Australia's Health 1996

Contents

1 The health of Australians

1.1 Health and its determinants | 1.2 Mortality | 1.3 Disability and handicap | 1.4 Newer measures of health | 1.5 Health and ill-health in special populations | References | Footnotes

Australia is one of the healthiest countries in the world and the health of Australians generally continues to improve. Australia's Health 1996 describes many improvements in health. This first chapter examines information on mortality, sickness and disease, disability, handicap and risk factors for disease as measures of the health (or lack of it) of the nation. Many of the illustrations in Section 1.5 demonstrate substantial health differences among subgroups of the Australian population. Although there have been great improvements in health, much remains to be done, particularly for those subgroups whose health is not as good as that of others.

1.1 Health and its determinants

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What is health?

In 1946 the World Health Organization (WHO) defined health as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' (WHO 1946).

This definition has stood the test of time. It has the virtue of placing a strong emphasis on health as a positive experience, rather than as the absence of negatives. Another strength is that the inclusion of social wellbeing places health in a broad social context. However, the broad context makes development of measures of health difficult.

Health can be seen as a major contributor to total wellbeing which itself includes:

• health;
• social wellbeing;
• economic wellbeing;
• environmental wellbeing;
• life satisfaction;
• spiritual or existential wellbeing; and
• other characteristics valued by humans.

To complicate the problems of definition, almost all 'health statistics' (and, indeed, most statistics in this volume) are of ill-health, rather than of health.

What determines health?

The evolution of thinking about what determines health is instructive. Twenty years ago, disease was seen as an outcome of the interaction of human biology, lifestyle factors and environmental factors, as well as being modified by health care (Lalonde 1974). An analysis of the factors related to the ten leading causes of death in the United States attributed 50% of premature mortality to unhealthy behaviour and lifestyles, 20% to human biology, 20% to the physical environment and 10% to inadequate health care (Centers for Disease Control 1977).

Later, despite persisting uncertainties about the actual causative mechanisms, the importance of social factors was recognised. The elements of the social environment seen as important in health and disease include psychological, cultural, educational and economic factors. They also include occupation, marital status, major life events, social networks and social support.

The Ottawa Charter (WHO 1986) reflected these developing views by placing great emphasis on the need to develop very broad health promotion strategies to bring about changes in the physical, social and economic environment in which people live.

The Ottawa Charter provided a broader framework for public policy to influence health. It provided for intersectoral approaches, that is, for changes from beyond the health sector, to improving health. There have been many intersectoral changes in the physical environment which have improved health; an example considered later in this report (Section 3.4.3) is the phasing out of lead from petrol. There are fewer examples of demonstrated improvement in health following deliberate change in the social and economic environments. An example of successful intersectoral action from the economic environment is a study which reduced the proportion of low-birthweight babies by providing an income supplement to single social security beneficiaries during pregnancy (Kehrer & Wohn 1979).

The Ottawa Charter also provided for health promotion approaches to improving health. It recognised that the capacity of individuals to alter their behaviour is greatly influenced by social and cultural factors. Its health promotion strategies included the advocacy of a clear political commitment to health (sometimes referred to as healthy public policy); creating supportive environments; strengthening community action; developing personal skills; reorienting health services towards the promotion of health; and changes in professional education and training. The strategy was reviewed in detail in Australia's Health 1992.

It is now generally accepted throughout the health sector that social and environmental factors, as well as the knowledge, attitudes and behaviours of individuals, determine the health of populations and individuals. There is growing evidence that if we are to succeed in reducing inequalities in the health of population subgroups, and improve the health of the whole population, socioeconomic and environmental factors must be addressed.

The relationships among health and its major determinants are illustrated in Figure 1.1.

This model recognises that health care both contributes to the productivity of the population and reduces productive capacity by drawing capital and highly skilled people into the sector. Economic prosperity generally contributes to the wellbeing of the population, and this, of itself, reduces illness.

Money spent on health reduces the amount available to be spent on other activities which increase total wellbeing; where resources are limited, improvements to health may have a cost in other aspects of total wellbeing. Many of the factors that contribute to other aspects of wellbeing are also important determinants of health.

Implications

As a wider range of factors that support good health has been identified, and understanding of 'causes' of ill-health has expanded, so the scope for action to improve health has widened. Rather than simply responding to immediate needs, we can now ensure sustainable improvements in health and a better quality of life. To achieve this, the health sector must develop partnerships with a wide range of other groups, disciplines, and sectors to plan and execute health-related activities which ensure the best use of limited technical and financial resources. It must also ensure health-related consider-ations influence the decisions made by other sectors.

There continues to be debate about the effectiveness and relative cost-effectiveness of health services, including public health and health promotion programs. This debate arises from different understandings of what constitute satisfactory health outcomes. If reductions in mortality, morbidity, or behavioural risk factors are regarded as health outcomes, it is difficult, but not impossible, to link individual health interventions to such changes. This challenge is common to all across the health system. It can take many years before outcomes in terms of reduced morbidity and mortality can be measured. For example, it is only in recent years that Australia's long-term commitment to action against smoking has been shown to be effective in reducing mortality from lung cancer.

On the other hand, the revised national health goals and targets (see Section 6.2.3) recognise that there is a relationship between good health, the presence of supportive social and physical environments, and the extent to which individuals and communities have sufficient knowledge and skill to take action to maintain or to improve their health. Changes in environments, and in levels of community knowledge and skills, are more likely to occur within a relatively short period of time, making causal attribution a more feasible proposition.

Reorienting health care services to improving health

Australia's approach to the planning and delivery of health care is changing. Commonwealth, State and Territory governments are faced with growing demands on treatment and care services. Population growth and ageing, the introduction of new technologies, uneven distribution of doctors, patterns of medical practice and patient expectations are all affecting demand for services. Australian health systems are exploring a number of mechanisms for reconciling these pressures with expenditure constraints. Approaches to improving the efficiency of health services have led to increased emphasis on maximising the cost-effectiveness of health interventions, in output-based funding of hospital services, in setting performance targets and benchmarks for health systems, and in attempts to develop coordinated care management.

At the same time, governments have increasingly come to accept that much of the illness and injury in the community is potentially preventable, and that a complex mix of social, cultural and environmental factors is vital to the maintenance of health.

Australian Health Ministers have been attempting to develop a shared policy framework for the health system to meet this challenge. These efforts are an acknowledgement by governments of the need to reorient policies and programs towards improving health rather than simply providing health care services, and build on the significant efforts which have been made in the past decade to restructure the health system, improve data collection and rationalise roles and responsibilities.

The common aim is to raise the health status of Australians to equal the best in the world. This is to be achieved through the health system's having a population health focus (that includes reducing premature deaths and improving wellbeing for all people), providing accessible, high-quality health services and continuity of care, and developing and implementing cooperative strategies to reduce major causes of ill-health and premature death including environmental and lifestyle factors.

1.2 Mortality

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There are many ways of measuring health or ill-health. Mortality is one of the best known measures, and certainly the most widely available. The availability is important, because in studies of health statistics the question is almost always one of comparison-is the mortality in one place better or worse than in another?, is the mortality in one population subgroup better or worse than in another?-and rarely of the absolute value.

Mortality in Aboriginal and Torres Strait Islander peoples is discussed in Section 1.5.1, page 21. Mortality in migrants is discussed in Section 1.5.2, page 30.

Death rates

When national statistics first became available in 1907, there were 12 deaths per 1,000 population per year. By the middle of the century, the crude death rate had fallen to 10 per 1,000, and in 1994 it was 7.1 per 1,000 population per year. The lowest crude death rate recorded was 6.9 deaths per 1,000 population in 1991, and again in 1993.

In 1924, the male and female age-standardised death rates were 17.3 and 13.9 deaths per 1,000 population. By 1994, they had declined to 8.6 and 5.2 per 1,000 population.

Major causes of death

Trends in major causes of death since 1924 are shown in Figure 1.2 (as rates per 100,000 population). In 1924, infectious and parasitic diseases were the fourth major cause of death and, with an age-standardised death rate of 1.6 deaths per 1,000 population for males and 1.2 for females, accounted for 9% of all deaths. By 1954, the death rate from these causes had declined to less than 0.3 per 1,000 population for males and 0.1 for females, accounting for 2% of all deaths. In the last 40 years there has been a further decline in the death rate from infectious and parasitic diseases to 0.06 deaths per 1,000 population, less than 1% of all deaths.

