Determinants of Health

Ill-health doesn’t develop in a vacuum.

The British Academy[1] suggests that only 20% of our experience of health is influenced by our access to health professionals – the other 80% is a consequence of a range of other factors: our environment (~10%), our risk factor profile (whether we smoke, exercise etc ~30%) and the social determinants of health (how good is our education, what sort of job we have, our social interactions, etc ~40%).

Connectedness, social cohesion, and wellbeing

The Alliance’s vision is to achieve good health and wellbeing for everyone living in rural and remote Australia.  Wellbeing, while being linked to health, is not dependent upon it. It is possible to have good health and poor wellbeing and to have good wellbeing despite having poor health.  But wellbeing is optimised when health is optimised.

There are several surveys that examine the linkages between health and wellbeing and report on both for people living in rural and remote Australia.

Data is available from the following sources:

 

Personal wellbeing

Personal wellbeing is reported for 2005, in rural versus city areas using the ARIA classification.

Areas compared are ARIA’s Highly Accessible (generally cities, but including some rural cities such as Tamworth, Nowra and rural towns like Braidwood), Accessible and Moderately Accessible (generally rural towns and surrounding rural areas), and remote and very remote areas (HA, A, MA, R and VR areas).

The following results are provided here for HA, A, MA, R and VR areas respectively, largely direct quotes from the ACQOL report.

The study found that:

  • The highest level of personal wellbeing is achieved by people who live in rural towns (as opposed to places like cities and remote areas). Personal wellbeing index scores were 74.6, 76.2, 77.2, 74.9 and 75.1 respectively.
  • People living in cities tended to rate lower in terms of satisfaction with safety and community connection, than people living in rural and remote locations. Personal safety index scores were 77.4, 79.4, 81.7, 78.5 and 80.1 respectively. Community connection index scores were 69.6, 74.5, 75.3, 74.2, and 73.9 respectively.
  • People living in the Very Remote categories have a lower satisfaction with Government than do people from the other locations. Satisfaction with Government index scores were 54.2, 54.5, 55.4, 56.5 and 51.2.
  • People in the Accessible category (rural towns and surrounding areas) have the lowest household income. Clearly, the high wellbeing experienced by this category of people is not being driven by high income.
  • The Very Remote category has the highest personal income, yet their personal wellbeing is no higher than people who live in cities. It seems that their high income is not able to counteract the negative influence of remote environments on wellbeing.
  • The higher personal wellbeing associated with Accessible and Moderately Accessible environments only occurs amoungst people aged 26 to 55 years.

 

Life satisfaction higher in rural towns

A 2015 analysis of the Household, Income and Labour Dynamics in Australia (HILDA) survey data has shown that people living in small rural towns (and also to a slightly lesser extent in larger rural towns) have greater life satisfaction than people who live in major cities. From the data provided, it appears that life satisfaction of people living in a small rural town tends to be a bit more than 1 point higher. By comparison, people living in areas classified as the highest SEIFA decile, as opposed to lowest SEIFA decile, tended to be 0.6 to 1.0 point higher on the same scale; inferring that living in a small rural town is better for life satisfaction than living in a wealthy suburb compared with a poor suburb. Areas where there is active positive cooperation between neighbours adds up to 0.8 points, areas with hostile or aggressive people reduces the score by 0.7, while areas and prevalence of burglary reduce the score by 0.3.

See https://www.melbourneinstitute.com/downloads/hilda/Stat_Report/statreport_2015.pdf page 58.

Participation in voluntary work, 2011

Table 7: Volunteers, 2011

 

People aged 15 years and over who participated in voluntary work

Population aged 15 years and over

%  volunteers

Major Cities

1,970,110

12,171,787

16.2

Inner Regional

676,383

3,204,248

21.1

Outer Regional

355,113

1,562,623

22.7

Remote

56,892

235,154

24.2

Very Remote

26,750

145,407

18.4

Source: http://www.adelaide.edu.au/phidu/maps-data/data/ (Based on 2011 ABS Census)

The percentage of people 15+ who attended selected cultural venue in the past 12 months: MC 88.3%, IR 82.7%, OR/rem 81.0% (percentages appear to be crude).

