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Core 1: Health Priorities in Australia

The content covered in each of the focus questions within Core 1 Health Priorities in Australia is inter-related. It is important to take a holistic view when revising this course. Developing a deep understanding of the relationship between content covered in each of the focus questions will help you to apply various health information. Develop a clear understanding of the relationships between the focus questions and dot points in the syllabus. For example, think of the relationship between: epidemiology and the impact on health care facilities and services a growing and ageing population and health care facilities and services groups experiencing health inequities and the action areas needed to address Australia's health priorities high levels of preventable chronic disease, injury and mental health problems and health promotion based on the Ottawa Charter

How are priority issues for Australia's health identified?


Measuring health status Australia is one of the healthiest countries in the world; however, Australias population still experiences a range of health problems. The challenge for the Australian government is to allocate a limited amount of resources to address these health problems. This means that priorities need to be established. The Australian government has chosen to use a framework of priority health issues to achieve this. Epidemiology plays an important role, however issues such as social justice, potential for prevention and costs are also important. Role of epidemiology Epidemiology is the study of the frequency and distribution of a disease within a population and the attempt to identify the cause(s) of that disease. Collecting, verifying and analysing data about the incidence of disease in a given population gives researchers, health department officials and governments, indicators of the existence of health problems in a community. Some of the health indicators used to describe the health status of a population include mortality (death) rates, morbidity (illness) rates, life expectancy, and infant mortality rates. These indicators can also provide patterns of disease in terms of age, gender, ethnicity, socioeconomic status and educational opportunity. This level of data allows public health authorities to manage, evaluate and plan for health services to prevent, control and treat diseases and health problems (Australasian Epidemiological Association). Epidemiological information is used by health professionals and by the government to develop policies and health promotion strategies that promote the health of individuals in the community. What does epidemiology tell us? Evidence of morbidity (how many new cases are occurring). PDHPE Health Priorities Gina Marovic 1

Prevalence of morbidity and mortality (how many existing cases are occurring) The extent of the problem and possibility where to allocate resources Factors that are directly linked to morbidity and then hopefully strategies to deal with these problems Apparent cases and also compares different groups of people What doesnt epidemiology tell us? Statistical information tells us little about the severity of illness and how this impacts upon a persons quality of life Epidemiology data is sometimes lacking or non-existent on certain health issues for which gathering detailed info is different e.g. mental illness It doesnt address the reasons why health inequities exist Information is gathered on incidence of disease and death and related risk factors but often neglects other factors such as cultural and economic factors Need to be careful that the data collection is valid and reliable How do we use epidemiology to improve the health of Australian's? To identify health inequities between sub populations To establish priorities, enabling efficient use of funds To develop preventative programs and monitor health care services To monitor and evaluate programs Mental deterioration Cancerous growths in organs such as the skin or lining of the lungs To adjust or realign Refers to the incidence and prevalence of disease A period of time when the signs and symptoms of a disease have completely or partially disappeared A growth that may be either benign or malignant A substance that causes cancer Te spread of cancer cells An estimate of how long a person may be expected to live at a given point in time A condition where artery walls harden and lose their elasticity The number of deaths in a particular period of time The factors associated with the incidence of disease or illness The gathering and studying of information about illness, disease and death within certain populations Cancers arising in connective tissues such as cones, cartilage, muscles etc.

Dementia Carcinoma Reorient Morbidity Remission Tumour Carcinogen Metastasis Life expectancy Arteriosclerosis Mortality Determinants Epidemiology Sarcoma

Measures of epidemiology Mortality refers to the number of deaths in a given population from a particular cause and/or over a period of time. An objective and often easily determined measure of health status, data on mortality can be used to compare health status across groups and between years. PDHPE Health Priorities Gina Marovic 2

Infant mortality refers to the number of infant deaths in the first year of life, per 1000 births. This measure is considered to be the most important indicator of the health status of a nation, and can also predict adult life expectancy. Divided into neonatal (deaths within the first 28 days of life) or post-neonatal (deaths in remainder of first year of life). Improved support services such as baby health clinics and immunisation programs have contributed to the reduction in infant mortality in Australia over the last century. Morbidity is the incidence or level of illness, disease or injury in a given population. Theyre all conditions that reduce our quality of life, either temporarily or permanently. Information about the incidence and prevalence of these conditions in the total population gives us a broader perspective on the nations health than that provided by mortality statistics. Morbidity measures and indicators include: hospital use, doctor visits and Medicare statistics, health surveys and reports, disability and handicap. Life expectancy is the length of time a person is expected to live. Average number of years of life remaining to a person at a particular age, is based on current death rates. Improvements in death rates can be attributed to lower infant mortality, declining death rates for cardiovascular disease, declining overall death rates for cancer, and a fall in deaths from traffic accidents. Medical knowledge and management have improved. This has resulted in an ageing population where more nursing homes or facilities for the ages have had to be put in place to compensate for them. Identifying priority health issues The determination of priorities for health spending can be very challenging. Different people in the community will take different perspectives. The Australian government has determined that along with epidemiology, the following considerations are important. This means that it is not simply morbidity and mortality rates that determine Australias health priority issues. There are a range of factors that need to be considered. For example, groups who are identified as experiencing significant health issues such as Aboriginal and Torres Strait Islander peoples need significant support and resources to address any health inequities that exist. Social justice principles Social justice means that the rights of all people in our community are considered in a fair and equitable manner. While equal opportunity targets everyone in the community, social justice targets the marginalised and disadvantaged groups of people in our society. Public policies should ensure that all people have equal access to health care services. People living in isolated communities should have the same access to clean water and sanitation as a person living in an urban area. People of a low socioeconomic background should receive the same quality health services that a person in a higher socioeconomic income receives. Information designed to educate the community must be provided in languages that the community can understand. A focus on social justice aims to social justice is to reduce the level of health inequalities in Australia. The four principles of social justice are equity, access, participation and rights. Social justice is what faces you in the morning. It is awakening in a house with an adequate water supply, cooking facilities and sanitation. It is the ability to nourish your children and send them to a PDHPE Health Priorities Gina Marovic 3

