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Chapter 6: Challenges and opportunities - Key challenge 2: Make prevention a key to reducing health inequality

Quotation by Sir Michael Marmot

The health of many Queenslanders is good and continues to improve. People are living longer, many are taking positive action to preserve their health and build vigorous healthy lives for themselves and for their families. Yet good health is not enjoyed by all. Differences in health occur across many population groups in Queensland; most notably between non-Indigenous and Indigenous people, between those with greater socioeconomic advantage and those with less, and between those living in cities and those living in remote areas. These differences are described throughout this report.

Health inequalities are differences in health status (such as rates of illness and death or self reported health) that result from social, economic and geographic influences that are avoidable, unfair and unnecessary.[390] There are three dimensions to health inequality:

  1. Inequality of access to healthy choices and services that support health and wellbeing (due to cost, remoteness, services that are not culturally appropriate etc).
  2. Inequality of opportunity which refers to the social and economic resources necessary to achieve and maintain good health such as quality education, secure employment and income, safe housing and a supportive environment in which to live. Lack of material resources directly impacts on health. However, health inequalities may also result in psychological and social conditions which further exacerbate poor health outcomes. For example, poor education, unemployment and low income can lead to social isolation and feelings of exclusion from the mainstream community.
  3. Inequality of impacts and outcomes due to differences in health status between groups (gender, age, Indigenous people, people with disabilities, newly arrived refugees etc). It is important to measure health outcomes in order to monitor health and wellbeing and intervene where required to benefit all groups in the community.

Closing the life expectancy gap between Indigenous and non-Indigenous people is a priority of the Australian government. Addressing health inequality is also a priority of the Queensland government. So the questions are: How can the gap between the health advantaged and the health disadvantaged be closed? Can prevention be a key to reducing health inequality?

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How serious is health inequality in Queensland?

Is prevention a key to reducing health inequality?

Many Queenslanders could enjoy three to six more years of healthy life if the rates of ill health were the same throughout the state. This equates to the gains made in average life expectancy since the early 1980s.

Are we heading for a similar situation to that of USA? In the midst of life expectancy improvements over the past 40 to 50 years in the USA, there was initially a narrowing of the health divide, that is the difference in health status between the advantaged and disadvantaged. This narrowing has more recently been reversed, with stagnation in health outcomes for those most at disadvantage.[391] That is, there has been a ‘reversal of fortune’ for the disadvantaged since the 1980s.

The level of preventable risk factors for chronic disease is predictably much higher in those populations and areas of Queensland which have the highest rates of chronic disease. People in socioeconomically disadvantaged areas, people living in remote areas and Indigenous people are more likely to smoke, drink alcohol to harmful levels, are more likely to be overweight or obese, more likely to be physically inactive, have poorer nutrition, and are less likely to breastfeed than people in socioeconomically advantaged areas. Reduction in risk factor levels in populations which have the poorest health in Queensland will substantially reduce the divide between those with the best health and those with the worst.

Gains in life expectancy and quality of life over the past century have been largely due to population health interventions to prevent ill health of all the population using population health approaches, rather than reparative care provided by the health system.

Population health interventions are characterised by attempts to address the diversity of risk and protective factors that impact on the health of the community, including health behaviours, community capacity, and the environmental and socioeconomic impacts.[94] Some of the strategies used to achieve population level health outcomes and benefit everyone in the community include:

Chronic disease prevention can no longer be addressed by focusing exclusively on poor health behaviours and risk factors. We need to understand and modify the ways in which the social and physical environment in which we live affects our decisions and the health behaviours in which we engage.

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What do we need to do?

Prevention is indeed a key principle in our determination to reduce health inequality. Health behaviours are not randomly distributed in the population and an individual’s risk of illness cannot be considered in isolation to their social and economic status. The greatest improvements in population health are now being derived from answering the question ‘why does this population have this particular distribution of risk?’ and targeting interventions appropriately.[392]

Inequality and its causes are complex. To reduce health inequalities it is critical that we understand that how we organise our society and how we live our lives is the result of not just individual action but also of activites across government, in businesses and communities. For an individual to be held fully responsible for these individual actions, a person needs the social and economic resources to make healthy choices, access to services to help change behaviour and the knowledge and assistance to build a healthy life.