 

Education

Both the educational attainment of the population and the educational opportunities for the population are important.

An individual’s level of education has been recognised as a social determinant of health for several reasons:

  • Your level of education is an indicator for your level of health literacy, and health outcomes improve for people with better levels of health literacy;
  • There is a link between higher levels of education and lower levels of morbidity from chronic diseases;
  • People with higher levels of education have lower levels of personal risk factors for chronic diseases;
  • People with higher levels of education make better use of health services resulting in better health outcomes; and
  • Education is also a factor for improved life expectancy.

Importantly, education also is the means of offering young people a sense of hope for the future and pathways to improve their future socio-economic status.  Schooling completion rates therefore offer insight into future health risks of younger generations.

Year 12 completion rates

Table 8: Year 12 completion rates 2013

 

Metropolitan

Provincial

Remote

Very remote

 

percentage

2013

76

68

68

41

Source: http://www.pc.gov.au/research/recurring/report-on-government-services/2015/childcare-education-and-training/school-education

Over 75% of children in metropolitan areas complete year 12, compared with just under 70% of children in provincial and remote areas, and only 40% of children in Very remote areas.

Note that the geographic classification used in the table above is the MCEETYA geographic classification used by the Department of Education. Metropolitan relates to cities greater than 100,000, remote relates to areas very roughly equivalent to remote under ASGS, and provincial very roughly correlates with regional under ASGS (see http://www.curriculum.edu.au/verve/_resources/geographiclocation_file.pdf page ix for details).

University participation

Table 9: School leavers enrolled at an Australian University as a proportion of the population of 17 year olds, 2012

MC

IR

OR

R

VR

percent

36.7

20.1

16.1

13.1

4.3

Source: http://www.adelaide.edu.au/phidu/current/graphs/sha-aust/remoteness/aust/education.html

Just over 35% of young people living in Major cities go on to university, compared with 20% and 16% of young people living in IR and OR, and 13% and 4% of those living in Remote and Very remote areas. This most probably reflects both the lower relevance of tertiary education for people in rural and remote areas and the personal and financial difficulties associated with accessing tertiary education, often at a considerable distance from the family.  And if education is the pathway to increased socio-economic status, it also indicates the lack of opportunity that exists for those in remote and very remote Australia.

 

Performance/achievement at school

Data not included here but available at http://www.pc.gov.au/research/recurring/report-on-government-services/2015/childcare-education-and-training/school-education/rogs-2015-volumeb-chapter4.pdf

 

Vocational training

Table 10: VET participation, all ages, by region

 

 

 

percent

 

 

 

MC

IR

OR

R

VR

of population (all ages) 2012 (PHIDU)

7.4

10.7

11.2

11.9

10.4

 

MC

IR

OR

R/VR

 

of population 0-64 years, 2013 (PC)

5.7

7.9

7.8

9.1

 

Sources: http://www.adelaide.edu.au/phidu/current/graphs/sha-aust/remoteness/aust/education.html

Additional information can be found at http://www.pc.gov.au/research/recurring/report-on-government-services/2015/childcare-education-and-training/vocational-education-and-training/rogs-2015-volumeb-chapter5.pdf.

 

Educational status of the population

The proportion of people who left school at or before year 10 was 31% in Major cities, 42% in Inner and Outer regional areas, 41% in Remote areas and 50% in Very Remote areas.

http://www.adelaide.edu.au/phidu/current/graphs/sha-aust/remoteness/aust/education.html

Remoteness x Indigenous/non Indigenous comparison at http://www.dpmc.gov.au/sites/default/files/publications/Aboriginal_and_Torres_Strait_Islander_HPF_2014%20-%20edited%2016%20June2015.pdf   page 91.

