“Both Federal and State governments, right across the country, need to step up and invest in rural health if they are serious about this.
There have been numerous examples of initiatives developed to improve access to health care in rural and remote areas being extended into urban areas to prop up under-funded services in for the socially disadvantaged.
This has resulted in the unintended consequence of further disadvantaging Aboriginal and Torres Strait Islander people living in rural and remote Australia.
We need continued investment in health infrastructure and services aimed at addressing the disparity in health outcomes between those who live in the city and those who live in the bush… and this extends across both our Indigenous and non-Indigenous populations.
Without this, as a nation we are never going to close the gap, and the divide for the health outcomes of Aboriginal and Torres Strait Island people living in rural and remote Australia will never be addressed.”
Dr John Hall, President of the Rural Doctors Association of Australia (RDAA), said that without access to high quality health services in rural areas, the gap will never close.
” I’m particularly concerned with successive government failure to halve Indigenous child mortality rates.
A lot of this is about access, it’s around health literacy.
It’s also about the holistic care, it’s also around education, housing and a whole range of other things”.
Australia needs to boost hospital and birthing facilities in rural and regional areas in order to overcome entrenched Indigenous health disadvantage, according to Rural Doctors Association of Australia CEO Peta Rutherford told SkyNews .
Another disappointing Closing the Gap Report, released this month [12 February 2020], demonstrates why health care in rural and remote Australia is a key driver to Closing the Gap in health.
“The Government’s Closing the Gap Report 2020 showed that the Gap between Indigenous and non-Indigenous Australians on key health indicators has not closed,” Dr Hall said.
“Two key health-related benchmarks were chosen by the
Government in 2008, with a target of halving the gap in child mortality by 2018, and to close the gap in life expectancy by 2031.
“Neither of these targets are on track.
“The main cause of Aboriginal and Torres Strait Islander child deaths are perinatal conditions such as complications of pregnancy and birth.
“With 85 per cent of these deaths occurring during the first year of life, maternal health and risk
factors during pregnancy play a crucial role.
“Access to quality, culturally safe, medical care is the most direct way of improving these outcomes,” Dr Hall said.
Similarly, life expectancy in Aboriginal and Torres Strait Islander people is strongly influenced by health and health care, with the report attributing 34 per cent of the gap to social determinants (such as education, employment status, housing and income), 19 per cent to behavioural risk factors (such as smoking, obesity, alcohol use and diet), leaving 47 per cent attributed to what is clearly a disparity in health outcomes and associated health care issues.
In rural and remote areas there is a noticeable difference of a more than six year reduction in life expectancy of Aboriginal and Torres Strait Islander males and females, when compared to those living in major cities.
This demonstrates a failure across the board in these key areas, all of which are influenced by the provision of quality health care.
“Clearly we can’t close the gap without a functional health system in rural and remote Australia,” Dr Hall said.
“And this cannot just be solved through funding Aboriginal Medical Services (AMS); the other parts of the health system need to be equally funded to service these communities in order to be able to provide the standard of care that will result in a reduction in the gap in health outcomes.
“We can’t have hospital services downgraded and expect to close the gap.
“We can’t have communities with no access to medical birthing services and expect to close the gap.
“We can’t have people needing to travel hundreds of kilometres to access cancer or surgical treatment and close the gap.
“We need quality rural hospitals, staffed by Rural Generalist doctors, with the skills needed to meet the needs of these communities in both the General Practice and hospital settings, if we are serious about improving health outcomes and actually closing the gap.
” Health risk factors like smoking, excessive drinking, illicit drug use, lack of physical activity, inadequate fruit and vegetable intake and overweight have powerful influences on health, and there are frequently clear inter-regional differences between the prevalence of these.
While it can be argued that there is some degree of personal choice involved in whether individuals have a poor health risk profile, there is clear evidence that external factors such as environment, opportunity, and community culture each have very strong influences.
For example, access to affordable healthy food can often be poor in smaller communities and this, coupled with lower incomes in these areas, adversely affects the quality of peoples’ diets, the prevalence of overweight, and consequently the prevalence of chronic disease.”
