In respect to the ever increasing in longevity and growth of population, healthcare delivery has become a challenging matter. This confrontation may attribute to the government’s policy on healthcare delivery and the inaccessibility of healthcare facilities by some underprivileged groups. In Australia, a number of individuals are subjected to different kinds of socio-economic disadvantages such as low social status, unemployment, remoteness, and communication barrier that prevent them from the access proper healthcare services. In recognising these social factors, various health promotion approaches are developed to improve the existing conditions and reduce the health inequality. These socio-economical factors and approaches are being discussed.
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Australia healthcare system has been adopting a traditional bio-medical model with doctors’ dominance over the decision making process (Baer,2008). The funding mechanism for health services is through the Federal Government, State, Territory and Local governments, health insurers, individuals and a diversity of other sources. The service providers include different medical practitioners, allied health professionals from public and private hospitals, clinic and other government or non-government agencies. With the introduction of Medicare, a publicly funded universal health care scheme, in 1984; and the enforcement of Medicare levy in 1996 and 2007 by the Labour government; Medicare is currently one of the main vehicles in financing health care services (Duckett and Willcox2011, p41).
Determinant of health is a factor or characteristic that contributes to the health outcome, either for the better or for the worse (Reidpath, 2004). In 2003, the World Health Organisation (WHO) has identified ten major social health determinants: the social gradient, stress; early life; social exclusion; work; unemployment; social support; addiction; food and transport. The critical determinants are being categorised to socioeconomic, income inequality, ethnicity and gender factors in nature.
Socioeconomic determinant is the major cause for the inequality of health. It comprises of social, cultural and gender role factors and is considered as a factor that people are born, grow, live or work and age regarding health system. This determinant is constrained by the distribution of funds, power and resources at local, national and global level, and are influenced by the choice of policy.
Socio-economic status (SES) is a combined total measure of a an individual’s economic and social position in relation to the society based on income, wealth, level of education, social influence, occupation and employment status. Harris et al.(2004) argued that socioeconomically disadvantaged groups are less likely to utilise age-appropriate immunisation and to participate cancer screening programs. According to Reidpath (2004), people of a lower SES tend to have a poorer health outcome than those of the higher SES (Duckett and Willcox 2011.p31). Likewise, people of more socio-economically disadvantaged countries tend to have sicker population than those of less socio-economically disadvantaged countries (Reidpath, 2004), because poverty restricts the capability of an individual to get access for necessities such as food, nutrition and transport, education and other appropriate health care, hence an inequality in accessing health facilities.
“Absolute wealth” is regarded as an important determinant of health. Research has shown there is a poorer health outcome in the areas of higher income inequality than the income of the lower inequality area (Reidpath,2004). The psychosocial interpretation argues that this is due to the psychological stress that directs people to express their perception towards the unfairness and inequality of the society. Notwithstanding some stress may be positive to health, psychosocial explanation recognises a prolonged exposure to such a stress may pose risk to health hence increase the mortality and morbidity rate. In fact, research has uncovered that patients of low occupational status receive 21% less time in health care services than patients from higher occupational groups (Wiggers and Sanson-Fisher,1997).
Alternatively, the neo-materialists explain the poor health outcome of the disadvantaged group is because less investment is being made on social infrastructure in their unequal society they live in, for example, housing, transport and health services. Therefore, a poor health outcome is resulted from a combination of inadequacy in resources in providing health. Hence, the wider the gap between the income and social status, the more the inequality exists in the accessibility for health.