 

Criminal justice

Table 11: Young people aged 10–17 under supervision (including detention) on an average day by remoteness of usual residence, states and territories, 2012–13

 

MC

IR

OR

R

VR

 

 

rate per 10,000 population

 

Detention

2.3

3.4

5.2

5.6

8.4

Supervision without detention

13.2

22.6

31.3

58.3

91.1

All supervision

15.5

26.0

36.5

63.9

99.5

Source: http://www.aihw.gov.au/publication-detail/?id=60129546738HYPERLINK "http://www.aihw.gov.au/publication-detail/?id=60129546738&tab=3"&HYPERLINK "http://www.aihw.gov.au/publication-detail/?id=60129546738&tab=3"tab=3

 

Living arrangements

Homelessness

In 2014, 13% of people 15+ living in Major cities had ever experienced homelessness, compared with 14% and 15% of people living in Inner regional and Outer regional/remote respectively (percentages appear to be crude).

Source: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4159.0Main+Features12014?OpenDocument

 

Health Literacy

Table 12: Health literacy2006

Health literacy level

Major cities

Inner regional

Outer regional

Remote

 

Percent

Lowest level

19.3

18.9

20.7

17.5

low level

38.6

42.9

43.6

43.8

high level

35.6

33.6

31.3

34.4

Highest level

6.4

4.5

4.3

4.4

Source: http://abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4233.02006?OpenDocument

Compared with those in Major Cities, people in regional and remote areas were slightly more likely to have lower levels of health literacy, and slightly less likely to have higher levels of health literacy.

 

Income in rural Australia

In 2010-11, wage and salary earners outside Australia’s capital cities earned only 85% the amount that their capital cities counterparts earned. Data from this source are not available by remoteness areas, but a capital city/balance comparison is available for each state.

The percentage of employed people earning $15,600 or less is 15% higher outside capital cities, while the percentage of employed people earning 78,000 or over is 26% lower outside capital cities.

In 2011-12 the median gross household income in the cities across Australia was 1.37 times higher than for the 'balance of state'. This compared with 1.27 to 1.32 between 1997-98 and 2005-06, and 1.16 in 1996-97.  The city-country income differential was significantly larger in 2011-12 than fifteen years earlier.

Table 13: Median gross household income, Australia

Year

Capital city

Balance of state

city/bal ratio

1996-97

 $           500

 $           432

1.16

1997-98

 $           544

 $           418

1.30

2002-03

 $           940

 $           713

1.32

2005-06

 $        1,139

 $           898

1.27

2011-12

 $        1,612

 $        1,176

1.37

This increasing income inequality for those living outside the capital cities is shown, by state, in the Table below.

Table 14: Median gross household income by State

Year

NSW

Vic

Qld

SA

WA

Tas

Aust

 

Ratio of capital city to balance of state

1996-97

1.25

1.12

1.06

1.13

1.11

1.04

1.16

1997-98

1.44

1.26

1.25

1.31

0.92

1.07

1.30

2002-03

1.56

1.31

1.10

1.02

1.21

1.04

1.32

2005-06

1.47

1.23

1.14

1.24

1.08

1.20

1.27

2011-12

1.54

1.46

1.19

1.26

1.15

1.31

1.37

Eighteen of the 20 electorates with the lowest household incomes are outside the capital cities. The eleven poorest Federal electorates measured by median household income per head are Barker, Grey, Bass, Braddon, Mallee, Wide Bay, Lyons, Page, Lyne, Hinkler and Cowper.

 

Taxable income by postcode

The ATO publishes taxation statistics for each previous financial year by postcode, including details of private health insurance.

 

Cost of living

The WA Regional Price Index

Calculated every second year for regional WA.
Food, clothing, housing, healthcare, etc costs comparison  - small regions compared with Perth. Latest version relates to 2013.
Shows substantial variation between regions

http://www.drd.wa.gov.au/publications/Documents/Regional_Price_Index_2013.pdf

Food prices

Queensland Healthy Food Access Basket survey 2010
http://www.health.qld.gov.au/ph/documents/hpu/hafb-2010.pdf

SA Healthy Food Prices 2012
http://www.rrh.org.au/publishedarticles/article_print_1938.pdf

The WA Regional Price Index (see link above)

Australia’s Food and Nutrition 2012 has some description of food pricing and availability in rural and remote areas. Food prices in major supermarkets in regional centres appear similar to those in major cities, but higher elsewhere (eg in smaller centres).