From the National Rural Health Alliance ResearchView HERE
National data pertaining to personal health risk factors typically comes from the ABS National Health Survey and the AIHW National Drug Strategy Household Survey (NDSHS). Some State and Territory Health Departments run their own health surveys (which cannot be aggregated nationally with each other or with the ABS survey because of the different methodologies and definitions used (think different State rail gauges). Consequently data describing aspects of health in regional and especially remote areas can be thin (ie with imprecise estimates in some or all areas).
Example 1
Table 14: Fruit and vegetable consumption, Aboriginal and Torres Strait Islander people 15+ years, 2012-13
Roughly 60% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate fruit intake, closer to 50% in remote areas (compared with around 50% of all Australians 18+ in major cities and regional/rural areas).
Roughly 95% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate vegetable intake, perhaps higher (98%) in Very remote areas (compared with around 90%-94% of all Australians 18+ in major cities and regional/rural areas).
Example 2
NACCHO provided graphic
Table 16 Below : Overweight and Obesity, Aboriginal and Torres Strait Islander people 15+ years, 2012-13
Aboriginal and Torres Strait Islander people in rural/regional and Remote areas (29%-33%) were a little more likely to be overweight than those in Major cities (28%), with those in Very Remote areas (26%) least likely to be overweight.
Aboriginal and Torres Strait Islander people in Inner regional areas (41%) were more likely to be obese than those in Major cities (38%), but those in Outer regional (36%) and remote areas (~33%) were less likely to be obese.
Overall, Aboriginal and Torres Strait Islander people in Inner Regional areas were most likely to be overweight/obese (70%), those in Major cities, Outer Regional and Remote areas were less likely to be overweight/obese (~66%), while those in Very Remote areas were the least likely to be overweight/obese (59% )
At the time of writing, the most recent National Health Survey was conducted in 2014-15[1], while the most recent AIHW NDSHS[2] was conducted in 2016, with most recently available results from the 2013 NDSHS. The most recent ABS Australian Aboriginal and Torres Strait Islander Health Survey[3] was conducted in 2012-13.
Some organisations (eg the Public Health Information Development Unit (PHIDU)) have calculated modelled estimates for small areas (eg SLA’s and PHN’s), where the prevalence of some risk factors has been predicted based on the age, sex and socioeconomic profile of the population living there.
Some sites (eg ABS) present risk factor data as crude rates, other sites (eg PHIDU) present risk factor data as age-standardised rates. The advantage of the age-standardised rates is that the effect of age is largely removed from inter-population comparisons.
For example, older populations (eg those in rural/regional areas) would be expected to have higher average blood pressure than younger (eg Major cities) populations even though the underlying age-specific rates happened to be identical in both populations (because older people tend to have higher blood pressure than younger people).
While crude rates for the older population will be higher, the age-standardised rates in such a comparison would be the same – indicating a higher rate that is entirely explainable by the older age of one of the populations.
Both crude and age standardised rates are useful in understanding the health of rural and remote populations.
Compared with Major cities (13%), the prevalence of daily smoking by people 18 years and older in Inner regional (17%) and Outer regional/Remote areas (21%) is higher.
The NDSH survey reflects these trends albeit with a slightly different age group (14+) and a different definition of smoking (daily plus less frequently), but the NDSH survey adds detail for remote areas where smoking rates are higher again (around 25% versus around 23% in Outer regional).
In addition, the average number of cigarettes smoked by each smoker is higher in regional/rural areas (~110/week) than in Major cities (86/week), and higher again (126/week) in remote areas.
