prof ian olver - cancer council australia - social determinant of health conference 2013
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Chronic Disease and the Socially Disadvantaged Ian Olver AM
CEO Cancer Council Australia
Social Determinants of Health
Social and economic conditions and their
distribution that determine health
Risk factors e.g. availability of healthy food,
workplace environment, income, physical
environment, stress, addiction, early childhood
development etc.
Definition of chronic disease - DOH
Characteristics of chronic disease:
• Prolonged development and
duration
• No spontaneous resolution
• Rarely completely cure
• Contributes to death and or
disability
• Worse with aging
Chronic diseases in Australia (AIHW)
Ischaemic heart disease
Stroke
Lung cancer
Colorectal cancer
Depression
Type 2 diabetes
Arthritis
Osteoporosis
Asthma
Chronic obstructive pulmonary disease (COPD)
Chronic kidney disease
Oral disease
AIHW http://www.aihw.gov.au/burden-from-chronic-disease/
Prevalence: Department of Health
2007-08 National Health Survey indicates:
• cancer (2% of the population – up from 1.6% in 2001)
• diabetes (4% - up from 2.9% in 2001)
• asthma (10% - down from 12% in 2001)
• long-term mental or behavioural conditions (11% - up from fewer than
10% in 2001)
• arthritis (15% - up from 14% in 2001)
• conditions of the circulatory system (16% - down from 17% in 2001)
• The ageing population is key role in increased chronic disease
• 2007-08 National Health Survey nearly all 65 years and over had at least
one long-term condition (> 80 per cent of people > 3) cf 27% of children
• In 2010, chronic diseases were the leading causes of death in Australia,
including cardiovascular disease, cancer, chronic lung and diabetes
Chronic Disease
Impact of chronic disease
(Dept Health) • In 2006-07, arthritis, diabetes and depression accounted for 2.5% GP
consultations Australia's health 2008
• Over 1/2 of all potentially preventable hospitalisations are from chronic
conditions Australian hospital statistics 2007-08
• Ischaemic heart disease, stroke lung cancers, COPD and colorectal
cancer all featured in the top 10 leading causes of death in 2005.
Australia's health 2008
• Indigenous Australians experience higher levels of chronic conditions
than non-Indigenous Australians. In 2004-05 Indigenous health
• In 2004-05, people with chronic disease were less likely participate in
the labour force, be employed full-time, and more likely to be
unemployed Chronic disease and participation in work.
Australian Institute of Health and Welfare
Weight, smoking and alcohol by
location and social disadvantage
• Adults outside cities are more likely to be obese,
smoke, and face long term risk from alcohol
In main cities:
• Overweight and obesity increased between 2007-
8 and 2011-12 from 58.5 – 61.5%
• Smoking decreased from 17.6% to 14.8%
• Long term alcohol risk decreased
Adults in disadvantaged areas*
• Smoking which has dropped in the most
disadvantaged areas (from 28.7% to 24.5%) but is
still higher than in advantaged areas
• They are more likely to be overweight
• They are less likely to be at risk of long term
harm from alcohol
*Disadvantaged is bottom 20% and well off the top 20%
Australian Bureau of Statistics
Underlying Causes of Chronic
Disease - Smoking • Smoking rates are associated with socioeconomic status: the
proportion of smokers in the lowest socioeconomic status tier (24.6%) is
almost double that of the highest (12.5%)
• Disadvantaged populations have higher than average smoking rates
– single parents (37%)
– lone mothers 18–29 years of age (59%)
– people living with psychosis (66%)
– adults with mental illness (36%)
– at-risk young people (63%)
– people with drug disorders (73%)
– the homeless (73%)
– intravenous drug users (90%)
– prisoners (85%)
– ATSI (47%)
– those living in remote areas (28.9%)
– children of those who smoke at home
Link between smoking and disadvantage
• Disadvantage is associated with smoking; increased
disadvantage is associated with increased smoking prevalence
• For example, women in the UK were at increased odds of being a
heavy smoker if they experienced childhood disadvantage, left
school aged 16 or less, were a mother at age 22 or younger, or if
they experienced severe disadvantage as an adult
• The relationship between smoking and disadvantage has been
shown to be cumulative, that is as the number of experiences of
disadvantage accrue smoking rates increase
Graham H, Inskip HM, Francis B, Harman J. Pathways of disadvantage and smoking careers:
evidence and policy implications J Epidemiol Community Health 2006 Sep;60 Suppl 2:7-12
[Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17708005].