The shift away from infectious disease deaths was accompanied by an increase in both the age-standardised death rates and the proportion of deaths attributed to diseases of the circulatory system and to cancers. In 1924, 23% of deaths in Australia were caused by diseases of the circulatory system and 11% by cancers. By 1965, these causes together accounted for nearly 75% of deaths.

In the 1960s, the general consensus was that prospects for lower mortality as a result of advances in prevention or treatment were limited, so that further declines in mortality would be minimal. This expectation, which persisted into the 1970s, arose mainly from the constancy of mortality rates, especially among males, from the 1940s through to the 1960s.

To a large extent this expectation has held true for deaths from cancers, with increases in the age-standardised death rates for males and females from 2.1 and 1.3 per 1,000 males and females in 1965, to 2.4 and 1.4 respectively in 1994. Despite this relatively small absolute increase in cancer death rates, because of the decrease in total mortality, the proportion of total standardised mortality attributed to cancers increased from 15% in 1965 to 27% in 1994.

For diseases of the circulatory system, the expectation was not borne out. Following a steady increase in mortality from cardiovascular diseases from the early 1900s, a phase of decline started in the late 1960s and has continued to the present. In 1968, the age-standardised cardiovascular disease death rates per 1,000 population were at their highest, at 8.4 deaths per 1,000 for males and 5.5 deaths for females. In 1994, the age-standardised death rates, at 3.6 per 1,000 for males and 2.3 for females, were less than half of those of 1968.

There have been considerable year-to-year variations in deaths from respiratory disease. The general trend was for rapid decreases in both sexes until the early 1950s. Male mortality then increased until about 1970, since when it has fallen back to below the level of the early 1950s. Female mortality from respiratory disease has decreased slowly over the entire period since the early 1950s.

The fall in rates of death from cardiovascular and respiratory diseases since the late 1960s has had a major impact on Australia's total mortality profile. Although most of the reduction in mortality in the early part of the century was among younger people, the reduction in the last 25 years has been mostly among the elderly.

That is not to say that there have not been any recent reductions in death rates at younger ages. Mortality from injury and poisoning has decreased substantially in recent years, lower mortality from road traffic injury having more than offset some increases in suicide rates in younger men (Section 2.6, page 80).

Mortality by State

In recent years, there have been substantial differences in death rates among the States and Territories. Table S16, page 221, shows that the Australian Capital Territory has the lowest age-standardised mortality rate for males and Western Australia the lowest age-standardised mortality rate for females. The Northern Territory has the highest age-standardised mortality rate for both sexes.

Reasons for death rates for Tasmania, which has the next highest rates, exceeding those in the Australian Capital Territory by 31% (males) and 12% (females), and other vari-ations in death rates among States and Territories have not been studied in detail.

Table S19, page 227, shows age-standardised death rates by major causes of death for each of the States and Territories. Again, both males and females in Tasmania and the Northern Territory show higher mortality rates for a number of different causes. However, for several of these causes the number of persons dying is quite small.

Several States and Territories also record lower than average death rates for certain causes. For example, both males and females in Western Australia, and males in the Australian Capital Territory had lower mortality rates from circulatory diseases. These inter-State/Territory variations also need further study.

Life expectancy

Life expectancy is the average number of years of life remaining to a person at a specified age if mortality does not change. It is usually calculated using age-specific death rates for a particular period.

An Australian boy born in 1994 can expect to live 75.0 years and a girl can expect to live 80.9 years. In 1920-22, life expectancy at birth was 59.2 years for boys and 63.3 years for girls.

The reductions in the death rates at the older ages, especially from diseases of the circulatory system, have led to significant improvements in life expectancy of adults. Between 1920-22 and 1960-62, the life expectancy of men aged 65 years increased from 12.0 to 12.5 years. This gain of 0.5 years over a 40-year period may be compared with a gain of 3.2 years over the 33-year period from 1960-62 to 1994 when life expectancy for men at age 65 reached 15.7 years.

For women, life expectancy at age 65 improved by 2.1 years between 1920-22 (when it was 13.6 years) and 1960-62 (15.7 years). This compares with an increase in life expectancy of 4.0 years in the period from 1960-62 to 1994, when life expectancy for women at age 65 reached 19.7 years (Table S13, page 218).

Figure 1.3 compares expectation of life in Australia in 1992 with that in a number of other countries. Japan has the highest life expectancy at birth for both sexes. The lower expectation of life in Eastern European countries has attracted much attention in recent years.

1.3 Disability and handicap

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Disability and handicap occur from a combination of biomedical, demographic and personal factors, interacting with environmental and social conditions. As well as reflecting the long-term consequences of disease and impairment, levels of disability and handicap in the Australian population provide some indicators of needs for medical, rehabilitation and welfare services.

The primary sources of recent national population data on disability are the Australian Bureau of Statistics (ABS) surveys on disability and ageing (ABS 1990a, 1993b). These surveys defined disability and handicap as described in Box 1.2 (page 11). These definitions are related to the World Health Organization's conceptual framework for impairment, disability and handicap (WHO 1980), but were geared to ensuring that all eligible people were included in the survey.

Disability

In 1993 an estimated 18.0% of the Australian population had one or more disabilities, as defined by the ABS survey. The total number and proportion of males reporting disability were both slightly higher than those for females (Figure 1.4, page 10).

Arthritis and other musculoskeletal disorders were the most commonly reported main disabling conditions, affecting 4.9% of the total population and 3.3% of the population aged under 65. Diseases of the ear were the second most frequently reported main disabling condition (2.6%). Respiratory diseases were reported as a main disabling condition by 1.7%, more commonly among people aged 5-14 or aged 65 and over. An estimated 1.6% reported an intellectual disability or 'other mental' condition and 0.4% had psychiatric conditions (Table 1.1, page 13).

The most common disabling conditions among people aged 0-64 years were diseases of the ear (1.8%), other musculoskeletal disorders (1.8%), and intellectual and 'other mental' conditions (1.6%).

Figure 1.5 (page 15) compares the prevalence of various conditions, according to whether they were reported as main conditions or among a number of disabling conditions. All conditions were reported more frequently than indicated by their presence as a main condition, suggesting the common occurrence of multiple conditions. Head injury, for instance, was frequently reported as occurring in combination with other conditions, whereas psychiatric conditions were much less likely to be.

These disability prevalence estimates may differ from those derived from clinical assessments or administrative sources. Reasons for this include the self-reporting in the surveys, the reliance in the survey on screening questions relating to disability broadly, rather than diagnosis based on clinical assessment, and the difficulties for some respondents in identifying 'main disabling condition'.

For similar reasons, estimates of the prevalence of mental health problems may differ from the ABS survey estimates. It has been estimated, for instance, that at any one time some 3-4% of all Australians experience severe mental disorders (Australian Health Ministers 1992). This figure is considerably higher than the 0.4% in Table 1.1. Again, the reasons for these differences could include the reliance of the ABS survey on self-reporting and the focus on ongoing disability rather than on clinical diagnosis. Further, the focus in Table 1.1 on primary disabling condition as well as the reliance on screening questions has been identified as a source of underestimation of prevalence of psychiatric disability (Madden et al. 1995). The lack of reliable Australian data on mental health (AIHW 1994) is being addressed by the current plans for a national mental health survey in 1997.

Handicap

Some 14.2% of the total population reported they had a disability which caused a handicap (Table 1.2, page 14). Females aged 65 and over have much higher rates of profound and severe handicap than do males. The proportion of people reporting a profound or severe handicap was slightly over 4% of the total population aged 5 and above, or 2.6% of those aged 5-64 years (AIHW 1995).

People with psychiatric conditions, nervous system diseases, or with head or brain injury as a main disabling condition were the most likely to report associated profound or severe handicap and also the most likely to report multiple areas of handicap (see Australia's Welfare 1995 for more detailed information on areas of handicap). People with diseases of the ear as their main disabling condition were the least likely to report a handicap, fewer than half of them doing so.

Table 1.1: People with a disability, main disabling condition as a percentage of the population of that sex and age group, 1993( ¹ )

Changes in prevalence of disability and handicap

To examine trends, estimates have been derived from the 1993 survey data, using definitions consistent with the 1988 survey screening questions (see Box 1.2).

After removing the influence of changes in age structure, the differences between the standardised prevalences of disability were slightly reduced, but the increase remained (Table 1.3). The prevalences for males have exceeded those for females in both surveys.

The age-standardised prevalence of handicap fell slightly between 1988 and 1993. The prevalences of handicap in 1988 and 1993 for males and females were similar. In contrast, the age-standardised prevalences of severe handicap were stable, remaining slightly over 4% for the population overall and 2.5% for people aged 15-64. The prevalences were consistently higher among females than among males.

