Many people think the poorer health and lower life expectancy of people living in rural or remote Australia are attributable to the under-supply of health services in those areas. But this is only one contributing factor.
Far more important is the distribution of health risk factors and how they interact with the nature of rural and remote places, which results in people dying younger. Data from the National Health Performance Authority shows life expectancy at birth ranges from 83.6 years in metro areas to 81.5 in regional hubs and 78.2 in rural places.
The picture is even grimmer when we look at avoidable deaths. From a population of 100,000, there are 115 avoidable deaths in metro areas compared to 171 in regional hubs and 244 in rural places. Clearly, there’s more than one factor at play here.
Compared with those living in major cities, the people of rural and remote Australia have fewer years of completed education and lower incomes. And a greater proportion of them have a disability, smoke, and drink to risky degrees. They also have poorer access to the internet and mobile phones.
And then there’s access to health professionals, including doctors, which is notoriously poor in rural areas. Compared with the rate at which city people access Medicare, people in rural and remote areas are at a massive disadvantage – there’s a so-called “Medicare deficit” of around $1 billion a year.
In 2012-13, for instance, there were 5.8 GP services per head funded by Medicare, compared to 5.9 in inner regional areas, 5.2 in outer regional areas, 4.1 in remote areas and 3 in very remote areas. In country areas, there’s also less access to private hospitals, even for those who are privately insured.
And apart from these well-known deficiencies in access to health services, people in rural and remote areas also have less access to health-promoting infrastructure, such as targeted smoking cessation activities, organised physical activities and the information contained in health promotion campaigns.
All in all, there’s a slanting line across key health measures such as potentially avoidable death, potentially avoidable hospitalisation and life expectancy from major cities through to very remote areas. Cancer survival rates show the same pattern.
Social factors that impact health, such as income, completed years of education, disability, smoking and risky drinking, show the same gradient. All of these result in a higher incidence among the people of rural remote areas of various disadvantages relating to work, income, education and children (think of the proportion of families with young children in poverty).
If we are to address these disadvantages, we need to unpick the relationship between socioeconomic status and geography. From an equity standpoint, the important issues are why levels of employment are low, why in a particular place there are few professionals and many labourers, why internet access is low, and why are there fewer people with education above year 11 – and what can be done about these things.
It seems safe to assume that the causes of health deficits include “rurality” – a combination of remoteness and town size because it’s obvious that town size, not just remoteness, will strongly influence variables, such as income, educational attainment, work skills and housing costs.
But our current measures are so crude that Urana, a town of 800 people in the Riverina region of New South Wales, Townsville, with around 195,000 people, and Darwin, with around 130,000 people are in the same category.
Another data set collects measures socioeconomic status. Variables used to calculate this index typically include income, internet connection, the percentage of people schooled to year 11 only, the proportion in the labour force who are unemployed, long-term health conditions or disability, and people paying less than $166 rent per week.
All of these are almost certain to be influenced by two characteristics of place: its distance from a capital city or other large centre, and the size of the town. The remoteness and the size of a particular community influences its access to schools, jobs and high-paid employment. Other issues, such as the nature of the main local industries, or economic drivers, such as weather, are also influential.
We can keep doing new analyses to expand our understanding of how various factors interact to cause the clear health disadvantage in rural and remote areas. These might even suggest the causes for the different but they will be misleading without a solid understanding of underlying variables.
While the role of income and education on health status are universal and universally accepted, it’s too early to dismiss place – especially “rurality” – as a determinant of health status.
It seems likely that place is a primary determining factor in the worse health of rural and remote Australians, with socioeconomic status being an intermediary. In other words, low income might be the toxin, with place being what allows it to harm people.
We know socioeconomic status is a major determinant of health, but understanding how the characteristics of a particular place impact health is critically important if we are to understand how to improve health and longevity in rural and remote Australia.
ACKNOWLEDGMENT Gordon Gregory and Andrew Phillips from the National Rural Health Alliance contributed to this article.