school where their education not only equips them for employment, but reinforces their knowledge and understanding of their cultural inheritance. It is the prospect of genuine employment and good health: a life of choices and opportunity, free from discrimination. "Equity in health is not about eliminating all health differences so that everyone has the same level of health, but rather to reduce or eliminate those which result from factors which are considered to be both avoidable and unfair. Equity is therefore concerned with creating equal opportunities for health and with bringing health differentials down to the lowest levels possible." Priority population groups High levels of preventable chronic disease, injury and mental health problems have been identified as one of the priority health issues for Australians. Within each of these health areas, certain groups in our population have been identified as at increased risk of developing these diseases or health conditions. By identifying at risk population groups, government health care expenditure and health promotion initiatives can be directed towards these groups to attempt to reduce the prevalence of the disease. Prevalence of condition Analysing statistics allows us to interpret the prevalence of a condition or disease. Prevalence means how common a condition is in the community. Morbidity statistics are reliable indicators of the prevalence of a condition. They can often highlight points of difference for the same condition, e.g. the mortality (death) rate for a disease/condition may be low but the morbidity rate quite high. Governments can then look at the reasons why (e.g. improved technology for detection and treatment) and further allocate resources. Hospital admissions and health surveys are two examples of how statistics are accumulated to give us a picture of the health status of a population. Potential for prevention and early intervention There are many behaviours that can influence the incidence and prevalence of diseases and conditions. These are often related to lifestyle behaviours, e.g. smoking, lack of physical activity and a diet high in fat and salt increase a persons risk of cardiovascular disease. By making lifestyle changes such as eating a healthy diet, regularly exercising, limiting alcohol intake and refraining from smoking, many lifestyle related conditions can be prevented. For example, cardiovascular disease has some very highly preventable risk factors including smoking and lack of physical activity. An individual could modify their lifestyle by stopping smoking and taking up regular exercise in order to decrease the risk of developing cardiovascular disease. For many Australians, behaviour change is difficult to achieve. There are many social and environmental factors that influence behaviour, e.g. access to mammograms for people from isolated areas. Making decisions about the allocation of resources for health issues is a complex one. Changing behavioural, social and environmental determinants provides great potential for decreasing the burden of poor health on the individual and society. It is through prevention and early intervention where some diseases and conditions, if detected in the early stages, can be treated successfully.

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Examples where early detection and intervention have been successful in reducing mortality rates include breast and skin cancer. Costs to the individual and the community Ill health impacts across all aspects of a persons life. Loss of life, quality of life and the financial burden to a family, are examples of the detrimental effect of developing a chronic health condition. Many people, who suffer from serious illness, may need to be hospitalised for lengthy periods of time. This may prevent them from maintaining employment status and consequently place a financial strain on their families. It is important to remember that the cost of ill health to individuals and communities is not simply the direct financial costs. It includes the indirect financial, physical, social, emotional and mental costs as well. The burden of an acute or chronic health condition on the social and emotional health of an individual or family is extremely difficult to measure and fully comprehend. According to the Australian Institute of Health and Welfare (AIHW), the average health expenditure per person more than doubled between the years 1995-96 and 2005-06. In 1995-96, the average health expenditure per person was $2146 compared to $4874 in 2007-08. The estimated total expenditure on health in Australia in 200708 was $103.6 billion, exceeding $1 billion for the first time. Reasons for this are varied. Life expectancy has increased by 20 years since the beginning of the twentieth century and is continually increasing for the Australian population. This means that more money will be required to fund health care to care for the increased number of elderly living longer lives. As survival rates from chronic illnesses such as cancer improve, the increased burden of this older population living longer will inevitably result in Australians contributing more towards the expenditure of health care costs in Australia. Increasing use of Medicare also places extra emphasis on Australias health system and expenditure. Improved technological advances that provide Australians with more effective methods of treatment do come at a great expense, and yet are essential in providing individuals with the best possible treatment.

What are the priority issues for improving Australias health?


By measuring health status and identifying the priority health issues for improving Australias health, the Australian government has identified the following priority issues for improving Australias health. Groups experiencing health inequities The population of a nation can be divided into specific groups when interpreting current health trends. This makes it easier to see if there is an unequal distribution of some illnesses and conditions within each group. Some have shorter lives, higher levels of risk factors that contribute to preventable disease and injury, and a lower level of access and/or use of health services. Although there may be many groups experiencing health inequity, the following groups have been identified as having special concerns in relation to their health. The consequences of having fewer resources, less power to make healthy lifestyle choices and a reduced capacity to be healthy all impact on their ability to achieve better health. PDHPE Health Priorities Gina Marovic 5

The health status of Australians has improved over the last century. It is in line with several other developed countries. Australia has one of the highest life expectancies in the world, although, life expectancy in Australia is not uniform across all population subgroups. The population of a nation can be divided into specific groups when interpreting current health trends. This makes it easier to see if there is an unequal distribution of some illnesses and conditions within each group. Some have shorter lives, higher levels of risk factors that contribute to preventable disease and injury, and a lower level of access and/or use of health services. Although there may be many groups experiencing health inequity, the following groups have been identified as having special concerns in relation to their health. The consequences of having fewer resources, less power to make healthy lifestyle choices and a reduced capacity to be healthy all impact on their ability to achieve better health.

Aboriginal and Torres Strait Islander peoples No greater contrast can be found in health status in Australia than that between Aboriginal and Torres Strait Islander peoples and the rest of the Australian population. Aboriginal and Torres Strait Islander peoples experience significantly more ill health than other Australians. They typically die at much younger ages and are more likely to experience disability and reduced quality of life because of ill health. Although there have been improvements in the mortality rates of Indigenous Australians in recent years, available data suggest that the relative gap in overall mortality rates between Indigenous and non-Indigenous Australians is widening. Indigenous children aged 04 years died at around twice the rate of non-Indigenous children during 2003-2007 In the 2004-05 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS), conducted by the ABS, the following trends could be found. After adjusting for differences in the age structure between the Indigenous and non-Indigenous populations, Indigenous people were more than ten times as likely as non-Indigenous people to have kidney disease, three times as likely to have diabetes, and one-and-a-half times as likely to have asthma. Based on self-reported height and weight information trends for overweight and obesity for indigenous adults were similar to nonIndigenous adults (rate ratio of 1.2). The proportion of Indigenous adults who smoked regularly (one or more cigarettes a day, on average) was also high at 50%, and more than twice the rate for non-

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Indigenous adults. One in five Indigenous adults (19%) reported drinking at short-term risky/high risk levels at least once a week in the last 12 months, double the rate reported by non-Indigenous adults. Indigenous peoples health is a major issue for the nation and there have been some strategies and programs which have been undertaken so far that have had limited success. Modern approaches to health care and health promotion require a multi-faceted approach. Some agencies/programs that are working to improve the health of Indigenous Australians are: The Office of Aboriginal and Torres Strait Islander Health (OATSIH) The National Aboriginal Community Controlled Health Organisation (NACCHO) The Aboriginal Health and Medical Research Council of NSW (AH&MRC) Healthy for Life (H4L) Program National ASTI Child and Maternal Health Exemplar Site Initiative

Socioeconomically disadvantaged people Many studies show that people or groups who are socially and economically disadvantaged have reduced life expectancy, premature mortality, increased disease incidence and prevalence, increased biological and behavioural risk factors for ill health, and lower overall health status. The link between socio-economic status (SES) and health begins at birth and continues through life, but the strength of the relationship varies at different life stages. Because economic and social inequalities go hand in hand, their combined impact can result in limited opportunities and life chances for those who experience them. Those with the highest socioeconomic status tend to be those who have the most resources, opportunities and power to make choices, whereas those with the lowest status have less of these. This forms a social gradient, with overall health and wellbeing tending to improve with each step up the socioeconomic ladder. Thus, people with a higher income generally enjoy better health and longer lives than people with a lower income. The rich tend to be healthier than those in the middle, who are, in turn, healthier than the poor. Some factors that can lead to SES effects on health include: access to high-quality health care individual factors such as smoking, exercise, nutrition, stress and depression environmental factors such as pollution, housing and overcrowding social environments such as neighbourhoods, work, interpersonal support or conflict, and violence and discrimination.