Wen et al. (1995) used demographic decomposition techniques to separate changes in the reported overall prevalences into three components: changes in age structure; changes in age-specific reported prevalence; interactions and residuals. For disability, the contribution of age structure increased, to account for over 40% of the total increase in prevalence. The handicap prevalence actually declined slightly because the decline in age-specific prevalences more than counterbalanced the effect of changes in the age structure of the population.

1.4 Newer measures of health

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There are many reasons it is important to quantify and measure health:

At the level of the individual

• to measure specific aspects of health before and/or after treatment. Often such measures relate to a single aspect of health, such as joint mobility, or to physiological measures such as blood pressure.

At the level of the group

• to measure outcomes of different treatments for the same condition in order to evaluate their effectiveness.
• to compare outcomes from health services to manage different conditions in order to make funding decisions within health services budgets.
• to compare outcomes from health promotion or non-health sector programs with those from treatment programs to make funding decisions. For example, should we have more 'Quit smoking' campaigns, increase tobacco tax or spend more on anti-cancer drugs for lung cancer sufferers?

At the level of the population

• to monitor trends in the health of the entire population.
• to compare and monitor health of population subgroups to identify inequalities, inequities and problems of access to care.
• to measure benefits from health services at the population level, and to monitor progress towards national health goals and targets related to health intervention strategies.

Multidimensional measures of health-the SF-36

There is a wide range of instruments designed to measure single dimensions of function or health, such as functional status, mental health, or pain, both in clinical and population settings. Increasingly, there is a desire to place measures of single health dimensions into a broader health context.

The Medical Outcomes Study Short-Form 36 (SF-36) appears to be most widely used of the multidimensional instruments which are compact enough for inclusion in population health surveys. It measures eight dimensions of health: physical functioning, role limitations due to physical problems, social functioning, bodily pain, general mental health, role limitations due to emotional problems, vitality, and general health perceptions.

The SF-36 instrument is currently being used in North America in over 200 clinical trials. In Australia, it has been included in a number of health surveys. In 1994 and 1995, the SF-36 was collected by self-completed questionnaire from 6,903 adults as part of the Australian Bureau of Statistics (ABS) Population Survey Monitor program. This data collection was analysed by the Australian Institute of Health and Welfare (Stevenson 1996).

Figure 1.6 shows the SF-36 age-adjusted mean score profiles for men and women, for both Australian and US data. The US data are for a 1990 sample of the total US population (Ware et al. 1993).

An interesting feature of the Australian data is that the differences between the scores for men and women are smaller for each scale than in the US data. Further, although the scores for American women are uniformly below those of American men, the score for Australian women is above that for Australian men for the general health perceptions scale.

SF-36 mean scores vary with age. The scores measuring predominantly physical health show a decline with increasing age, though under 55 years the decline is less marked for women than for men. The decline is smaller for the scores measuring predominantly the mental health component.

Global measures of health

It would clearly be useful to have a single index of health, not only to compare outcomes of different interventions, but also to measure changes in health. Unfortunately, combining a set of health scores on a number of dimensions into a single health index presents considerable methodological problems.

A widely used simple global measure of health status is the question:

In general would you say your health is:
Excellent, very good, good, fair, or poor?

This has been included in a large number of national health surveys, including the 1989-90 and 1995 National Health Surveys in Australia. It is also included in the SF-36 questionnaire.

There is increasing evidence that self-assessment of health status is a good measure of current physical health and a significant predictor of mortality for some subgroups of the population. There is a growing appreciation that instruments based on subjective data from patients can provide important information that may not be evident from physiological measurements and may be as reliable as-or more reliable than-many of the clinical, biochemical, or physiological indexes on which doctors have traditionally relied (Epstein 1990). A recent Australian study of people 60 years and over found that self-reported health status of fair and poor (women) and poor (men) was a significant predictor of mortality over a seven-year follow-up period. It remained an important predictor of subsequent mortality after controlling for demographic factors, major illnesses, co-morbidities, minor illness, disability, depression and social support (McCallum et al. 1994).

Figure 1.7 shows the proportion of adult Australians aged 25-64 years who reported in 1989-90 that their health was fair or poor, according to level of family income, adjusted for numbers of adults and dependent children in the family. The proportion reporting fair or poor health was very much higher in the low-income group than in either of the other groups. There was some difference between the intermediate- and high-income groups.

Health expectancy indicators

An alternative approach to developing global indicators of population health has been to extend the concept of life expectancy to consider the quality of life as well as its duration. The first example of such an indicator was devised by Sullivan (1971). It used the observed prevalence of disability at each age in the current population to show the expected number of years lived with and without disability in a period life table cohort at the same ages. This class of indicator is now widely used to monitor the evolution of population health (Mathers & Robine 1993).

Health expectancies provide a powerful tool for monitoring population health and developing public policy. In Europe and North America, health expectancy indicators are being proposed for monitoring national progress in relation to health. In the United States, one of the official objectives is to raise healthy life expectancy from an estimated value of 62 years in 1980 to 65 years by the year 2000 (US Department of Health and Human Services 1990). Health expectancies have also often been used in the debate over whether older people in developed countries are experiencing a compression or expansion of morbidity, that is, a shorter or longer period of disability at the end of life as life expectancy increases. The 1991 report Disability in America (Pope & Tarlov 1991) stated: 'More than half of the 4-year increase in life expectancy between 1970 and 1987 is accounted for by time spent with activity limitations.'

Health expectancies in Australia 1993

The ABS conducted a national survey on disability and ageing in 1993 (see Section 1.3 for more detail). The survey data and ABS life tables for 1993 have been used to estimate health expectancies for 1993.

Total life expectancy at birth was 75.0 years for males and 80.9 years for females in 1993. Disability-free life expectancy at birth was 58.4 years for males and 64.2 years for females (Table 1.4). The difference between these two sets of figures is the expectation at birth of years of disability: 16.6 years for men and 16.7 years for women. In other words, for both sexes, if mortality and disability prevalence at all ages remain constant at their 1993 levels, on average just under 80% of life will be lived without disability.

Of the 16.6 years of disability for males, 12.6 are years of handicap of which 3.4 are years of severe or profound handicap. Females experience 14.0 years of handicap and 5.7 of these are years of severe handicap. Men have a lower life expectancy at birth than women and also a lower expectation of years of disability, handicap and severe handicap (Table 1.5).

Trends in Australian health expectancies

Prevalences of disability and handicap reported in ABS publications from the 1993 survey are not directly comparable with those from an earlier survey in 1988 because of the addition of a number of items to the disability screening question (see Box 1.2, page 11). The estimates below have been derived from the 1993 survey data, using definitions consistent with the 1988 survey.

Between 1988 and 1993, life expectancy at birth increased from 73.1 to 75.0 years for males and from 79.5 to 80.9 years for females. Over the same period, disability-free life expectancy remained unchanged for males, whereas handicap-free life expectancy increased by 1.4 years and severe handicap-free life expectancy increased by 1.7 years (Table 1.5). In contrast, disability-free life expectancy increased for females (63.4 to 64.0 years), as did handicap-free life expectancy (increase of 1.4 years) and severe handicap-free life expectancy (increase of 1.7 years).

Reviews of international data (Robine et al. 1993; Robine 1994) have suggested that there is no evidence of expansion of morbidity based on more stringent measures of disability prevalence. Data from the Australian disability surveys suggest there has been little change in the overall expectation of life with disability and handicap over the latest five years, although the numbers of disabled and handicapped people are increasing as the population ages. Although disability-free life expectancy has not changed for males, it has increased slightly for females, as has handicap-free life expectancy for both sexes. Trends in severe handicap-free life expectancy continue to parallel those for total life expectancy, although there is some suggestion of a reduction in severe handicap expectancy for older women only.

1.5 Health and ill-health in special populations

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The remainder of this chapter presents information on health and ill-health in seven subgroups of the Australian population.

1.5.1 Aboriginal and Torres Strait Islander people

The health status of Aboriginal and Torres Strait Islander people continues to be much worse than that of other Australians. In some cases, it appears that the gap may be widening, especially for women.

Mortality

From 1988 to 1994, the rate of death from all causes decreased by about 10% among Australians as a whole but remained steady among Aboriginal men, and increased among Aboriginal women. As a result, the gap between Aboriginal and total Australian rates widened, especially for women.