Table 2: Smoking characteristics by Remoteness, 2013, 2014 and 2014-15
MC
IR
OR
remote
8.8
17.8
19.3
27.8
Proportion of pregnant women who gave birth and smoked at any time during the pregnancy (2013, crude, National Perinatal Data Collection, exposure tables, Table 5.1.2 )
8.5
17.0
18.9
27.5
Proportion of pregnant women who gave birth and smoked in the first 20 weeks of pregnancy (2013, crude, National Perinatal Data Collection) exposure tables, Table 5.2.2)
3.6
3.1
4.1
*9.4
Proportion of dependent children (aged 0–14) who live in a household with a daily smoker who smokes inside the home (2013, crude, NDSHS exposure tables, Table 6.3)
2.5
2.0
2.7
*2.9
Proportion of adults aged 18 or older who live in a household with a daily smoker who smokes inside the home (2013, crude, NDSHS, exposure tables, Table 7.3)
16.2
15.4
14.7
15.5
Average age at which people aged 14–24 first smoked a full cigarette (2013, crude, NDSHS, uptake tables, Table 9.3)
17.8
22.7
17.8
28.3
Proportion of 12–17 year old secondary school students smoking at least a few puffs of a cigarette (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, uptake tables, Table 10.3
54.7
61.1
64.9
67.2
Proportion of persons (aged 18 or older) who have smoked a full cigarette (2013, crude, NDSHS, uptake tables, Table 10.8)
2.5
3.4
2.5
3.7
Proportion of secondary school students (aged 12–17) who have smoked more than 100 cigarettes in their lifetime (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, transition tables, Table 2.3)
20.2
25.9
44.1
45.2
Proportion of young people (aged 18–24) who have smoked more than 100 cigarettes in their lifetime (2013, crude, NDSHS, transition tables, Table 2.6)
21.3
16.8
19.0
15.5
Quitting: Proportion successfully gave up for more than a month (2013, crude, NDSHS, cessation tables, Table 4.3)
Mean age at which ex-smokers aged 18 or older reported no longer smoking (2013, crude, NDSHS, cessation tables, Table 11.2)
53.1
51.5
46.3
45.0
The proportion of ever smokers aged 18 or older who did not smoke in the last 12 months (2013, crude, NDSHS, cessation tables, Table 12.3)
4.9
6.0
4.8
7.0
Proportion of secondary school students (aged 12–17) who were weekly smokers (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, established tables, Table 1.3)
6.9
9.3
6.8
10.4
Proportion of secondary school students (aged 12–17) who were monthly smokers (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, established tables, Table 13.3)
13.0
16.7
21.2
18.8
Proportion of adults aged 18 or older who are daily smokers (2014-15, crude, ABS NHS, established tables, Table 3.3)
10.9
7.8
2.9
n.p.
Proportion of smokers aged 18 or older who are occasional smokers (smoke weekly or less than weekly) (2014-15, crude, ABS NHS, established tables, Table 14.3)
40.1
44.7
42.3
52.7
Proportion of Aboriginal and Torres Strait Islander people aged 18 or older who are daily smokers (2012-13, crude, ABS Australian Aboriginal and Torres Strait Islander Health Survey 2012–13, established tables, Table 8i.3)
Women in rural and remote areas were much more likely to smoke during pregnancy, with 28% of women in remote areas smoking during pregnancy, compared with 18-19% in regional/rural areas, and 9% in Major cities.
It is unclear whether exposure to environmental tobacco smoke varies by remoteness.
Young people outside major cities appeared to have their first cigarette at an earlier age (~15 years as opposed to ~16 years in Major cities.
Secondary school students in Inner regional (~23%) and remote (~28%) areas were more likely to have had at least a few puffs of a cigarette than those in major cities (~18%).
While 20% of young people in Major cities had smoked more than 100 cigarettes in their lifetime, 26%, 44% and 45% of young people in Inner regional, Outer regional and remote areas had done so.
People outside Major cities were as likely or slightly more likely to have attempted to quit smoking, but were less likely to be successful (and more likely to be unsuccessful).
A higher proportion of secondary students outside Major cities were weekly or monthly smokers (6%, 5% and 7% in IR, OR and remote areas versus 5% in Major cities weekly, 9%, 7%, and 10% in IR, OR and remote areas versus 7% in Major cities monthly).
Table 3: Current daily smoker, Aboriginal and Torres Strait Islander people 15+ years, by Remoteness, 2012-13
Prevalence of smoking amongst Aboriginal and Torres Strait Islander people 15 years and older is around 35%-40% in Major cities and regional/rural areas, and close to 50% in remote areas. Note that while the pattern is similar in Table 2 and Table 3 above, the figures for 18+ and 15+ year olds are slightly different.