Smoking and disadvantage
• Smoking accounts for more than half the
difference in mortality between men in the top
and bottom social strata
• Disparities in health status between
Indigenous Australians and the total
population account for 59% of the total
burden of disease for Indigenous Australians
• Smoking accounts for 17% of this health gap,
making it the primary risk factor contributing
to health disparities in Indigenous Australians
Smoking and disadvantage
• As well as health impacts, tobacco contributes to poverty and
disadvantage through:
– the cost of tobacco-related illness
– loss of family breadwinner
– impact on family stress and finances
– impact on children’s education and employment opportunities
• Spending on tobacco products, school absence and loss of
income due to smoking-related illness reduces the capacity of a
household:
– to accumulate assets such as a family home
– to insure against losses
– to save for financial requirements in retirement and to pass on assets to the next
generation
• In addition, higher smoking prevalence among adults in lower
socio-economic families is associated with higher uptake of
smoking among children from these families, continuing the
cycle of financial stress and ill health
Smoking and Poverty • Tobacco exacerbates the impact of poverty by
reducing funds available for food, clothing + housing
• Households that smoke are 3 times more likely to
experience severe financial stress and go without
meals or home heating than non-smoking households
• Children in smoking households are 2x as likely to
experience food insecurity and 3x severe food
insecurity than children in non-smoking households
• In the lowest-income households, expenditure on
tobacco products as a proportion of total household
weekly expenditure is over 2x that in the highest
income households
Barriers to Quitting in Disadvantaged
• Heavier nicotine dependence
• Experiencing financial stress
• Friends, family and communities with a high prevalence of smoking
• facing daily stressors for which smoking is seen as a means of coping
• lack of support for quitting among family and friends
• unaware of, or having misconceptions about cessation services
• lower levels of confidence in their ability to stop smoking
• regarding smoking as their ‘only pleasure
• specific marketing by tobacco companies
Effective strategies targeting disadvantaged groups
Population Wide
• Tobacco price increases, emotional advertisements,
increasing TV advertising and the extending of
smoke-free policies from restaurants to pubs have a
strong impact on smokers in lower SES groups
• Population-wide strategies reduce uptake and
experimentation of smoking among all adolescents,
but in particular adolescents from low SES
• While population-based tobacco control approaches
have demonstrated effectiveness among smokers
from low socio-economic groups, there is increasing
recognition that more targeted strategies are required
to reach the most disadvantaged population groups.
Community- based interventions
• integrate smoking cessation support in social and
community organisations already working with
disadvantaged groups decreases smoking
• Review and revise organisational policies, supporting
staff to quit, change practices to de-normalise
smoking, make more active quit support for clients
part of routine care, and change systems to record
and monitor smoking status
• Applied in non-government and government social
and community services with clients with smoking
rates, e.g. prisons, mental health facilities, drug and
alcohol and family services, and homeless shelters
Improve access to cessation aids
• Encourage better use of existing services and
treatments by low income groups
• Quitting medications when subsided or free, are
increasingly used by disadvantaged smokers if easily
accessible
• Key elements of effective cessation approaches with
disadvantaged population groups include: a non-
judgemental, holistic and empowering approach;
provision of social support; flexibility and
accessibility; and well trained staff
Financial Incentives
• Financial incentives have been used in US and UK as smoking
cessation initiatives to encourage participation and to support
the quitting process including rewarding cessation
• Increased quit rates among pregnant women in disadvantaged
groups (increasing abstinence more than three-fold)
• Other areas to explore further include:
– how to implement financial incentive schemes for promoting
smoking cessation within the Australian context
– the merits of cash payments versus payments in kind (e.g. grocery
vouchers)
– the most effective type and size of incentives, maintaining
incentives to achieve cessation in the long term, and efficacy in
different population groups
Social and Economic Policy support
Macro level policies that
– reduce poverty
– enhance family functioning
– reduce childhood adversity
– improve housing
– provide access to quality education
– provide access to stable employment
have an impact on smoking prevalence as they
reduce the negative social conditions that are
associated with higher smoking rates and
Research
Need specific research on
disadvantaged groups because
population surveys will not be
sensitive enough to provide
evidence of their needs.
Obesity
• Adult obesity rates in Australia have tripled in 30 yrs.
• In addition to the obese, more than 1 in 3 Australian
adults were overweight in 2007-08
• The prevalence of overweight and obesity combined
was 61% (3.9 million Australian adults are obese and
an additional 5.8 million people are overweight.)
• Overweight and obesity are more common in people
of lower socioeconomic status
• 66% of adults in the most disadvantaged social
groups are overweight or obese, compared with 56%
of adults in the least disadvantaged groups
• Overweight and obesity are also more common in
inner regional areas of Australia (56-60% of adults in
2004-05) than in major cities (52%)
Obesity and disadvantaged groups
Obesity is more prevalent among:
– Australians in lower socioeconomic groups
– people living in rural and remote areas
– Indigenous Australians
Affordable access to healthy foods and
opportunities to engage in physical activity are
major contributors
The development and implementation of specific
interventions targeting the social determinants of
health in these groups is key to addressing this
clustering of risk factors
Issues of Equity in obesity and
alcohol
• Low income groups have a greater burden of diet-
related chronic disease than people of higher SES
• A food tax is likely to be regressive for low income
households.
• With tobacco taxes those on low incomes are more
responsive to price increases
• If this holds for food products, low income
households could benefit more from food tax.
• Also incorporating subsidies (e.g. for fresh fruit and
vegetables) into a tax design to support those on low
incomes may help to combat the impact of a tax on
unhealthy foods and may result in higher
consumption of healthier foods such as fruit and
vegetables.
Conclusions
• Chronic disease risk factors need to be
addressed by lifestyle changes in lower SES
groups
• This requires both community and government
policy approaches
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