Rates of death from circulatory disease, infectious disease, injury and poisoning, and mental disorders all declined in Aboriginal and Torres Strait Islander men during this period, but no similar trends were observed for women. Deaths from neoplasms appeared to be increasing for both sexes. The death rate from diabetes rose rapidly in men in the late 1980s and by 1992 had reached the same high level as that in women. Aboriginal and Torres Strait Islander death rates from diabetes in 1992-94 were 12 times higher for men and nearly 17 times higher for women than rates for other Australians.

Diseases of the circulatory system, injury and poisoning, respiratory illness, and neoplasms continue to be important causes of death in Aboriginal and Torres Strait Islander people. Deaths from infectious diseases and from genitourinary disorders, although somewhat less common, continue to occur at much higher rates than among other Australians.

Available data show that life expectancies in 1992-94 for Aboriginal and Torres Strait Islander men and women were 15-20 years below those of other Australians.

Age-specific death rates are higher for Aboriginal and Torres Strait Islander people than for other Australians at virtually every age, but the contrast is most marked at 25-54 years (Figure 1.8, page 24). At these ages, Aboriginal and Torres Strait Islander people die at rates 5 to 7 times higher than those experienced by other Australians.

Infant and maternal mortality

After great reductions in infant mortality rates in the 1970s, there was a levelling off in the 1980s and early 1990s, with rates remaining 3 to 5 times higher than those of other Australians.

Babies born to Aboriginal and Torres Strait Islander women average about 200 grams lighter at birth than babies born to other Australian women. In 1991, Aboriginal and Torres Strait Islander babies were twice as likely as other babies to be classified as low birthweight (below 2,500 grams), a state which carries a higher risk of poor perinatal outcome.

Although maternal death is an uncommon event, it is substantially more common among Aboriginal and Torres Strait Islander women than among other Australian women. About 30% of maternal deaths occur in Aboriginal and Torres Strait Islander women, who contribute only about 3% of confinements.

Morbidity

Among Aboriginal and Torres Strait Islander people in New South Wales and South Australia, hospital admission rates in 1991-92 were 60% higher for men and 50% higher for women than would be expected based on rates for other Australians. Identification of Aboriginality remains incomplete in most areas, so this is likely to be a substantial underestimate.

The National Aboriginal and Torres Strait Islander Survey (NATSIS)

The first National Aboriginal and Torres Strait Islander Survey was completed in 1994 and is described in Box 1.3 (page 22). Selected results are described below. In many cases, these highlight marked differences in the reported health experiences of Aboriginal and Torres Strait Islander people according to place of residence.

Self-reported health status

Four in ten Aboriginal and Torres Strait Islander people surveyed (40% of males and 42% of females) reported that they had experienced an illness, injury, or disability in the two weeks before being interviewed. This is much lower than the 73% who reported a recent illness in the 1989-90 National Health Survey (ABS 1991). The use of different survey instruments and methods means that these figures are not directly comparable. Reports of recent illness in the NATSIS ranged from 34% among those aged 5-24 years to 68% among those aged 55 and older. Respiratory illness was reported by 35% of those who said they had a recent illness and was the most commonly reported illness overall and for all age groups up to 44 years of age. Circulatory diseases were slightly more commonly reported by people aged 45 and over. Reports of recent illness were more common in the southern states (Victoria 54%, Tasmania 48%, South Australia and New South Wales 44%) than in Queensland, Western Australia, or the Northern Territory (all 38%). Whether this is a result of real differences in illness experience or population structures or merely a reflection of differences in reporting patterns is unknown.

The most commonly reported long-term conditions were asthma (13%) and ear or hearing problems (9%; Figure 1.9). As with recent illness, most long-term conditions were more commonly reported in the southern states than in Queensland, Western Australia, or the Northern Territory. Diabetes was a notable exception, with the highest reported rates in South Australia, Western Australia, the Northern Territory, and Queensland.

Despite the well-documented health disadvantages of Aboriginal and Torres Strait Islander people, most survey participants (88%) considered themselves to be in good, very good, or excellent health. Another 10% described their health as fair, and only 2% considered themselves to be in poor health. This contrasts with the results of the 1989-90 National Health Survey (ABS 1991), in which over 1 in 5 respondents reported their health as poor (4.5%) or fair (16%). Again, the use of different methods in the two surveys means that such comparisons must be viewed with great caution.

Nutritional status

Among adults aged 18 years and over, body mass index (BMI) was calculated for the 78% of men and 71% of women whose height and weight were measured. Among these people, 60% of men and 58% of women were overweight or obese (BMI greater than 25). These percentages are substantially higher than the corresponding figures of 44% for Australian men and 30% for Australian women from the 1989-90 National Health Survey.

Although the National Health Survey figures were based on self-reported heights and weights, Waters (1993) found that estimates of BMI based on self-reports provided valid estimates of actual BMI. This implies that overweight and obesity are far greater problems among Aboriginal and Torres Strait Islander peoples than among the Australian community in general. Aboriginal and Torres Strait Islander men in capital cities were more likely to be overweight or obese (62%) than were men in rural areas (54%), but this urban-rural difference was not obvious for Aboriginal and Torres Strait Islander women. A greater proportion of NATSIS participants in rural areas were missing information on height and weight, so some bias may have occurred.

Access to services and health-related actions

Access to services depends in part on the distance of those services from the potential user. The proportion of NATSIS respondents who reported having health facilities, services, and health professionals within 25 kilometres is shown in Table 1.6. As expected, people living in capital cities and other urban areas were more likely to have such services nearby.

Almost half (44%) of the people surveyed reported taking a health-related action in the two weeks before the survey. Of these, 72% used medication, 42% consulted a doctor, 28% reduced their daily activities, 18% visited an emergency or outpatients clinic, 14% consulted an Aboriginal health worker, 13% consulted a nurse, and 9% used bush medicines. These actions varied considerably by place of residence (Table 1.7), with greater importance of Aboriginal health workers and nurses and greater use of bush medicines in rural areas.

Perceived health-related and substance use problems

Survey participants aged 13 years and older were asked to select (from lists of choices) the things they considered to be health problems and substance use problems in their areas. Some 59% thought that alcohol was a health problem in their area, and 76% considered it to be a substance use problem. The proportions varied according to place of residence (Table 1.8, page 28). People who lived in rural areas were more likely than those in urban areas to perceive illnesses and conditions such as diabetes, heart problems, diet and nutrition, and skin problems as important health problems in their areas.

Smoking

Smoking was not included in the questions on perceived health and substance use problems in the area, but its potential impact on the health of Aboriginal and Torres Strait Islander people is quite large. Smoking was reported by 54% of men and 46% of women aged 13 years and over, and 10% of children aged 13-14 years said that they smoked.

The rates of smoking varied considerably across the country from 29% in the Alice Springs ATSIC region to 61% in the Jabiru ATSIC region (both in the Northern Territory).

Disability and handicap

In NATSIS, 2.8% of respondents aged 25-44 and 1% of those aged 15-24 reported severe or profound handicap. Although these figures appear similar to those for the overall population, they may not be strictly comparable with those of the National Health Survey (see Section 1.3). A study in one region of New South Wales suggested rates of severe handicap among Aboriginal people 2.4 times higher than the total Australian population (Thomson & Snow 1993).

Dental health

As early as 1925 Aboriginal groups were reported as having a substantial advantage over other Australians with regard to dental health (Campbell & Moore 1930). Although there is little published information specifically comparing the dental caries experience of contemporary Australian Aboriginal people with that of other Australians, the existing literature indicates a loss of this historical advantage. For instance, while there has been a major decrease in caries experience in other Australian children since the 1970s (see Section 2.5), there has been an increase in caries experience in Aboriginal children (Schamschula et al. 1980).

The present state of Aboriginal children's dental health is illustrated by data from the Children's Dental Service (CDS) in the Northern Territory, which provides a dental health program for school-age children, with coverage in excess of 85% (AIHW Dental Statistics and Research Unit 1995).

The comparison also distinguishes dental caries experience in children born outside Australia. This is to provide an additional reference point when discussing differences between Aboriginal and other Australian-born children by comparing both groups with another (i.e. overseas-born) which has not had lifetime exposure to the Australian health care system.

The experience of caries is reflected in both active disease (decay) and past disease (missing and filled teeth). Aboriginal children have a greater number of infant teeth affected by dental caries than either other Australian-born children, or overseas-born children. In addition, active decay indicates unmet need; the decay component accounts for 29% of total caries experience in other Australian-born children compared with 73% in Aboriginal and 55% in overseas-born children (Figure 1.10; see Section 2.5 for explanation of the dmft and DMFT indexes).