Results from the 200708 National Health Survey (NHS) indicate that people with lower socioeconomic status are more likely to smoke, exercise less and be overweight and/or obese. These are risk factors for a number of long-term health conditions such as respiratory diseases, lung cancer and cardiovascular diseases Among the long-term health conditions explored in the 200708 NHS, those reported most often by people experiencing disadvantage were cardiovascular disease, diabetes, depression and respiratory diseases (including asthma). The survey also found that those who were socioeconomically PDHPE Health Priorities Gina Marovic 7

disadvantaged reported more visits to doctors and hospital outpatient and accident and emergency services, but were less likely to use preventive health services, such as dental services. People in rural and remote areas Australias rural and remote regions reflect the variety of Australian life. Despite this variation and the perceived health advantages of living in rural areas (clean air, less traffic, more relaxed lifestyle), those who live in rural and remote areas generally have poorer health than their major city counterparts, reflected in higher levels of mortality, disease and health risk factors. There is evidence to suggest medical services in rural and remote Australia are not as accessible as in metropolitan areas and people in these areas are exposed to different health risks. In contrast, rural Australians generally have higher levels of social cohesiveness, for example, higher rates of participation in volunteer work and feelings of safety in their community. Defining rural and remote is challenging because of the diversity of these areas. In summary, it usually reflects all those areas outside major cities. Indigenous Australians are important in any discussion about the health of people living in rural and remote areas. Although they make up 2.5% of the total Australian population, Aboriginal and Torres Strait Islander peoples constitute 24% of the population in remote or very remote areas. The poor health status of the Indigenous population form a significant part of the health statistics of some rural and remote areas. Overseas-born people Australia has one of the largest proportions of immigrant populations in the world, with an estimated 25% of the total population (5.5 million people) born overseas. Well over half of these were born in a non-English-speaking country. Migrants bring to Australia their own unique health profiles. Research has found that most migrants enjoy health that is at least as good as, if not better than, that of the Australian-born population. Immigrant populations often have lower death and hospitalisation rates, as well as lower rates of disability and lifestyle-related risk factors. Australian Institute of Health and Welfare: Singh & de Looper, 2002 This healthy migrant effect is believed to result from two main factors: a self-selection process which includes people who are willing and economically able to migrate and excludes those who are sick or disabled a government selection process which involves certain eligibility criteria based on health, education, language and job skills. There is evidence that the healthy migrant effect decreases the longer they live in Australia, i.e. the longer they live in Australia, the closer they align to health patterns of the whole population. Australian Institute of Health and Welfare Despite these advantages, certain health risk factors and diseases are more common among some country-of-birth groups in Australia, reflecting diverse socioeconomic, cultural and genetic influences such as:

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significant psychological distress, especially related to war and conflict and/or the disruption of moving and leaving friends and family, has been observed among some migrant groups people from non-English speaking backgrounds are less likely to report medical conditions they may be experiencing, may have difficulty access health services due to language barriers, less likely to immunise their children, less likely to exercise and more likely to be slightly overweight. The elderly Good health is a crucial factor for older Australians enabling them to enjoy a good quality of life, stay independent and participate fully in the community. Good health among older Australians helps to moderate demand for health and aged care services, which is important as Australias population ages over coming decades. In response to population ageing, Australia has made the improvement of older peoples health a national research priority. The evidence shows that todays older Australians are living longer and healthier lives than previous generations. Older Australians, defined in this section as people aged 65 years or over, make up 13% of the population. Around 1.6% of Australias population were aged 85 years and over. By comparison, in 1956, 8.4% of the population were aged 65 years and over and 0.4% were aged 85 years and over. During the past several decades, the number and proportion of the population aged 65 years or over have increased rapidly in Australia. The increase in the population aged 85 years or over was even more marked. It is estimated that these trends will continue. Evidence also reveals that as people are living longer, there is more time spent living with a disability in the later years of their life. This makes them less mobile and they will need more access to health care. Amongst older Australians, in 2007, coronary heart disease and cerebrovascular disease (notably stroke) were the two leading causes of death among older males (26%) and females (29%). These diseases are also major causes of disability among older Australians. Lung cancer was the third most common cause of death for older males and the fourth for older females. Colorectal cancer was also prominent for both sexes, and prostate cancer and breast cancer were two prominent sex-specific causes of death. People with disabilities Diseases and injuries can often impair how a person functions for a while, but many people do recover fully. For some people the effect can be long term because there is residual damage or the health condition becomes chronic. Alternatively, a person may have permanent damage or loss of function from birth. In these cases, the resulting disability may bring special needs for assistance in the persons daily life. Many Australians live with long-term health conditions. Most of these conditions are not major causes of death, but they are common causes of disability and reduced quality of life. One in five Australians lives with some degree of disability. Disability can be defined in the following categories:

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severe or profound core activity limitationwhere the individual sometimes or always needs help with at least one core activity: self-care, communication or mobility moderate or mild core activity limitation, or schooling or employment restriction where the individual does not need assistance but has difficulty performing a core activity (moderate); or has no difficulty performing a core activity but uses aids or equipment because of disability (mild), or has restriction in schooling or employment participation only no specific core activity limitation, or schooling or employment restrictionwhere the individual is identified by the ABS Short Disability Module as having disability but without having specific limitations or restrictions. The large majority of disabilities are of a physical nature, including arthritis, respiratory diseases, circulatory diseases and musculoskeletal disorders. Sensory disorders (such as diseases of the ear and eye) are also common, as are mental disorders. Rates of disease and co morbidity (having 2 or more conditions at the same time increase with the severity of disability) People with disabilities often experience inequities due to the socioeconomic circumstances they experience. These include factors such as a lack of access to employment opportunities and the need for ongoing health care. People with disability also encounter more difficulty accessing health services, have lower life expectancy and experience poorer health across a range of areas. How people experience and cope with disability is greatly affected by the opportunities and services provided for them. For example, people needing wheelchair access need a variety of support including access to the wheelchair or other technical aids, accessibility to buildings and public transport can limit access to health services, job opportunities and support and policies that support employment. High levels of preventable chronic disease, injury and mental health problems While there have been downward trends in death rates, cardiovascular disease (heart, stroke and vascular) imposes the largest burden on Australia in terms of illness, disability and death. The emphasis here is on the preventable nature of these conditions. Improving peoples access to resources and support for prevention will reduce pressures on the health system and improving Australias health. The following health preventable and chronic diseases and conditions have been identified as priority issues due to the impact they have on the health of Australians. The areas selected as priorities for improving Australias health are cardiovascular disease, cancer (skin, breast, and lung), diabetes, respiratory disease, injury and mental health problems and illnesses. Almost 80% of the total burden of disease is covered by these conditions as described in Australias Health 2008: Among the broad categories of disease, cancer is the leading cause of disease burden (19% of Australias total), closely followed by cardiovascular disease (18%), then mental disorders (13%). Death rates are falling for many of our leading health concerns: cancer, heart disease, strokes, injury and asthma are examples. Death rates are falling for many of our leading health concerns: cancer, heart disease, strokes, injury and asthma are examples. 10

PDHPE Health Priorities Gina Marovic

Heart attack rates are falling and survival from the attacks is improving. Survival is improving for cancer overall. Asthma has become less common among children and young adults. Diabetes is becoming more commonprevalence at least doubling in the past two decades. There has been a tripling in new cases of treated end-stage kidney disease in the past 25 years.

