Key skills Variations in health within Australia FIgURE 3.31 Trends in asthma mortality, Source: ACAM and AIHW analysis of AIHW National Mortality Database. FIgURE 3.32 Proportion of overweight/obese Australians aged 15 44, by Indigenous status and age group, Source: ABS, Australian Aboriginal and Torres Strait Islander Health Survey: First Results, Australia, Deaths per population Per cent PRACTISE the key skills 3 (a) Using data from figure 3.31 (below) identify two trends with regards to the death rate from asthma in Australia. (b) Using the determinants of health as a basis of your discussion, discuss possible reasons for the trends indentified in part (a) Females all ages Males all ages Males 5 34 Females (a) Identify two trends with regards to the overweight/obesity rates shown in figure (b) Using the determinants of health as a basis of your discussion, discuss possible reasons for the trends identified in part (a) Indigenous Non-indigenous Age group Key skills exam practice 5 People living in rural and remote areas suffer worse health outcomes than their urban counterparts with regards to numerous indicators. There is a range of determinants that lead to these differences. Select one factor from each of the following four determinants and discuss how it may contribute to the differences in health status between these two groups. (a) Biological (b) Behavioural 130 UNIT 3 Australia s health

36 (c) Physical environment (d) Social = 6 marks 6 Various determinants impact on health status. Choose two determinants and describe how each may contribute to higher rates of cancer among males compared to females = 4 marks Variations in health within Australia CHAPTER 3 131

37 CHAPTER 3 review Interactivities: Chapter 3 crossword Searchlight ID: int-2913 Chapter 3 definitions Searchlight ID: int-2914 Chapter 3 concept cards HD to HD Chapter summary Even though health status is generally good in Australia, there are certain population groups who do not share the same level of health as the rest of the population. Indigenous Australians, males, people from lower socioeconomic status groups and those from rural and remote areas suffer worse health outcomes for almost all health indicators. Indigenous people have higher death rates at every age compared with non-indigenous people. The life expectancy of indigenous people is about ten years less than that of the non-indigenous population. Indigenous people suffer from cardiovascular disease, cancer, type 2 diabetes, kidney disease and asthma at significantly higher rates than the rest of the population. The examples of determinants that contribute to Indigenous people s ill health are complex, but include higher rates of low birth weight babies, overweight/obesity, poor nutrition, smoking, alcohol and drug misuse, poor housing conditions, low socioeconomic status and social exclusion. Men are more likely to die at every lifespan stage when compared with women. Males experience higher mortality rates due to cardiovascular disease, cancer, injuries and diabetes. Males experience lower rates of osteoporosis, arthritis and mental health illness. The examples of determinants that lead to the poor health status of males include genetics, risk taking behaviours, alcohol misuse, smoking, food intake, reluctance to visit a GP, work environments, peer group pressure and gender roles and stereotypes. Generally, the higher the socioeconomic status, the better the health status. People with low socioeconomic status have lower life expectancy and higher mortality rates than those with a higher socioeconomic status. People with low socioeconomic status also experience higher rates of many conditions such as cardiovascular disease, cancer and diabetes. Some of the examples of determinants contributing to the lower health status of those with low socioeconomic status include obesity, a higher rate of low birth weight babies, higher smoking rates, lower levels of physical activity and education, poorer housing, exposure to environmental tobacco smoke, and less access to and use of health care services. People living in rural and remote areas experience higher mortality rates and higher rates of conditions such as cancers, cardiovascular disease and diabetes. People in rural and remote areas face a number of challenges to their health such as the natural environment, the nature of work in these areas and geographical barriers. ther determinants contributing to the lower levels of health experienced in rural and remote areas include higher levels of obesity, higher rates of smoking and risky alcohol consumption, dangerous occupations, social isolation, food insecurity and lack of access to health care services. Rural and remote populations are made up of relatively high numbers of Indigenous Australians and people from low socioeconomic status groups, which contributes to the poorer health statistics of people in rural and remote areas. 132 UNIT 3 Australia s health

38 TEST your knowledge 1 Copy the following summary table and complete it for the four population groups explored in this chapter. Population group Key differences in health status Determinants contributing to the differences 2 List three variations in health status that are common to all of the population groups studied. 3 Discuss the impact genetics can have on the health of males compared to females. APPlY your knowledge 4 (a) What is meant by low birth weight? (b) Why might babies born with a low birth weight be more susceptible to death and disabilities? (c) Which population groups are more likely to have low birth weight babies? Why? 5 How could unemployment affect people in rural and remote areas compared with those in urban areas? 6 Cultural change and historical events have been a huge influence on the health status currently being experienced by Indigenous Australians. Using the knowledge you have gained in this chapter, write a response to this statement. 7 Identify three similarities in health between Indigenous and rural/remote populations. Variations in health within Australia CHAPTER 3 133

KEY TERM DEFINITIONS chronic kidney disease (CKD) the gradual, permanent loss of kidney function. Kidneys filter the blood and, if CKD progresses, the

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