Smoking Trends
Table 4: Comparison of declines in smoking rate estimates across remoteness areas, people 18+, based on ABS NHS surveys, 2001 to 2011-12
Survey year
MC
IR
OR/Rem
Australia
Crude percent daily smokers
2001
21.9
21.9
26.5
22.4
2004-05
19.9
23.0
26.2
21.3
2007-08
17.5
20.1
26.1
18.9
2011-12
14.7
18.3
22.2
16.1
2014-15
13.0
16.7
20.9
14.5
Source: ABS National Health Surveys
From Table 4 above, rates of smoking have clearly declined in Major cities areas, but have been slower to decline in Inner regional and Outer regional/Remote areas. Rates of smoking in rural areas, apparently static last decade, now appear to be declining. Rates in Major cities and Inner regional areas have declined to 0.59 and 0.76 times the 2001 rates in these areas. The 2014-15 rate in Outer regional areas is 0.79 times the 2001 rate.
Figure 1: Daily smokers 18 years and older, 2007-08, 2011-12 and 2014-15, NHS
Note: Smokers include daily, weekly and less frequent smokers.
Figures 1 and 2 above both show clear declines in Major cities and Inner regional areas, but the trend in Outer regional and Remote areas is less clear, with ABS data showing a decline in daily smoking rates for people aged 18+ between 2007-8 and 2014-15, but NDSHS data showing little change in smoking rates for people 14+ between 2007 and 2013.
Alcohol
Table 5: Alcohol risk status, by remoteness, 2013 and 2014-15
The figures in Table 6 are not strictly comparable with those for the total population in Table 5, because Table 6 refers to people who are 15 years and older, while Table 5 refers to people who are 18 years and older.
The percentage of the 15+ ATSI population exceeding 2009 NHMRC Lifetime risk guidelines is around 15-20% with little apparent inter-regional variation, compared with, for the total population 18+, 16% in Major cities, increasing to 23% in Outer regional/remote areas.
The percentage of the 15+ ATSI population exceeding the 2009 single occasion risk guidelines is around 50-60%, and around 40% in Very remote areas, compared with, for the total population 18+, 40-50% in Major cities, rural and regional areas.
Alcohol trends
Table 7: Type of alcohol use and treatment for alcohol, by remoteness area (per 1,000 population)
Notes:
Single occasion risk (monthly): Had more than 4 standard drinks at least once a month
Lifetime risk: On average, had more than 2 standard drinks per day
Very high risk (yearly): Had more than 10 standard drinks at least once a year
Very high risk (monthly): Had more than 10 standard drinks at least once a month
Very high risk (weekly): Had more than 10 standard drinks at least once a week
There is a clear increase in the prevalence of people who drink alcohol in such a way as to increase their single occasion risk (eg from car accident, assault, fall, etc) and their lifetime risk (eg from chronic disease – liver disease, dementia, cancer etc) as remoteness increases.
In 2013, single occasion risk ranged from 25% of people 14 years or older in major cities to 42% of people in remote areas, while lifetime risk increased from 17% in major cities to 35% in remote areas.
In 2013, The prevalence of people who drank more than 10 standard drinks in one sitting at least once per week, increased from just under 3% in Major cities to 7% in remote areas.
In 2013-14, there were just under 70 closed treatment episodes per 1,000 people living in Major cities, increasing to around 80 and 90 per 1,000 population in Inner and Outer regional areas, to 155 per 1,000 people living in remote Australia.
Illicit drug use 2013
Table 8: Illicit drug use, “recent users” 14+, 2013
Note: * indicates large standard error (therefore some degree of uncertainty)
Illicit drug use appears to be higher in Outer regional and remote areas compared with Major cities and Inner regional areas, in large part due to higher rates of cannabis use in these areas, but with apparent lower use of ecstasy and cocaine in regional areas compared with Major cities.
Physical activity
Table 9: Physical inactivity, people 18+, 2014-15
MC
IR
OR/Remote
Percentage of people aged 18+ who undertook no or low exercise in the previous week (crude) (a)
64.3
70.1
72.4
Percentage of people aged 18+ who undertook no or low exercise in the previous week (age standardised) (b)
In 2011-12, adults living in Outer regional/Remote areas took slightly more steps than those living in Major cities or Inner regional areas, while the number of steps taken by children and adolescents in regional/Remote areas was slightly greater compared with those in Major cities.