Diseases and injury impose major costs on society in terms of health system use, reduced quality of life and days off work (because of illness or to care for people who are ill). Despite diseases and injuries remaining significant problems, the situation is improving on many fronts. The increase in the number of people with certain diseases such as diabetes and mental health problems however, is cause for concern. It is possible to identify risk factors for these diseases and illnesses, the determinants of health and ways that behaviours can be modified to reduce the impact of such conditions. If government agencies and health authorities give priority to reducing the high prevalence of such diseases and illnesses, the overall health status of Australians is likely to improve. As part of the syllabus requirements, you are required to research and analyse cardiovascular disease, cancer (skin, breast, and lung) and ONE other condition (either: diabetes, respiratory disease, injury or mental health problems and illnesses). To determine why these health conditions have been selected as priority issues, it is important to research and analyse each priority area in terms of: - The nature of the problem - The extent of the problem (trends) - Risk factors and protective factors - The sociocultural, socioeconomic and environmental determinants - Groups at risk Cardiovascular disease (CVD) CVD is a term used to describe all conditions that affect the heart and blood vessels. The underlying cause of CVD is atherosclerosis. CVD continues to be one of the biggest health problems affecting Australians. CVD remains the leading cause of death for Australians; however there is a decreasing mortality trend and morbidity trend. CVD is highly preventable. The major modifiable risk factors are lifestyle related such as tobacco smoking, high blood cholesterol, insufficient physical activity and poor nutrition. The groups at highest risk of developing CVD are Aboriginal and Torres Strait Islanders peoples, socio-economically disadvantaged people, the elderly and those born in Australia.

The nature of the problem PDHPE Health Priorities Gina Marovic 11

Cardiovascular disease (CVD) is a term used to describe all health conditions that affect the heart (cardio) and blood vessels (vascular system). The definition of cardiovascular diseases differs between organisations. The terms cardiovascular disease, circulatory disease and heart, stroke and vascular diseases are often used interchangeably to convey the same meaning. Cardiovascular disease includes: Coronary heart disease (CHD) Cerebrovascular disease (stroke) Peripheral vascular disease. The main underlying causal mechanism in cardiovascular disease (CVD) is the formation of plaque which occurs as a result of atherosclerosis. Atherosclerosis is a long term process where there is a build up of fat, cholesterol and other substances in the inner lining of the arteries. It is most serious when it leads to a reduced or blocked blood supply to the heart (causing angina or heart attack) or to the brain (causing a stroke). Cardiovascular disease continues to be one of the biggest health problems requiring attention in Australia. Extent of the problem (trends) Cardiovascular disease has a major impact on the health status of Australians. It remains the leading cause of death for Australians and is a major cause of morbidity. Morbidity Data from the 2007-08 National Health Survey indicates that there has been a decrease in the prevalence and incidence. The cardiovascular disease burden increases markedly with age. (National Health Survey: Summary of results 2007-2008) Mortality Despite declines in mortality rates in the last 30 years, in 2005 cardiovascular disease remained one of the leading causes of death in Australia, accounting for 35% of all deaths. (Year Book Australia 2008, 2008, p.347). Risk factors and protective factors Cardiovascular disease is highly preventable. The factors that increase a persons chance of getting cardiovascular disease are called risk factors. These risk factors can be modifiable or non-modifiable. The sociocultural, socioeconomic and environmental determinants Factors which affect health outcomes are complex. They can interact in many ways to reduce an individuals health. The broad features of a society, its sociocultural aspects, the socioeconomic and the environmental factors, e.g. living conditions of an individual or a group, can determine the extent to which a person can be affected by a disease. Groups at risk For all diseases there are groups of people that are more at risk. PDHPE Health Priorities Gina Marovic 12

Cancer Cancer refers to a large group of diseases characterised by uncontrolled growth and spread of abnormal body cells. The most common cancers in Australian females are breast cancer, melanoma of the skin, lung cancer and colorectal cancer. For males the most common cancers are prostate, colorectal, melanoma of the skin, and lung cancer. Cancer is the second most common cause of morbidity and mortality. There has been a decreasing mortality trend despite the overall cancer incidence rate remaining virtually unchanged. The major risk factors for cancer are specific to each type of cancer. Family history, smoking and exposure to UV rays play a large role in developing cancer. Low socioeconomic status is a large determinant to the development of most forms of cancer as well as environmental factors. The groups at risk for cancers are specific to each type of cancer. The nature of the problem Cancer is a disease of the body's cells. Normally, cells grow and reproduce in an orderly manner. Sometimes, though, abnormal cells will grow and be defective. These abnormal cells may then reproduce, sometimes at a very rapid rate, and spread (metastasise) uncontrolled throughout the body. Cancer is the term used to describe about 100 different diseases including malignant tumours, leukaemia, Hodgkin's disease and non-Hodgkin's lymphoma. Tumours are swellings or enlargement caused by a clump of abnormal cells. They can form and remain localised with no threat of spreading and are known as benign tumours. These can be treated surgically. However, if the tumour has the potential to spread uncontrolled throughout the surrounding normal cells and affect their functioning, it is known as a malignant tumour. These malignant cancer cells can often break off and enter the blood stream and lymphatic system and travel to other parts of the body, where they can cause new cancers to grow. Extent of the problem (trends) Morbidity According to the AIHW and the Australasian Association of Cancer Registries of the new cancer cases in 2005, prostate cancer was the most common cancer followed by colon and rectal cancer. The next most common cancers were breast cancer, melanoma of the skin and lung cancer. Cancer occurred more commonly in males than females and was most prevalent in those aged over 65 years. (Year Book Australia, 2009-2010) Overall cancers occur at higher rates in males than females, with an overall male-to female ratio of 1.4, that is, the male rate is 1.4 times the female rate .The most common cancer in females in 2005 was breast cancer, which made up over 27% of all diagnoses, followed by melanoma of the skin and lung cancer. For males the third most common cancer in 2005 was melanoma of the skin, followed by lung cancer.