Future investments must be based on evidence based principles. Although population health measures benefit everyone in the community, one of the potential challenges of such approaches is that highly educated and resourced individuals tend to demonstrate greater uptake of good health messages and opportunities compared to disadvantaged people.[24,393] Available research reinforces the need to integrate the Ottawa Charter [394] principles in developing population health initiatives that address inequality in health.[24] These principles are:

Prevention strategies need to recognise the specific needs of the target populations. Due to the risk of unintentionally increasing disadvantage with whole of population approaches, prevention strategies to reduce health inequalities need to include targeted interventions that address both the economic and social needs of disadvantaged groups.[24] According to the Queensland Council of Social Services (QCOSS), in order to design population level interventions that will be effective for disadvantaged groups, we need to ‘develop an understanding of the lived experience of disadvantage and the multiple factors that impact individual choice and health related behaviours’.[24]

We have good examples of effective interventions. The QCOSS report [24] found that effective population health interventions targeting disadvantaged groups have been underpinned by common elements operating at three levels: the individual level, at community level and at service provision level. A number of current population health interventions that effectively target disadvantaged Queenslanders have been identified- see box below.

Population health prevention strategies are applied throughout the life course and certain life stages are recognised as particularly susceptible periods when the influences of inequality are more pronounced. Research has shown that overall health in middle and late adulthood is shaped by socioeconomic conditions experienced during childhood, and from the accumulation of instances of disadvantage over an individual’s lifetime.[395]

Inequalities begin in childhood. A national quality framework for early childhood education is currently under discussion.[396] There is now extensive evidence supporting the value of quality early childhood education and care with respect to such skills as language and school readiness. While all children benefit, positive outcomes are particularly demonstrated in disadvantaged children. Historically,[397] Australia’s investment in early education has been well below the Organization for Economic Co-operation and Development (OECD) average, and so increased funding and commitment could have significant impacts for children not just in the short term but also by reducing health inequalities and their impacts on health outcomes in later life.

Defining, measuring and monitoring inequality is important. Unless health inequalities are monitored in Queensland we do not know whether interventions are effective and we do not know if they are narrowing the gap or actually widening the gap in health inequality. Therefore it is critical to develop a suite of indicators to monitor health inequalities. It is also critical to routinely collect, analyse and report such information.[398]

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Prevention is a key to reducing health inequality

Government and other agencies are clearly focussed on reducing the gap; underpinned by wide public support. It is clear that many major drivers of population health and health inequalities are not the direct responsibility of the clinical and curative services of health departments. [399] Queensland Health therefore works in partnership with other government and non-government agencies to improve the circumstances and health of all Queenslanders. Furthermore, there is investment in a range of programs across government which will improve the determinants of health among those most disadvantaged in Queensland. Ensuring these investments are ongoing and effective and that there is effective monitoring of health outcomes of those at greatest disadvantage is critical to reducing health inequality in Queensland.

 

Population health interventions identified by Queensland Council of Social Service (QCOSS) that effectively target disadvantaged Queenslanders: [24]

  • For women living in rural and remote areas - the Rural and Remote Women’s Health: Royal Flying Doctor Service which aims to combine primary medical care with both prevention and health promotion service delivery.
  • For disadvantaged young people - the Brisbane Youth Service provides an extensive range of outreach, referral and follow-up support services to homeless and disadvantaged youth.
  • For Culturally and Linguistically Diverse communities - The Logan Women’s Health and Wellbeing Cervical Screening Project which provides culturally appropriate services to CALD women, many of whom report having never had a Pap smear.
  • For Indigenous people - Ipswich Indigenous Young Men’s Project has developed a young men’s rugby training program, which in addition to encouraging a sense of belonging and physical activity, incorporates health education messages related to reduced alcohol and substance abuse and healthy eating.

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Last Updated: 03 October 2013
Last Reviewed: 16 May 2011