One of the key determinants of health is one’s socioeconomic status, so it is no surprise to find that people who are socioeconomically disadvantaged have poorer health outcomes than other Australians, particularly those in the higher SES brackets. In fact, the relationship between SES and health is so clear that it has its own term: “the social gradient of health”. The social gradient of health relates to the fact that the higher your level of education and income the healthier you are. This can be seen both nationally in Australia and around the world. This gradient exists, because the higher your SES the more able you are to afford better housing, and health care, along with a wider choice of healthy activities and pursuits. Higher SES also are more able to make informed consumer choices about health and make better choices about behavior reducing their risk factors for lifestyle diseases.
Two examples of this include smoking and physical activity. The higher the SES the less likely a person is to smoke. Those socioeconomically disadvantaged had smoking rates around 23% in 2011-12, twice that of the highest SES group (10%). Socioeconomically disadvantaged people are less likely to be physically active. In 2007–08, 66% did not undertake recommended levels of physical activity compared with 48% of high SES people. Alcohol consumption was also more dangerous in socioeconomically disadvantaged people with 22% placing themselves at risk of lifetime harm compared to 17% in higher SES groups. Other health measures and risk factors with known social gradients include life expectancy, self-assessed health status, obesity, cancer survival, oral health and end-stage kidney disease.
The nature and extent of the health inequities
The nature and extent of the inequities in health cover a number of chronic and lifestyle diseases and include large gaps in health outcomes. Chronic disease is one of Australia’s greatest health concerns going forwards, and socioeconomically disadvantaged people have poorer outcomes in this area when compared to other Australians. Socioeconomically disadvantaged people have:
- 40% higher death rates from coronary heart disease with a slower decline rate than the higher SES areas.
- 6 times the incidence of lung cancer and worse survival rates
- a third higher rates of overweight and obese women and two thirds higher amongst children.
- Higher mortality rates from all cancers combined and poorer 5 year survival rates
- Lower life expectancy, self assessed health statues, oral health and kidney disease
- Higher burden of stroke
- Double the rates of COPD and 33% more asthma, and
- More likely to have diabetes
The sociocultural, socioeconomic and environmental determinants
The sociocultural factors that determine the health of socioeconomically disadvantaged people include: family, peers, religion, culture and media influences. People who live in areas of lowest socioeconomic status are more likely to take part in risky health behaviour, or combinations of behaviours, which can lead to poorer chronic disease outcomes. In 2011–12, people living in areas of lowest socioeconomic status were 2.3 times as likely to smoke as those living in the highest (ABS 2013a). This means people brought up in these homes have greater exposure to second hand smoke and are more likely to take up smoking. Socioeconomically disadvantaged people were 1.7 times as likely to report having 4 or more risk factors (AIHW 2012b). These include being overweight or obese, which also influences the children brought up in the homes as parents decide what the children eat and teach bad habits. Other risky behaviours in socioeconomically disadvantaged households include: Higher rates of drinking at levels that could cause lifetime harm, and lower rates of physical activity.
Socioeconomic factors relate to levels of education, employment and income. Socioeconomically disadvantaged people by definition have lower levels of education and lower rates of income. This reduces the options for health care and healthy behaviours. People with lower levels of education are less informed about the choices they have and the services available to them. This affects health as healthy choices are improved if the choice is an informed decision– also referred to as lower health literacy. They also have less choice in type of employment, and have higher rates of hazardous work types, such as transport. Higher rates of unemployment also affect mental health as sense of purpose and achievement is often connected with employment and providing for yourself and your family.
The environmental determinants refer to the location and condition of living. Socioeconomically disadvantaged people have higher rates of homelessness. A lack of shelter and living on the street or in someone else’s house affects physical and mental health, as well as bringing a social stigma that will affect social health. Homelessness also limits access to services as many benefits through Centrelink and other services require a living address. There are also higher rates of socioeconomically disadvantaged people in rural and remote areas when compared with urban areas, meaning socioeconomically disadvantaged people have poorer access to health services and greater distances to travel for medical care and other health related services.
Where people are in the social hierarchy affects the conditions in which they grow, learn, live, work and age, their vulnerability to ill health and the consequences of ill health (WHO 2014). The World Health Organisation concluded that social inequalities in health arise because of inequalities in the conditions of daily life and the fundamental drivers that give rise to them: inequities in power, money and resources (Commission on Social Determinants of Health 2008). Socioeconomic status may have the largest impact on health. It accounts for up to 40% of all influences on health (The British Academy 2014).
The roles of individuals, communities and governments in addressing the health inequities
Individuals can begin to address these inequities by focusing on good decision making and taking responsibility for their own health and the health of those around them. Actions such as remaining in school, or seeking to attend university improve ones SES and provide further information to help individuals make informed choices about their health and health care used. Individuals can also help promote health in their family and friends by encouraging good health choices, such as not smoking or reducing alcohol intake. These decisions reduce the risk factors to health and will help address the health inequities.
Communities can address the health inequities by providing relevant health care and support services. Current programs such as PCYC, provide physical activity programs and welfare support for youth. Another example is ‘Youth of the Streets’ who aim to improve health outcomes for socioeconomically disadvantaged people.
Finally the Australian Government’s address this inequity by supporting many community programs and providing funding for free or reduced cost health care. The most obvious service is Medicare. Introduced in 1984, Medicare provides free or subsidised treatment from a range of health professionals including: doctors, optometrists, physiotherapists, Exercise Physiologists, and medical specialists. Medicare funds hospitals, medical services and pharmaceuticals (PHIO 2013). This includes free public patient care in hospitals, rebates for professional health services found in the Medicare Benefits Schedule and subsidized medicine through the Pharmaceutical Benefits Scheme (PBS). The goal of these schemes and arrangements is to provide all Australians adequate and affordable health care irrespective of their SES. These schemes are further supported by social welfare arrangements with smaller costs to those who have particular income-support payments.
Individuals, communities and governments need to work collaboratively to provide an intersectoral approach to the health of socioeconomically disadvantaged people. Intersectoral collaboration is the best approach to the health inequities in this group as they are present throughout every area of Australia.