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(Cancer - Australian cancer statistics update, 2010) The current situation is that, by the age of 75 years, 1 in 3 Australian males and 1 in 4 females will have been diagnosed with cancer at some stage of their life. The risk by age 85 years increases to 1 in 2 for males and 1 in 3 for females (Australias health 2010) Mortality Cancer is a major cause of death, accounting for 29% of all deaths in 2007. Over the last decade, improvements in early detection and treatment have resulted in improved survival and a clear decline in mortality for most cancers, despite the overall cancer incidence rate remaining virtually unchanged. This is due to the growing and ageing population as those aged over 65 years have the highest incidence and mortality for cancer. In 2007, lung cancer was by far the most common cause of cancer death for both males and females. Colorectal cancer was the second leading cause of death. Third came sex specific cancers, e.g. prostate cancer for males and breast cancer for females. Risk factors and protective factors Risk factors can be divided into two categories, those that can be modified and those that cannot be modified. The risk factors vary according to the type of cancer. The factors that protect an individual against the most common types of cancer include the following. Breast Cancer consumption of a diet high in fruits and vegetables, and low in fat practising self-examination regular mammograms if over the age of 50 years familiarity with family history

Lung Cancer avoid exposure to tobacco smoke avoid exposure to hazardous materials such as asbestos

Skin Cancer avoid sunlight reduce exposure to the sun by wearing a hat, sunscreen, protective clothing and sunglasses monitoring skin changes and having regular check ups

The sociocultural, socioeconomic and environmental determinants Cultural background is a factor in cancer rates, as seen by, high rates of lung cancer amongst Aboriginal and Torres Strait Islander peoples. In the demographic mix, cancer incidence and mortality is highest in the 65 years and over age group, so the prospect of an aging population is cause for concern for future cancer trends. Prevailing values and attitudes also have an effect, particularly, in regards to modifiable risk factor behaviours. PDHPE Health Priorities Gina Marovic 14

Education, employment status and occupation, and income and wealth are reflected in cancer data, which shows that people from socioeconomically disadvantaged backgrounds have notably higher rates of some cancers. Environment can often play a large role in the risk of developing cancer. This includes workplace influences, climate and UV exposure as well as exposure to tobacco smoke. Groups at risk Cancer is a significant cause of death in all age groups. For the studied cancers, the groups at higher risk of developing cancer are outlined below. Breast Cancer women who have never given birth obese women women aged over 50 years women who have a direct relative with breast cancer women who start menstruating at a young age women who have late menopause

Lung Cancer cigarette smokers people exposed to occupational or environmental hazards (e.g. asbestos) people working in blue-collar occupations men and women aged over 50 years

Skin Cancer people with fair skin people in lower latitudes people in outdoor occupations people who spend too much time in the sun without protection such as hats and sunscreen. children and adolescents

A growing and ageing population In Australia life expectancy is continually increasing. This section explores the impact a growing and ageing population has on the health care system, workforce, carers and volunteer organisations Australias population is growing and ageing. The ageing population is the consequence of sustained low fertility levels and increasing life expectancy at birth. With our ageing population, comes a number of health challenges to our community. An increase in people living with chronic diseases and disabilities, places a higher demand for health services and workforce shortages as well as the financial strain to provide these services.

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Government priority is to encourage healthy ageing so as to enable people to contribute for as long as possible and to reduce the burden on our health care system. It is projected that there will be little growth in the number of available carers, compared with the anticipated rise in demand for home-based support. This is likely to result in a shortage of carers in the future. Healthy ageing Good health not only helps older Australians to enjoy a good quality of life and to participate fully in the community, but also helps to reduce their demands for health and aged care services. This is important as Australias population ages over coming decades. For this reason, improving older peoples health is a national research priority in Australia (DIISR 2009). One area of special interest is the adoption of a healthy lifestyle at older ages. Health across the life stages because its benefits include preventing disease and functional decline, and promoting a longer life and a better quality of life (WHO 2002). Healthy ageing refers to activities and behaviours which aim to reduce the risk of illness and disease, and increase physical, emotional and mental health during the ageing process. It is concerned with the quality of life, not just the years of life, enjoyed by an individual. Evidence shows that todays older Australians are living longer and, in several respects, healthier lives than previous generations. According to the 200708 National Health Survey, the majority of older Australians consider themselves to be in excellent, very good or good health, although the proportion of older females reporting fair or poor health increases with age. Thus, many older people have a positive view of their health even though older age may be generally associated with increasing levels of disability and illness. Increased population living with chronic disease and disability The ageing population and greater longevity of individuals are leading to growing numbers of people, especially at older ages, with a disability and severe or profound core activity limitation. Coronary heart disease and cerebrovascular disease are the two leading causes of death and the major causes of disability among older Australians. The top ten causes of disease burden in Australia are chronic diseases. The prevalence of chronic disease increases with age. In 2004-5, more than 90% of coronary heart disease and osteoporosis, and over 80% of diabetes and arthritis, were reported for people aged 45 years and over. In 2003, the Australian Bureau of Statistics (ABS) Survey of Disability, Ageing and Carers (SDAC) one in five people in Australia had a reported disability with the rate being very similar for males and females. Disability was defined as any limitation, restriction or impairment, which has lasted, or is likely to last, for at least six months and restricts everyday activities. Examples range from hearing loss which requires the use of a hearing aid, to difficulty dressing due to arthritis, to advanced dementia requiring constant help and supervision. In 2003, just over half of the population aged 60 years and over had a reported disability (51%) and 19% had a profound or severe core-activity limitation. Of all people aged 60 years and over, less than half (41%) reported needing assistance, because of disability or old age, to manage health conditions PDHPE Health Priorities Gina Marovic 16

or cope with everyday activities. However, people aged 85 years and over reported a much higher need for assistance than those aged 60-69 years (84% compared with 26%). Demand for health services and workforce shortages The Australian health system is complex, with many types of service providers and a variety of funding and regulatory mechanisms. Those who provide services include a range of medical practitioners, other health professionals, hospitals, clinics, and other government and nongovernment agencies. Older people are much higher users of hospitals than their younger counterparts. As age increases, so does the average length of stay. On discharge from the hospital, older people are more likely than younger people to enter residential aged care or die. This is particularly the case for injury-related hospitalisations. Funding limitations are a significant factor contributing to the shortages. Calls for increased government allocation of funding have been made, and some have suggested that the funding process should be streamlined, with a key goal of trying to improve staff ratios. In 2008 the Council of Australian Governments (COAG) agreed to a National Partnership Agreement on Hospital and Health Workforce Reform. This agreement included a series of reforms aimed at alleviating the shortages in Australias health workforce and ensuring that the workforce would be able to meet expected increases in the demand for health care resulting from the ageing population, higher levels of chronic disease and rising community expectations. Availability of carers and volunteers A carer is any person who provides assistance in a formal paid role or informal unpaid role to a person because of that persons age, illness or disability. The provision of unpaid care by family members is an important complement to formal services. Carers may be needed to assist with tasks of daily living, such as feeding, bathing, dressing, toileting, transferring or administering medications. On other circumstances, there may only be the need for assistance with transport, financial or emotional support. Older people living in households most commonly reported needing assistance with property maintenance and health care because of disability or age. Service providers that offer aged care in the community and through aged care homes include a mix of private and religious or charitable organisations, as well as state, territory and local government. The Australian Government has the major role in funding residential aged care services and aged care packages in the community. The bulk of home and community based services for older people are provided under the Home and Community care (HACC) program. The program includes home nursing services, delivered meals, home help and home maintenance services, transport and shopping assistance, allied health services, home and centre based respite care, and advice and assistance of various kinds.