Figure 1.11 displays the status of permanent teeth for 12-year-old children. Both Aboriginal and overseas-born children had higher scores than the other Australian-born children. There were again significant differences in the number of teeth affected by active decay, with both Aboriginal and overseas-born children having higher numbers of decayed teeth than other Australian-born children. There was nearly a threefold variation in the mean number of decayed teeth at 12 years between the other Australian-born children and the Aboriginal children. Aboriginal children thus have a double disadvantage: more disease experience and a higher ratio of disease experience being untreated.

1.5.2 Health patterns of immigrants in Australia

How does the health of immigrants compare with that of people born in Australia? The answer to this question surprises many people. In general, immigrants have better health than the Australian-born population. However, there are some specific diseases and disease groups, notably some cancers, diabetes and infectious diseases, where immigrants from some countries have worse health.

Why does this happen? Immigrants are highly selected by health status, explicitly by health criteria applied by the Australian Government to people seeking to migrate to Australia and implicitly because people who are in poor health are less likely to have the ability and economic resources to migrate. Selection is thus commonly thought to play an important part in explaining the lower mortality rates of many immigrant groups, but in fact their health advantages involve complex interactions of social, cultural, environmental, biological and genetic factors. For health indicators based on self-report, it is additionally possible that some of the apparent differences between country-of-birth groups may be due to differences in reporting due in turn to language limitations or cultural differences. Lifestyle risk factors (smoking, risk drinking, overweight and inactivity) and socioeconomic factors (family income, family composition, employment status, education level and region of residence) are not important reasons for the health differentials between immigrants and other Australians.

Mortality of overseas-born Australians

A number of analyses have shown that immigrants to Australia generally have lower mortality rates than people born in Australia, but that the differences diminish with increasing length of residence in Australia (Young 1992). The social and cultural context of migrant health in Australia has been explored by Reid & Trompf (1990). The health status and service use of migrants with particular attention to language and cultural barriers to use of health services has also been studied (National Health Strategy 1993).

Table 1.9 shows the standardised mortality ratios (SMRs) for males and females aged 15 years and over according to country-of-birth group. Overall, the overseas-born population experienced mortality rates significantly lower than those for the Australian-born population. Standardised mortality ratios were lowest for Asian-born men and women at 0.65 and 0.74 respectively.

Overseas-born Australians aged 15 years and over had lower death rates than those born in Australia for most major causes of death. People born in other European countries (see Box 1.4) had higher death rates from diabetes with SMRs of 1.36 for men and 1.86 for women. Women born in these countries had a higher suicide rate (SMR of 1.57). Men and women born in Asia had higher death rates from infectious and parasitic diseases (SMRs of 1.68 and 1.53 respectively) and women born in Asia also had a higher death rate due to diabetes relative to Australian-born women (SMR of 1.64). AIDS-related death rates were higher for men born in 'Other' countries, largely due to a high SMR of 2.2 for men born in New Zealand.

These lower mortality rates for migrants translate to higher life expectancies as illustrated in Figure 1.12. Migrants from Europe have life expectancies at age 15 of 1.5 to 2 years higher than their Australian-born counterparts. Migrants from Asia have life expectancies 4.1 years higher for men and 2.1 years higher for women.

More detailed analysis of death rates and population survey data by individual countries of birth have been published by the Australian Institute of Health and Welfare (Donovan et al. 1992).

Cancer in migrants

Cancer incidence and mortality vary internationally. On migration to a new country, people generally bring with them the higher or lower cancer risks associated with their country of origin. As with mortality, cancer risks for migrants converge to those of the host country over time. These trends provide evidence of environmental influences on cancer risk that act later in life. They are important because they can hold clues to cancer-promoting aspects of lifestyle that may be amenable to intervention.

The most recent national study of cancer deaths in Australia covered the period from 1979 to 1988 (Giles et al. 1995). Most of the 24 largest migrant groups had mortality rates for all cancers combined below that of the Australian-born population. Most migrant groups had half the risk of death from melanoma of the Australian-born.

Females from the Netherlands had a significantly higher risk of breast cancer. Males and females from Scotland had an increased risk of death from the typically smoking-related cancers of the oesophagus, larynx, lung and bladder. The increased risk of migrants from China of oral cavity cancers is probably also related to smoking patterns, as well as alcohol consumption and some dietary components.

Migrants from Germany, Vietnam, the Pacific Islands and Scotland have risks of cervical cancer incidence or mortality significantly higher than Australian-born women, while women from Egypt have a reduced risk (Giles et al. 1995; McCredie et al. 1993). It is not known whether these results reflect screening differentials in the migrant populations or whether other factors such as sexual behaviour, diet, genetics or other factors are responsible, and to what degree.

Morbidity in overseas-born Australians

Mortality data may not necessarily reflect differentials in other important dimensions of health status, such as disability, handicap, illness prevalence and perceived health.

Table 1.10 shows the ratios of a number of key health indicators to their levels in the Australian-born population for young adults (15-24 years), working-age adults (25-64 years) and older people (65 years and over); definitions of some terms are given in Box 1.5 (page 37). People born overseas reported less serious chronic illness than did those born in Australia. In contrast, men and women born in continental Europe and Asia were generally more likely to report fair or poor health than Australian-born men and women.

Australia's Health 1994 showed that, as with mortality, there is a gradient of reported morbidity with duration of residence in Australia. Men and women aged 25-64 years who had been in Australia for less than 5 years reported 40% fewer chronic and recent illnesses than did Australian-born men and women. They also reported fewer days of reduced activity than did Australian-born people (50% fewer for men and 25% for women). As the period of residence in Australia increased, these indicators approached the levels of the Australian-born. A different pattern was seen for reported days of reduced activity. On average, migrants who had been in Australia 10 years or more reported 10% higher levels of reduced activity than did Australian-born men and women.

Overseas-born Australians had fewer hospital admissions and were slightly more likely to have visited a doctor in the last two weeks. Men and women born overseas reported fewer hospital episodes, and more doctor visits. In particular, average numbers of doctor visits were higher for working-age men born in the United Kingdom and Ireland, in other European countries and in Asia, and for young men and women born in 'other' countries. Working-age women born in other European countries and Asia were less likely to have had a mammogram or Pap smear in the last three years or to be immunised for rubella.

People who did not speak English at home, when compared with those who did, reported fewer chronic illnesses, but were much more likely to report their health was worse. When these people were excluded from analysis, differentials in self-reported health by birth region largely disappeared and differentials in numbers of illness reported were reduced. It is possible that non-English-speaking people had more difficulties in reporting specific illnesses than English-speaking people or that there are cultural differences in perceptions of health. The analyses discussed above should thus be treated with caution. It is also possible that language spoken at home is acting as a surrogate indicator of more recent migration or lower level of adoption of health-related aspects of Australian lifestyle.

Adjustment in a multivariate analysis for health factors, length of residence, language spoken at home and other factors generally had little effect on the health service utilisation differentials of overseas-born men. For women, however, adjustment for these factors removed the apparent higher doctor visit rate of European-born women (because they reported worse perceived health status) but suggested that Asian-born women were hospitalised more often than their reported health status and language distribution would warrant. Men born in the United Kingdom and Ireland visited the doctor more often than Australian-born men reporting the same health status. These broad analyses suggested that health service utilisation rates are broadly consistent with reported health status for most adult immigrant groups, but that there may be some immigrant groups whose utilisation is higher than expected on the basis of their reported health status. More detailed analyses would be required to explore this issue further.

1.5.3 Disadvantaged people

Low-income families

For this analysis, data from the 1989-90 National Health Survey were used to estimate the gross annual income of families, adjusted for the number of adults and children, and classified into three categories: high ($39,600 per annum or more), intermediate, and low (less than $23,400).

Young adults aged 15-24 years with low income were 50-60% more likely to report fair or poor health than young adults in high-income families (Figure 1.13, page 38; see Box 1.5 for definitions). They also reported 15-20% more days of reduced activity due to health problems, and were much more likely to report handicap or disability (Mathers 1996a). Chronic conditions reported much more often by young adults with low income included mental retardation and developmental delay, mental disorders, epilepsy and deafness.

Adults aged 25-64 years in low-income families reported much worse self-perceived health status than adults in higher-income families. Reports of fair or poor health were 2.7 times more frequent for men and 2.5 times more frequent for women. Severe handicap was 5.3 times more frequent for men and 2.8 times more frequent for women. The average number of serious chronic illnesses was 65% higher for men and 33% higher for women. Men and women in low-income families reported substantially more hospital episodes, outpatient visits and doctor visits, but fewer dental visits.