Table 11: Average time spent on physical activity and sedentary behaviour by persons aged 18+, 2011-12
MC
IR
OR/Remote
Australia
Hours
Physical activity(a)
3.9
3.4
3.9
3.8
Sedentary behaviour (leisure only)(b)
29.3
28.0
27.9
28.9
Sedentary behaviour (leisure and work)(b)
40.2
35.2
36.0
38.8
Notes:
(a) Includes walking for transport/fitness, moderate and vigorous physical activity.
(b) Sedentary is defined as sitting or lying down for activities.
Adults living in Inner regional and Outer regional/Remote areas were about as likely as (or very slightly less likely than) those in Major cities to be sedentary in their leisure time, but appeared to be slightly less likely to be sedentary overall (ie their work involved a greater level of physical activity).
Table 12: Whether children aged 2-17 years met physical and screen-based activity recommendations, 2011-12
MC
IR
OR/Rem
Crude percentage
Met physical activity recommendation on all 7 days(a)(b)
27.5
34.3
34.2
Met screen-based activity recommendation on all 7 days(b)(c)
28.0
29.7
31.0
Met physical activity and screen-based recommendations on all 7 days (a)(b)(c)
9.7
10.9
14.2
Notes:
(a) The physical activity recommendation for children 2–4 years is 180 minutes or more per day, for children 5-17 years it is 60 minutes or more per day. See Physical activity recommendation in Glossary.
(b) In 7 days prior to interview.
(c) The screen-based recommendation for children 2–4 years is no more than 60 minutes per day, for children 5-17 years it is no more than 2 hours per day for entertainment purposes.
Children in rural and regional Australia appeared more likely (34% vs 28%) to meet physical activity recommendations and slightly more likely (30%vs 28%) to meet screen-based activity recommendations than their Major cities counterparts.
Fruit and vegetable consumption
Table 13: Fruit and vegetable consumption, people 18+ years, by remoteness, 2014-15
Roughly 60% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate fruit intake, closer to 50% in remote areas (compared with around 50% of all Australians 18+ in major cities and regional/rural areas).
Roughly 95% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate vegetable intake, perhaps higher (98%) in Very remote areas (compared with around 90%-94% of all Australians 18+ in major cities and regional/rural areas).
Overweight and Obesity
Table 15: Overweight and Obesity, people 18+ years, by remoteness, 2014-15
Adults in rural/regional areas are more likely to be overweight or obese than people in Major cities (69% vs 61%).
However, there were inter-regional BMI and gender differences:
Compared with those in Major cities, males in Inner regional and especially Outer-regional areas were less likely to be overweight (41% and 34%, vs 44%) but much more likely to be obese (33% and 38% vs 26%).
Compared with those in Major cities, females in Inner regional and Outer-regional areas were about as likely to be overweight (~29%) but much more likely to be obese (~33% vs 25%).
Table 16: Overweight and Obesity, Aboriginal and Torres Strait Islander people 15+ years, 2012-13
Aboriginal and Torres Strait Islander people in rural/regional and Remote areas (29%-33%) were a little more likely to be overweight than those in Major cities (28%), with those in Very Remote areas (26%) least likely to be overweight.
Aboriginal and Torres Strait Islander people in Inner regional areas (41%) were more likely to be obese than those in Major cities (38%), but those in Outer regional (36%) and remote areas (~33%) were less likely to be obese.
Overall, Aboriginal and Torres Strait Islander people in Inner Regional areas were most likely to be overweight/obese (70%), those in Major cities, Outer Regional and Remote areas were less likely to be overweight/obese (~66%), while those in Very Remote areas were the least likely to be overweight/obese (59%).
These figures compare with 61% – the prevalence of overweight/obesity for (predominantly non-Indigenous) people living in Major cities.
High blood pressure
Table 17: High blood pressure, people 18+, by Remoteness, 2014-15
Age for age, people in rural/regional Australia appeared to be as likely, or very slightly more likely to have high blood pressure than their counterparts in Major cities (~23% vs ~24%). However, because people in rural/regional areas are older (on average), the prevalence of people with high blood pressure is higher (~26% vs 22%) than