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What role do health care facilities and services play in achieving better health for all Australians?
The Australian health care system consists of a wide variety of facilities and services. They mainly focus on diagnosis, treatment, rehabilitation and care for people who are sick or injured. These are often referred to as the primary health care components of the health system. Increasingly, there is recognition of the importance of prevention and health promotion. There is ongoing political debate about funding and allocation of resources to primary and preventative health care. Health care in Australia The Australian health care system is vital in maintaining and improving the health of all Australians. Government and non-government sectors work together to improve the provision of health care. Health care services are funded and provided by the public and private sectors. The health care system provides diagnosis, treatment, rehabilitation and health prevention and promotion campaigns. The Commonwealths funding includes two national subsidy schemes - Medicare and the Pharmaceutical Benefits Scheme (PBS). Emerging new treatments and technologies can improve access to better health care and provide early detection for chronic disease, however, can be very costly. Medicare provides a base level of cover for all Australians. Individuals can choose to pay for private health insurance as well which increases cover for health care. Factors which impact on the health care system include a growing and ageing population, equity of access for certain population groups and high levels of preventative disease. The health of all Australians is an important issue for government. People need to be healthy to live long, productive and fulfilling lives. The Australian health care system is vital in achieving a healthy nation. Its role is to provide facilities and services that meet the needs of all Australians. Facilities and services range from being government owned, funded and delivered, to being provided by private practitioners and organisations on a fee-for-service based system (or somewhere in between). The Australian health system is complex, with many different providers of services, and a range of funding and regulatory mechanisms. It promotes an intersectoral approach where government and non-governmental organisations (public and private sectors) work together at all levels to improve the provision of health care. Australias health care system provides diagnosis, treatment, rehabilitation and health prevention and promotion campaigns. More recognition is being given to health promotion as an essential element in enabling people to increase control over, and to improve, their health. Explore the following links to develop a deeper understanding of Australias health care system. Focus on investigating issues of access and adequacy in relation to social justice principles. Range and type of health facilities and services PDHPE Health Priorities Gina Marovic 18

Australia has a complex and diverse range of health facilities and services. The Australian health system produces some of the best health outcomes for individuals compared to the rest of the world. Medical practitioners, nurses, other health professionals, hospitals, clinics, government and non-government agencies provide health services. Australias Health 2010 (page 333) classifies the range of facilities and services into broad categories, e.g. public health services, primary care and community health care services, hospitals, specialised health services and goods. There is acknowledgement that some facilities and services may fit into more than one category. The first point of call for a person is usually their General Practitioner (also known as GP or doctor). GPs are in the primary care and community health care service category. There is growing concern about the Australian health care systems ability to cope with increasing demands. Some reasons for this include; lower numbers of people studying to be health professionals (e.g. nurses), the effects of an ageing population on the capabilities of the system, the high cost of health care and a lack of access for specific groups to some facilities and services. Responsibility for health facilities and services Responsibility for health facilities and services consists of two parts. The first part is the responsibility for funding. Health care services are funded and provided by the public and private sectors. The Australian government provides over 40 per cent of the total health funding, and is the major source of public funds. State and territory and local governments fund around one third. Commonwealth of Australia, 2010 The Commonwealths funding includes two national subsidy schemes - Medicare and the Pharmaceutical Benefits Scheme (PBS). These schemes cover all Australians and subsidise their payments for medical services and for a high proportion of prescription medicines bought from pharmacies. The Commonwealth and State Governments also jointly fund public hospital services so they are provided free of charge to patients. Between them, these three funding provisions aim to give all Australians, regardless of their personal circumstances, access to adequate health care at an affordable cost. More information about the Australian health care system, including Medicare and the PBS funding can be accessed from the Intergenerational report 2010 or the Australian Bureau of Statistics. Currently, the financing of health care in Australia comes from three main sources: the Medicare levy, general taxes paid to various levels of government, and payments for private sector services. The continuing challenge for governments is trying to meet the increasing demands on the health care system with the limited funds that are available. The second part of responsibility relates to the functioning of health facilities and services, i.e. who governs and controls them. In a system so complex, it varies between government, non-government and private organisations. Equity of access to health facilities and services

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The Australian health care system aims to provide fair and equal access to all Australians. The Australian Government provides subsidies and discounts through the Medicare system and the Pharmaceutical Benefits Scheme (PBS). These two functions have improved access to health facilities and services for most Australians by subsidising the cost of accessing a health service. Unfortunately, due to a variety of factors, there are still some groups of people that have limited access to certain health facilities and services. The groups experiencing health inequity are often those affected by limited access to health facilities and services. There are a variety of factors that compound the challenge of access to health services, some of these unique to certain regions of Australia. Examples include: the decreasing supply of skilled health workers, e.g. doctors and nurses; the geographical size and nature of Australia; long waiting lists for elective surgery in public hospitals; increased numbers of people suffering from chronic disease; and a growing and ageing population. A number of initiatives have been put in place to address more localised or specific health inequities. Some of these include: The Royal Flying Doctor Service The Aboriginal and Torres Strait Islander peoples community controlled health services Regional Health Services. Health care expenditure versus expenditure on early intervention and prevention Expenditure on health care versus expenditure on early intervention has always been a matter of contention for governments. Where should the money be spent to reap the greatest health rewards for the Australian population? Consider the following example for cardiovascular disease. Many people are suffering from some form of cardiovascular disease and it can be life threatening if not caught early enough. Medical treatment is needed. This costs the government a considerable amount of money. On the other hand, there are many preventative measures that can be put in place to help prevent cardiovascular disease from occurring, e.g. regular physical activity and a healthy diet or intervene early so the impact on the health care system is reduced. Governments currently invest money on increasing individual and community capacity to partake in preventative measures to reduce the amount of people experiencing CVD. The difficulty is determining what proportion of money is spent on health care or treatment compared to early intervention and prevention. All levels of government spend an enormous amount on health for Australians. Total expenditure on health in 2007-08 was $103.6 billion compared with expenditure of $94.9 billion the previous year, an increase of 9% in nominal terms. This represented an average rate of health expenditure in 2007-08 of almost $4,900 per person. Health care expenditure is expected to increase remarkably in the next 40 years. The Australian government spent just over $50 billion on health expenditure in 2009-2010. With our growing and ageing population and the increased demand for health care, this is projected to be over $250 billion by the year 2050. A major concern for government is how the current health care system will be able PDHPE Health Priorities Gina Marovic 20

to cope in the future. Explore the future projections of Australias health expenditure on page 51 from the Intergenerational report 2010. In recent years, there has been pressure to continue increasing expenditure on early intervention and prevention of chronic disease and conditions. Although federal, state and territory governments have increased the amount of expenditure in this area; there is much debate in the professional arena about the need to increase expenditure even more. The issue is how to allocate funds when evidence shows that prevention can save enormous amounts of money in the long run, however, in the meantime people need treatment for existing conditions. Prevention does not always see immediate change. It is a longer process and therefore is often seen as greater risk of investment for current governments. The NSW Department of Health produced a report in 2007 titled Healthy people NSW: Improving the health of the population. Interestingly, it highlights the cost effectiveness of prevention on page 6. Research plays an important role in health. It allows for breakthroughs in technology for early detection, prevention (such as genetic analysis) along with improved treatment and cures. The downside of research is that it is very costly. Determining what percentage of expenditure should be allocated to research is another major consideration for government. Impact of emerging new treatments and technologies on health care e.g. cost and access, benefits of early detection Research has provided many benefits in the discovery of new treatments and technologies used in health care. New treatments and technologies can improve health outcomes to individuals which, in turn, reduces the burden on the health care system. In the end, less people will require complicated health care. The more complicated the health care, the higher the cost. The types of benefits that are achievable through emerging new treatments and technologies include: early detection early treatment less side effects impacting on individuals lives due to improved treatment improved functionality of service, e.g. treat more patients and less follow up needed.