Significantly more serious chronic illnesses were reported for children (0-14 years) in low-income families than those in high-income families. There were 42% more illnesses for boys and 24% more illnesses for girls in low-income families. Chronic asthma was reported 33% more often for boys and 26% more often for girls in low-income families.

Box 1.5: Health indicator definitions Unemployed: not employed and seeking work. Not in the workforce: not employed and not seeking work. Life expectancy at age 15: expected number of years of life for a person on his or her fifteenth birthday if the current age-specific pattern of mortality does not change. Handicap: see Box 1.2, page 11. Lack of exercise: undertaking no physical exercise for recreation, sport or health/fitness reasons. Calculated using data from the National Health Survey on the amount of time spent in the last two weeks in walking, moderate exercise and vigorous exercise for recreation, sport or fitness reasons. Smoking: current smokers. Risk drinking: at medium or high relative health risk due to alcohol consumption of more than four (men) or more than two (women) standard drinks per day. Serious chronic illness: average number of serious chronic (long-term) illness conditions per person, estimated from the numbers of illness conditions which have lasted at least six months, or which the respondent expects to last for six months or more, reported in the ABS 1989-90 National Health Survey. Serious illness conditions were defined as conditions that required medical or surgical intervention, that carry a high risk of complications, or that can lead to significant recurring disability. Fair or poor health: percentage of people who reported 'Fair' or 'Poor' health in the National Health Survey, which asked survey respondents aged 18 years or more for self-assessed health status on a scale of Excellent, Good, Fair, Poor. Hospital episodes: number of inpatient episodes during last twelve months where both admission and discharge took place within the twelve-month period. Doctor visits: average number of doctor consultations per annum. 'Doctor' includes general practitioners and specialists. Estimated by multiplying by 26 the average number of doctor visits reported in the two weeks before the interview in the ABS 1989-90 National Health Survey. Dental visits: number of dental consultations per annum. 'Dental consultations' includes consultations with all dental professionals. Estimated by multiplying by 26 the average number of dental consultations in the two weeks before the interview. Other health professional visits: number of consultations per annum with chemist (for advice), optician/optometrist, physiotherapist, psychologist, social worker/welfare officer, chiropodist/podiatrist, nurse (school, baby health, other, but excluding dental nurse), dietitian, chiropractor, osteopath, naturopath, herbalist, acupuncturist. Includes only consultations at which some discussion and/or treatment of a health-related or medical condition took place or was arranged. Estimated by multiplying by 26 the average number of consultations with these health professionals in the two weeks before the interview.

These examples show that Australians with low family income generally have worse health. This largely explains their greater use of health services. Low-income Australians are also more likely to have lifestyle risk factors such as smoking, risk drinking, overweight or obesity and lack of exercise. They also are less likely to make use of preventive and screening services (Mathers 1994a).

Unemployed people

Unemployed (see Box 1.5, page 37, for definition) young men and women aged 15-24 years were 64% and 82% more likely to report fair or poor health than employed young men and women respectively. They also reported more serious chronic illnesses (Figure 1.14), were twice as likely to be disabled or handicapped, and 40% more likely to report symptoms of psychological distress. Unemployed young women were 60% more likely to be overweight or obese and 29% more likely to be a smoker than employed young women.

Unemployed adults (25-64 years) reported worse health than employed adults (Mathers 1994a). Serious chronic illness was 26% more frequent among unemployed than employed men, and much more frequent among men not in the workforce. It was 42% more frequent among unemployed than employed women (Figure 1.14). Fair or poor health was 2.1 times more common in unemployed than in employed men and 1.85 times more common in unemployed women. Self-reports of handicap were 82% higher for unemployed men and 29% higher for unemployed women.

Children (0-14 years) whose parents were both unemployed, whether seeking work or not, had 27% more serious chronic illnesses than children with an employed parent. Conditions reported much more frequently for children with unemployed parents included injuries (3 times more often for boys), deafness (2.4 times more often for girls) and bronchitis (85% more often for boys). Children whose parents were unemployed visited the doctor 26% more often for boys and 18% more often for girls, and had twice as many outpatient visits but significantly fewer dental visits (Mathers 1995).

Single mothers and their children

Although their number in the 1989-90 National Health Survey was small, the survey findings pointed to a pattern of worse health risk factors, worse health and higher hospitalisation rates for single mothers (Mathers 1994a). Single mothers were 64% more likely to have a disability and also 64% more likely to report fair or poor health than were mothers with a partner (Figure 1.15, page 40). Single mothers also reported more serious chronic illnesses and more doctor visits.

Australian children (0-14 years), especially boys, in single-parent families had worse health and higher levels of use of health services. Both boys and girls in single-parent families were more likely to be handicapped or disabled than their counterparts in two-parent families (Figure 1.16). Boys, but not girls, in single-parent families were reported to have significantly worse health, with 28% more serious chronic illnesses and 15% more recent illnesses.

Compared with their counterparts in two-parent families, boys and girls in single-parent families had more contacts with health professionals. Doctor visits were 32% more frequent for boys and 19% for girls, outpatient visits were 111% more frequent for boys and 71% for girls, and visits to other health professionals were 32% more frequent for boys and 27% more for girls.

Children aged 0-4 years in single-parent families were 45% (boys) and 68% (girls) more likely not to have been breastfed for at least 3 months.

1.5.4 Mothers and infants

Live births and birth rates

There were 258,051 live births registered in Australia in 1994 (ABS 1995c), 0.8% fewer than in 1993, and 6.6% fewer than the peak annual registration of 276,362 live births in 1972. After declining to 223,129 in 1979, annual numbers gradually increased to 264,151 in 1992 and have declined slightly since then.

The crude birth rate relates the number of live births in any one year to the total population size. This rate has declined from 21.7 per 1,000 people in 1971 to 14.6 per 1,000 in 1993, and 14.3 per 1,000 in 1994.

Age-specific birth rates express the number of children born in a year to mothers of a specified age as a proportion of the number of women of the same age group in the population. Recent trends in these rates have differed with age. For teenagers 15-19 years, the birth rate increased slightly from its historical low of 20.3 live births per 1,000 women in 1988 to 22.1 per 1,000 in 1990 and 1991, but then declined to 20.7 per 1,000 in 1994. The birth rates for women in their twenties declined to their lowest levels ever in 1994, down to 69.2 per 1,000 for women aged 20-24 years and 126.0 per 1,000 for women aged 25-29 years. Age-specific birth rates for older women have generally increased in recent years, reflecting the trend for some women to defer child-bearing until their thirties, or even later. Women aged 30-34 years had their lowest birth rates in the mid 1970s, those aged 35-39 in the late 1970s, and those aged 40-44 in the mid 1980s (Table S2, page 211).

Multiple births

Twin confinements have increased since the mid 1970s, and reached their highest proportion ever in Australia in 1994 when there were 3,409 twin confinements among a total of 254,547 confinements, or 13.4 per 1,000 confinements (Figure 1.17). There were 83 confinements of triplets and higher-order multiple births in 1994. Because the proportion of multiple births increases with advancing maternal age up to the late thirties, rates of multiple births are influenced by changes in maternal age distribution. The increasing use of assisted conception (in-vitro fertilisation and related techniques) to treat infertile couples has also contributed to the higher rates of multiple births.

In 1993, assisted conception accounted for 9% of twin confinements and 44% of triplets. Among the more than 12,500 confinements resulting from assisted conception since 1979, twins occurred in 19.1%, triplets in 2.9%, and other multiple births in 0.2%. These multiple births usually follow transfer of more than one embryo into the uterus, or more than one egg into the fallopian tube, in the course of the various treatment procedures. In the past few years, the policy of reducing the number of embryos or eggs transferred during assisted conception has been partly effective in reducing the incidence of multiple births (Figure 1.18) (AIHW National Perinatal Statistics Unit & Fertility Society of Australia 1995a). An unknown proportion of other multiple births occurs after fertility drugs are used but without assisted conception.

Termination of pregnancy

National information on fertility patterns and induced abortions is lacking because only South Australia and the Northern Territory collect population-based data on induced abortions. In South Australia in 1994, there were 5,139 induced abortions and 19,519 confinements; thus about one in five (20.8%) of all pregnancies in which early foetal loss (spontaneous abortion or ectopic pregnancy) did not occur resulted in abortions (Chan et al. 1995). Half of all teenage pregnancies were terminated.