Some examples of new treatments and technologies that have improved the burden on Australias health care system include cervical cancer screening, STI testing, mammogram technology for breast cancer detection, ultrasound and MRI scanning technology and more recently, genetic testing for a variety of cancers. Some barriers to the widespread use of emerging new treatments and technologies are included below. High cost of new technologies/treatments - new technology and treatments are often costly to research and develop. Time introduction of new techniques and technologies must be done with the assurance of safety and minimal side effects for the short and long term. Quality assurance takes time to ensure safe procedures and effects on individuals.

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Australias geographical size - when introduced, new treatment and technologies are often placed in major city areas first, limiting access to certain groups, e.g. rural & remote communities. Ethical - ethical practices play a major role in research. For example, consider the cloning debate for organs. Equity of access - people with money tend to be able to receive new, better treatment and technologies which increases the gap in health outcomes between the advantaged and disadvantaged. Increasing and ageing population - more people equals more health problems which need to be treated. The growing and ageing population impacts more as older people tend to require more health care. The government must allocate funds to the health care system to care for more people requiring access to health care. Health promotion campaigns have proved to be very successful. These have raised awareness in people to be able to perform self detection and seek early help for a variety of conditions. Using new treatments and technologies can have a significant positive impact on the health care system. Governments need to make decisions as to where to place funding and in what percentages. Ill people need treatment and money needs to be put into research to develop new treatments and emerging technologies. It is a challenging balancing act. Health insurance: Medicare and private Medicare is a system that is partly funded by taxpayers, who pay what is known as a Medicare levy as part of their tax. Under the levy, taxpayers pay a percentage of their taxable income for dedicated use by the health system thus providing access for all Australians. The government sets fee levels for services and provides rebates to customers based on these prices, e.g. GP visit, public hospital visit. For a GP visit, regardless of what fee is charged by the medical practitioner, every Australian is covered for 85% of the scheduled fee. The rest of the fee is often referred to as the gap which is paid by the patient. Some GPs allow bulk billing to take place which means they claim the minimum pay from Medicare itself and patients do not have to pay a gap. Under Medicare, people can choose to be treated as public patients in public hospitals free of charge. Individuals can choose to use only Medicare or combine Medicare with private health insurance to increase their cover. Private health insurance is available for people who wish to be covered for private hospital fees or ancillary services such as ambulance cover, physiotherapy and optical appliances (e.g. glasses, contact lenses etc). There are different levels of cover, e.g. the more you pay, the more cover you receive. The Australian government provides an incentive to Australians who choose to take up private health insurance by providing a 30% rebate. The rebate increases for older people, e.g. 35% for people aged 65-69 years and 40% for people aged 70 years and over. Complementary and alternative health care approaches Complementary and alternative health care approaches have rapidly grown in popularity.

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The reasons for growth of complementary and alternative health care approaches are due to increased demand from consumers and recognition by governments of the benefits and cost subsidies through private health insurance. There is a diverse range of products and services that offer prevention and management for specific conditions and maintenance of health. Regulatory authorities and professional associations have been put in place to ensure the credibility of complementary and alternative health care approaches. There are still many sceptics of complementary and alternative health care approaches due to limited evidence of their success. Some complementary and alternative health care approaches can interfere with conventional medical management and treatment. It is important to inform medical practitioners if you are using other treatments. Individuals need the knowledge and skills to make informed decisions regarding their health and the use of complementary and alternative health care approaches. Complementary and alternative health care approaches have grown in popularity across the world. Australia tends to refer to them as complementary and alternative health care approaches. Traditional, natural or holistic health care are other terms that are used internationally. The Australian Governments Health Insite websites explanation of complementary and alternative health care approaches provides a good overview. Complementary therapies complement conventional medical treatment, while alternative therapies are those which offer alternatives to conventional diagnosis and therapies. Complementary medicine used together with conventional medicine is known as integrative medicine. Reasons for growth of complementary and alternative health products and services In 2002, the World Health Organisation acknowledged that complementary and alternative health products and services were increasing in popularity and released a strategy to assist countries to regulate traditional or complementary/alternative medicine to make its use safer, more accessible to their populations and sustainable. The main reason for the growth of complementary and alternative health products and services is due to increased societal demand. NSW Health estimated that close to 60% of Australians access some form of complementary health care (NSW Health, accessed 2010). This may be due to the increased levels of chronic and preventable diseases and conditions, concerns about the side effects of conventional medicine or dissatisfaction with conventional medicine. Therapies such as massage and acupuncture are widely known for their relief of chronic pain. They may complement more conventional treatments. In Australia, people who have extras cover through their private health insurer can receive subsidies for their use of certain complementary and alternative health care services such as registered massage or acupuncture providers. This has contributed to increased use of complementary and alternative health services as people are able to receive treatment at a reduced price. The effect of rebates for their use implies that the Australian health care system recognises registered providers as creditable within the Australian health care system.

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The increased demand for complementary and alternative health care has increased employment in the area which has also increased demand for training courses. There has been significant growth in this sector of the health industry. Range of products and services available In complementary and alternative health care, the range of products and services is very diverse. Products are often referred to as medicines whereas services are often referred to as therapies. Some are a combination of both. Complementary and alternative medicines can include herbal, vitamin, mineral, homoeopathic, nutritional and other supplements. Therapies include herbal medicine, Chinese medicine, chiropractic, naturopathy, osteopathy, acupuncture, homoeopathy, reflexology, aromatherapy, Alexander technique, Bach and other flower remedies, massage, hypnotherapy, shiatsu, ayurvedic medicine, nutritional medicine, yoga, anthroposophical medicine, spiritual healing, iridology, kinesiology, meditation and others. How to make informed consumer choices Complementary and alternative health care approaches have come under much scrutiny over recent years. In the past, complementary and alternative health care approaches were passed through generations of culture, often taking years to master. After becoming more popular in western culture, many remedies and therapists started appearing all over the place with no real qualifications or experience in delivery. Some actually compromised conventional medicine and interfered with treatment for serious conditions. Others have claimed impossible success or cures for incurable diseases which had serious implications for some peoples ability to survive without conventional forms of medicine and treatment. This has led to the development of regulatory authorities and professional associations to ensure qualifications were obtained and regularly updated by providers and claims for success were substantiated. As these treatments move into an evidence based approach to health, more people will have the skills to research and understand who to believe. They will be able to make informed decisions about complementary and alternative health care approaches.

What actions are needed to address Australias health priorities?


Health promotion based on the five action areas of the Ottawa Charter Health Promotion is a broad practice, which includes actions directed at strengthening skills and capabilities of individuals and changing social, environmental and economic conditions. Effective health promotion requires a multi-faceted approach and is not just the responsibility of the health sector. The public health approach acknowledges that effective health promotion requires intersectoral involvement. The Ottawa Charter is at the core of good health promotion. It promotes social justice, increases the likelihood of positive health outcomes and has proven to be very successful.

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The five action areas of the Ottawa Charter: build healthy public policy, create supportive environments for health, strengthen community action for health, develop personal skills, and re-orient health services; have provided the framework for many successful health promotion initiatives. Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environment. Health is a positive concept emphasising social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being. The first International Conference on Health Promotion was held in 1986, where the World Health Organisation (WHO) recognised the importance of health promotion and developed the Ottawa Charter for Health Promotion to achieve Health for All by the year 2000 and beyond'. This conference was primarily a response to growing expectations for a new public health movement around the world and has remained the core of good health promotion. The Ottawa Charter identifies three basic strategies for health promotion. These are advocacy for health to create the essential conditions for health; enabling all people toachieve their full health potential; and mediating between the different interests in society inthe pursuit of health. These strategies are supported by five priority action areas build healthy public policy create supportive environments for health strengthen community action for health develop personal skills, and re-orient health services.

Levels of responsibility for health promotion The balance between personal and community responsibility for health is often discussed in public forums. The Ottawa Charter recognises that all levels of the community can support and promote better health. The Ottawa Charter aims to develop partnerships and support networks, resulting in governments recognising that health promotion is most successful if individuals, groups, governments and other organisations take a shared responsibility and joint action to improve health outcomes for Australians. The public health approach acknowledges that effective health promotion requires intersectoral involvement. It also emphasises the importance of creating an environment that is fully supportive of positive health behaviours and actively involves the community. Levels of responsibility for health promotion Commonwealth government Policy, funding, programs State and territory government Hospitals, health services, health promotion, regulatory and PDHPE Health Priorities Gina Marovic 25

Local government Private sector Community groups

licencing Environmental control e.g. waste removal Hospitals, health services, alternative health services, health promotion, nursing homes, pharmaceuticals Health promotion e.g. asthma foundation

The benefits of partnerships in health promotion, e.g. government sector, non government agencies and the local community A crucial feature of health promotion is the understanding that improving health is a shared responsibility. The success of the Ottawa Charter as a health promotion tool is increased if individuals, communities, government and non-government agencies work together in partnership toward achieving a common health goal. Integrated health promotion programs increase the chances of success of a program. It is important for individuals and communities to be included in the planning of all health promotion programs to ensure that their interests and needs are being addressed. This inclusiveness encourages participation which contributes to better health outcomes by empowering individuals and communities. Intersectoral action can be used to promote and achieve shared goals in a number of areas; for example policy, research, planning, practice and funding. It may be implemented through numerous activities, including advocacy, legislation, policy change, programs, community projects, consultative community meetings, surveys and the analysis of local health data. There is no doubt that intersectoral action for health works. One example of this is the National Mental Health Strategy which brings together federal government departments with state and territorial governments, community groups, professional associations and private sector organisations to develop an intersectoral response to addressing mental health issues. How health promotion based on the Ottawa Charter promotes social justice The principles of social justice - equity, diversity and supportive environments - are an essential part of effective health promotion. The Ottawa Charter promotes social justice as it is designed to provide access to health opportunities for all members of a community and aims to reduce the level of health inequalities in Australia. Social justice means that the rights of all people in our community are considered in a fair and equitable manner. While equal opportunity targets everyone in the community, social justice targets the marginalised and disadvantaged groups of people in our society. In a socially just community public policies should ensure that all people have equal access to health care services, for example the Medicare system in Australia. People living in isolated communities should have the same access to clean water and sanitation as a person living in an urban area. People of a low socioeconomic background should receive the same quality health services that a person in a higher socioeconomic income receives. Information designed to educate the community must be provided in languages that the community can understand.

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The Ottawa Charter incorporates three basic health promotion strategies: to enable, mediate, and advocate which are needed and applied to all health promotion action areas. The 5 key action areas of the Ottawa reflect the 'public health approach', with a strong emphasis on social justice issues. The following text is the World Health Organisation's summary of the action areas of the Ottawa Charter. Build Healthy Public Policy Health promotion goes beyond health care. It puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health. Create Supportive Environments Our societies are complex and interrelated. The overall guiding principle for the world, nations, regions and communities alike, is the need to encourage reciprocal maintenance - to take care of each other, our communities and our natural environment. Strengthen Community Actions Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities - their ownership and control of their own endeavours and destinies. Develop Personal Skills Health promotion supports personal and social development through providing information, education for health, and enhancing life skills. By so doing, it increases the options available to people to exercise more control over their own health and over their environments, and to make choices conducive to health. Reorient Health Services The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health care system which contributes to the pursuit of health. SEED Supportive Environments Equity Diversity PE HSC building healthy public Policy creating supportive Environments reorienting Health services developing personal Skills strengthening Community action PDHPE Health Priorities Gina Marovic 27

The Ottawa Charter in action The action areas of the Ottawa Charter are central to many health promotion initiatives and programs in Australia. The action areas also provide a useful framework for analysing each of the six identified priority issues for Australia's health. As part of the syllabus requirements, you are required to critically analyse the importance of the five action areas of the Ottawa Charter through a study of TWO health promotion initiatives related to Australia's health priorities. The following questions may help assist you to develop your understanding of the priority action areas. o o Which of the five action areas are of greater significance for the priority issue? How do the five action areas interact for the priority issue?

Building healthy public Policy o o Identify public policy developments that address priority issues What impact do these public policies have on health (reducing the priority issue)?

Creating supportive Environments o o o What community services exist to support/prevent people suffering from the priority issues? Has there been environment modification to reduce the burden of disease? What are some of the factors that influence these priority issues/population groups, for e.g. socio-cultural, physical, political, and economic?

Reorienting Health services o o o What health services are available for people suffering from this priority issue? Are these services aimed at prevention, cure or promotion of the issue? Is access to these services equitable for all? What restricts access? What can be done to improve access?

Developing personal Skills o o o o What personal skills are needed to improve health behaviours that contribute to this priority issue? What behaviour modifications are needed to improve health? Where can reliable/accurate information be found? Are there support services that can assist in developing positive health behaviours?

Strengthening Community action o o o What motivates people to take action and work towards improving the burden of disease? What initiatives have been developed to address priority issues? Are these initiatives addressed by a sole agency or an intersectoral approach?

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