Perinatal mortality

The perinatal death rate has declined markedly in the last two decades, to 8.0 deaths per 1,000 total births in 1994 (ABS 1995b), the lowest rate ever achieved (Figure 1.19, page 44). Foetal deaths (4.7 per 1,000 total births) accounted for 58.2% of perinatal deaths and neonatal deaths (3.4 per 1,000 live births) for 41.8%. The perinatal death rate for males (9.1 per 1,000 total births) was higher than for females (6.9 per 1,000 total births).

Maternal mortality

For many years the National Health and Medical Research Council (NHMRC) has published triennial reports on maternal mortality. The latest report covering the triennium 1988-90 recorded, for the first time since the series started, an increase in maternal mortality, from 11.8 deaths per 100,000 live births and stillbirths in 1985-87 to 12.7 in 1988-90, attributable to more maternal deaths among Aboriginal women. There was also an increase, from 4.4 to 4.9 deaths per 100,000, in the direct maternal mortality rate, that is, in deaths resulting from obstetric complications (NHMRC 1993a).

Birthweight

A key indicator of the health of babies born in Australia is the proportion having a birthweight of less than 2500 g. These low-birthweight infants have a greater risk of dying, of requiring a longer period of hospitalisation after birth, and of developing significant disabilities or handicaps. In 1993, there were 16,374 infants of low birthweight, a rate of 6.3% (AIHW National Perinatal Statistics Unit 1996), the same as in 1991 and 1992. Of 7,335 births to Aboriginal mothers nationally in 1993, 11.8% were low birthweight. Low birthweight is more common in the Northern Territory due to the relatively high proportion of Aboriginal births.

Type of delivery

Obstetric intervention may be needed if complications arise during pregnancy or labour, although there is debate about the rate of intervention. Caesarean birth rates have increased markedly in the last few decades (AIHW National Perinatal Statistics Unit 1993). In 1993, the national caesarean birth rate was 19.0% (Table 1.11), higher than the rates of 18.0% and 18.3% in 1991 and 1992 respectively. South Australia (22.5%) had the highest caesarean rate in 1993 and Tasmania (16.6%) the lowest. The caesarean rate for Aboriginal mothers was 17.8%, slightly less than for all mothers, but young Aboriginal mothers had relatively high caesarean rates. There was also considerable variation among the States and Territories in the rates of forceps deliveries and the use of vacuum extraction (AIHW National Perinatal Statistics Unit 1996).

Some States have information on caesarean birth rates according to whether the woman was a private or public patient (Table 1.12). The differential was greatest in Queensland where the caesarean rate was 58% higher in private than in public patients.

Congenital malformations

All States and Territories notify foetuses and infants with major congenital malfor-mations to a national monitoring system (AIHW National Perinatal Statistics Unit 1995b). The most frequently notified groups of malformations in 1993 were of the musculoskeletal system, malformations of the heart and circulatory system, genital malformations, and chromosomal abnormalities. The specific malformations accounting for these high rates were congenital dislocation of the hip, ventricular septal defect (hole between chambers of the heart), hypospadias (incomplete development of the underside of the penis), and Down syndrome (Table 1.13, page 46). Another relatively common malformation was cleft lip and palate.

Anencephalus and spina bifida are serious malformations of the brain and spine; the former is fatal and the latter often results in death or major disability and handicap. A randomised controlled trial has shown that supplements of folic acid are effective in preventing recurrence of these neural tube defects (Medical Research Council Vitamin Study Research Group 1991). Other studies indicate that supplements of folic acid are also likely to prevent many first occurrences of neural tube defects. The NHMRC has recently made a series of recommendations on periconceptional folic acid supplementation for women likely to become pregnant and for those with a close family history of neural tube defects (NHMRC 1993b). Monitoring of the effectiveness of these recommendations in reducing the occurrence of neural tube defects requires notification of any malformations in births and in pregnancies terminated after prenatal diagnosis of neural tube defects. Birth defects registers are now collecting this information in New South Wales, Victoria, Western Australia and South Australia, but data on induced abortions are still incomplete in some States and Territories.

1.5.5 Australian children

Communicable diseases preventable by immunisation are discussed in Section 2.2.

Box 1.6: Index of Relative Socioeconomic Disadvantage The Australian Bureau of Statistics (ABS) has constructed several socioeconomic indices to categorise areas on the basis of information collected in the 1986 Census of Population and Housing (ABS 1990b). The indices are compiled for small areas known as Collection Districts (CDs). In urban areas, CDs typically have a population of 300. In residential suburbs, this represents a small number of blocks. The Index of Relative Socioeconomic Disadvantage was constructed for each CD by summarising information from a number of underlying social and economic variables relating to socioeconomic disadvantage, such as low income, relatively low educational attainment levels, and high unemployment. A CD has a low value of this index if it contains comparatively disadvantaged households. The quintile of socioeconomic disadvantage of the CD of residence of National Health Survey respondents is used in studies quoted in Sections 1.5.5 to 1.5.7. Data for CDs can also be aggregated to larger geographic areas such as statistical local areas (SLAs). In most cases, SLAs correspond to local government areas. Mortality data supplied by ABS contain the SLA of usual residence of the deceased person. For studies of mortality referred to in Sections 1.5.5 to 1.5.7, SLAs were classified into quintiles (containing equal numbers of people aged 25-64 years) according to the Index of Relative Socioeconomic Disadvantage.

Health differentials according to socioeconomic disadvantage

There are increasing mortality and worse perceived health status with increasing level of socioeconomic disadvantage of area of residence (see Box 1.6, page 46) of children. In 1985-87 boys aged 0-14 years living in areas classified into the quintile of greatest socioeconomic disadvantage (fifth) had death rates 50% higher than boys living in areas in the quintile of least disadvantage (first) (Mathers 1995). For girls aged 0-14 years, there was a 67% differential (Figure 1.20).

Children living in disadvantaged areas had significantly higher death rates for all major causes of death except for cancers (both sexes) and disorders of the nervous system and sense organs (girls). In particular, death rates due to perinatal conditions were 54% higher for boys and 90% higher for girls in the fifth quintile than in the first quintile. The differences for fatal injuries were twofold for both boys and girls.

Some of the strongest differentials between the greatest disadvantaged and least disadvantaged quintiles for selected causes of death were:

• respiratory conditions-270% higher for girls and 150% higher for boys
• accidental drowning-over 200% higher for boys but not higher for girls
• congenital anomalies of circulatory system-100% higher for girls
• disorders relating to short gestation-almost 100% higher for girls
• motor vehicle traffic accidents-95% higher for girls and 53% for boys
• hypoxia, birth asphyxia-90% higher for boys and girls
• sudden infant death syndrome-69% higher for girls and 20% for boys.

The prevalence of serious chronic illness increased for boys (but not girls) with increasing index of disadvantage, so that boys in the most disadvantaged quintile were reported to have 25% more serious chronic illnesses. These boys also had 36% more days of reduced activity. Boys (but not girls) in the fifth quintile were substantially more likely not to be breastfed (46% higher than for boys in the first quintile).

There was no distinct pattern of health service use differentials by socioeconomic disadvantage of area, except for outpatient visits (over twice as many for both boys and girls in the fifth quintile), and fewer dental visits for both boys and girls (20% and 40% fewer respectively in the fifth quintile). Girls (but not boys) in the fifth quintile reported significantly more doctor visits and hospital inpatient episodes.

1.5.6 Australian youth

By world standards, most Australians aged 15-24 years enjoy good health. Their death rates in 1994 were 98 male and 33 female deaths per 100,000. Countries with lower mortality include Japan (64 male and 24 female deaths per 100,000) and the Netherlands (61 male and 26 female deaths per 100,000). The lowest recorded death rates for people aged 15-24 years are in Malta (41 male and 19 female deaths per 100,000).

Over the last decade, death rates for young Australian adults have been declining at a slower rate than those for children and middle-aged adults (Bennett et al. 1994).

Young men died at 3.0 times the rate of young women in 1994. They had higher death rates than young women for all major causes of death. Causes of death for which they had much higher death rates than young women included:

• suicide-6.3 times higher
• drug dependence-4.5 times higher
• motor vehicle traffic accidents-3.0 times higher
• cancers-1.3 times higher.

Young men were 88% more likely to report injuries than young women, but reported fewer illnesses for all major chronic illness groups. In particular, they were less likely to report cancers, diseases of the nervous system and sense organs, and circulatory or respiratory conditions, though their death rates were higher than those of young women for all these disease groups.

Young men aged 15-24 years reported 20% fewer chronic illnesses and 30% fewer recent illnesses (at all levels of severity) and fewer dental problems than young women. Despite these higher levels of reported illnesses among young women, young men and women were equally likely to report that their health was fair or poor (Table 1.14).

Chronic and minor conditions reported more often by young women included:

• eczema/dermatitis-170% more
• migraine-130% more
• headache-89% more
• musculoskeletal deformity-57% more
• skin rash-38% more
• bronchitis/emphysema-35% more
• influenza-33% more
• hay fever-20% more
• asthma-19% more.

More young women than young men reported symptoms indicating psychological distress or moderate or severe psychological distress in the 1993 Australian youth survey (Mathers 1996a).

Young men aged 15-24 years were significantly more likely to be overweight than women. Men aged 18-24 were more likely to drink at risk levels and were nearly 3 times more likely than women to report a hangover in the previous two weeks.

Young women were hospitalised more often than men and visited the doctor more often. After hospital episodes related to pregnancy (an average 0.09 admissions per woman) and to genitourinary conditions (an average 0.02 admissions per woman and 0.003 per man) were excluded, the admission rates for other conditions reduced to 0.1 episodes per person per year for both sexes.

Health differentials according to socioeconomic disadvantage

Disadvantaged young adults aged 15-24 years have worse health. This is measured by a wide range of indicators of mortality, illness and accident rates, and health service use according to measures of socioeconomic disadvantage based on family income, education, employment status, and socioeconomic disadvantage of area.

Since the ages 15-24 are a period of transition from dependence on family to economic independence, and usually to different household structure, it is difficult to define the socioeconomic status of young people in terms of measures such as their occupation, income or education level. An alternative approach is to look at variations in mortality rates by grouping residential localities according to socioeconomic criteria, as already done for children in Section 1.5.5.

Using a small-area index of socioeconomic disadvantage (Box 1.6, page 46), age-standardised death rates for young people have been analysed by quintile of socio-economic disadvantage. For young men and women, there was a gradient of increasing mortality with increasing level of socioeconomic disadvantage of area of residence (Figure 1.21). Comparing death rates for the quintile of greatest socio-economic disadvantage (fifth) with those for the quintile of least disadvantage (first), some of the strongest differentials were:

• all causes death rate-49% higher for males and 54% for females
• homicide-over 180% higher for both males and females
• circulatory disease-110% higher for males
• respiratory disease-110% times higher for males
• drug dependence-91% higher for males
• motor vehicle accidents-40% higher for males and 56% for females
• suicide-35% higher for males.

These differentials point to the importance of socioeconomic factors in determining the health of Australian youth. They also give some indication of the scope for further reducing the risk of death in the most disadvantaged groups. It is important to note that these differentials relate the mortality of all young people living in a geographic area to the overall level of socioeconomic disadvantage of that area. Socioeconomic status of individuals does vary within most areas. To the extent that the increased risk of mortality is associated with individual economic circumstances and living conditions rather than communal environment, the differentials understate the true differences in mortality according to socioeconomic disadvantage.

1.5.7 Older Australians

By world standards, most older Australians enjoy good health. In 1994, the life expectancy of Australians aged 65 years was 15.7 years for men and 19.7 years for women. These life expectancies are among the best in the world, only Japan, Hong Kong, Greece, Switzerland, France and Canada having higher life expectancies at this age.

Death rates for older adults have been declining since the mid 1960s. For example, the age-specific death rates at 65-69 years have declined from 40 and 20 per 1,000 men and women respectively in 1974 to 24 and 13 in 1994. This represents an average annual decline of 2.6% for men and 2.4% for women.

Men aged 65 years and over had a death rate 59% higher than the age-standardised rate of women in 1994 (Table 1.15, page 52). Older men had higher death rates than women for all major causes of death, including:

• suicide-men 4.7 times higher
• lung cancer-men 3.5 times higher
• bronchitis/emphysema/asthma-men 2.5 times higher
• stomach cancer-men 2.2 times higher
• motor vehicle traffic accidents-men 1.9 times higher
• coronary heart disease-men 1.6 times higher
• colorectal cancer-men 1.4 times higher.

In 1993, the prevalence of disability was also higher for older men than for older women, but there was a smaller difference in the prevalence of handicap and older women had a 29% higher prevalence of severe handicap. Older men reported fewer minor and recent illnesses, the same level of chronic illness and more serious chronic illnesses, fewer days of reduced activity and fewer visits to the doctor than older women. There was no difference in the reported levels of fair or poor health (Table 1.15).

Older men were more likely to report cancers, diseases of the nervous system and sense organs, and diseases of the respiratory and of the digestive systems. Older men were 16% more likely to be overweight and obese, 45% more likely to be smokers and 46% more likely to be risk drinkers than older women. Older women were significantly more likely to report circulatory system and genitourinary system diseases.

Sex differences in health are characteristic of all phases of the life cycle, and persist into older ages. Some have argued that sex differences in chronic illness levels increase in later life; women are more likely to reach old age, but more likely than men to experience chronic ill-health and minor illness. Older women do report more recent and minor conditions and have a higher prevalence of severe handicap. However, they do not report more chronic illness and do report less serious chronic illness.

Health differentials and socioeconomic disadvantage in older Australians

It is often assumed that old age is a time of universal ill-health, so that little attention has been paid to inequalities in health at older ages. Mathers (1994b) has shown that the inequalities in the health of younger Australians are also present at older ages. According to a range of measures of socioeconomic disadvantage, there is a consistent relationship between socioeconomic status and health among people aged 65 and over, although it is less marked than for younger people.

In particular for older men and women, there is a clear gradient of increasing mortality and worse perceived health status with increasing level of socioeconomic disadvantage of area of residence (Box 1.6, page 46). Mathers (1994b) compared death rates of older people for 1985 to 1987 for the quintile of most disadvantage (fifth) with those of the quintile of least disadvantage (first) and found:

• total death rate-14% higher for men and 11% higher for women
• pneumonia/influenza-53% higher for men and 16% higher for women
• diabetes-15% higher for men and 32% higher for women
• lung cancer-28% higher for men
• bronchitis/emphysema/asthma-18% higher for men
• coronary heart disease-10% higher for men and 15% higher for women
• stroke-16% higher for men and 6% higher for women
• suicide-44% lower for women.

There were no clear gradients of chronic or recent illness with level of socioeconomic disadvantage of area, although minor illnesses and some specific chronic illnesses were reported more frequently by those in the more disadvantaged quintiles. Older men and women in the fifth quintile were substantially more likely to be smokers (49% for men and 32% for women) and inactive (26% for men and 29% for women) than those in the first quintile. The prevalence of overweight and obesity increased with increasing disadvantage of area for older women but not for men.

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Footnotes

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1

Estimates of 1,900 or less have a relative standard error (RSE) of 50% or more. Estimates of 8,000 or less have an RSE of 25% or more. These estimates should be interpreted accordingly.

2

This group is the same as the group entitled 'Mental psychoses' in ABS publications.

3

This group is the same as the group entitled 'Other mental disorders' in ABS publications.

1993 ABS Survey of Disability, Ageing and Carers

4

Estimates of 1,900 or less have a relative standard error (RSE) of 50% or more. Estimates of 8,000 or less have an RSE of 25% or more. These estimates should be interpreted accordingly.

5

This group comprises all children with a disability aged 0-4 years and people who had a schooling or employment limitation only.

6

Severity of handicap was not determined for children with a disability aged 0-4 years. Some totals include people aged 5-64 only.

1993 ABS Survey of Disability, Ageing and Carers

7

Age-standardised to 1993 total Australian population.

8

Prevalence data for 1993 derived using screening items used in 1988.

9

Severe handicap rates for 1993 data refer to people with profound and severe handicaps.

Adapted from AIHW 1995, Table 6.5

10

Includes permanent services or professionals only, i.e. visiting services are excluded.

ABS 1995a

11

Persons may have reported more than one type of action.

ABS 1995a

12

Persons may have given more than one answer.

ABS 1995a

13

All deaths where AIDS is mentioned on the death certificate, irrespective of whether it is identified as the underlying cause of death. Since there were only 81 such deaths for women in 1992-94, these were not analysed by country of birth.

AIHW

14

Rates age-standardised to 1988 total Australian population.

Mathers 1994a, 1994b, 1996a

15

Data exclude Victoria and Northern Territory.

AIHW National Perinatal Statistics Unit

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