Australian population comprises of multi ethnicities that living in a diverse linguistic and cultural background. The difficulties in accessing healthcare may due to cultural, communication barrier or racism that compounds with social-economic or geographical impacts, especially for the Indigenous Australia residing in the remote areas. Culture relates to customs, tradition and beliefs of the family and community. Cultural support may provide positive support that lead to a healthier health outcome. Cultural barrier exists in ethnic groups owing to the divergence in the expectation on the standard of health and the absence of confidence towards western medical interventions. In fact, the indigenous population had an age-standardised death rate at least twice that of the non-indigenous population to non-indigenous (Duckett and Willcox 2011.p33). Besides, communication barriers are reported as a cause of misdiagnosis, inappropriate of medication, or poor compliance of treatment (Taylor et. al, 2013). In particular, racism may occur as ethnic groups are sometimes being stereotyped as homogenous, for example: shorter duration of consultation for a particular ethnicity due to assumed medical illiteracy. Further, communication barrier may cause a recommended treatment to result in a conflict. This has rendered medical interventions to be ineffective even a disadvantaged group has an opportunity to access health facilities, the services cannot be fully utilised. Therefore, the National Indigenous Reform Agreement was signed in November 2008 to monitor the outcome of Indigenous people (Duckett and Willcox2011.p.33).
Epidemiology reveals there is a significant difference in the health status between men and women, as some diseases are gender specific. Also, different gender may suffer from different disease at different stages under different environments. Generally, males are less actively to seek for medical treatments for the same health problem; more likely to participate in violence and high risk or drug related activities (Duckett and Willcox2011. p30) and more exposed to occupational hazards. Therefore, women have a longer life expectancy than men (Duckett and Willcox2011.p.22). However, women are more vulnerable for chronic condition due to aging. Traditional medical practices have attributed women’s illnesses to behavioural lapses. Also, sex preference is manifested in discrimination against female children in healthcare setting. Regarding women’s role function, marriage and child bearing responsibility has exposed women to the complications of various gynaecological problems. Further, women engaged in home care duty has prevented them from taking time off for healthcare. They also lack of independent income, hence lack of autonomy and decision-making power on treatment options(Okojie,1994). All these reasons have made women a disadvantaged group in accessing health care.
In order to take control over the health determinants, health promotion strategies have been developed after the WHO 1986 Ottawa Charter for Health Promotion Conference (Lin and Fawkes.2007). In Australia, the commonwealth, Federal, State and Local government are responsible in developing, planning, legislating, enforcing, coordinating and allocation of funding for health promotion. Other support groups includes the inter-sectoral organisation such as local council; the non-government organisations such as some community based self-help groups, for example, National Heart Foundation; consumer advocacy groups; pharmaceutical and health product marketing organisation. However, it is also an individual’s responsibility to maintain themselves in an optimum and healthy state.
Three approaches in health promotion are discussed below.
This approach aims at the minimisation of morbidity and premature mortality and is a targeted at the entire population or the identified high risk group.
The health promotion activity includes the promotion of medical intervention to prevent or improve ill-health through a number of medical approaches. Primarily prevention is to be performed on the prevention of onset of disease through consultation, for example, measuring body mass, immunisation; encouraging non-smoking. The secondary prevention is focused on the preventing of progression of disease such as screening. The tertiary prevention is aimed at reducing further disability those have a medical condition, for instance, rehabilitation, patient education or palliative care.
The popularity of medical approach lies on the employment of scientific method such as epidemiology where patterns, causes, and effects of health and disease conditions are investigated in defined populations. This approach advocates the idea of early prevention and detection of diseases being more effective than treatment. This strategy is operated with a top-down approach and led by medical experts, then reinforced by other healthcare professionals (WHO, 1996)
This approach reduces the mortality and morbidity rate through preventative and curative measures. It has been claimed to be an overwhelming success from the past, for instance, the eradication of smallpox since 1977 (WHO.2014). This approach also seeks medical and scientific evidence as a guideline for the intervention of medical defined problems. Therefore it provides a good direction for individuals lacking medical knowledge on the treatment process.
Base on the traditional biomedical model, this approach has stressed on the prevention of disease rather than promoting the health status, as the prevention procedure requires a logical rationale derived from epidemiological evidence, this approach depends heavily on medical knowledge and the compliance of treatment and the capability of the medical infrastructure in delivering screen or immunisation programme. Further, it has overlooked the social and environmental determinants of health and has ignored the health decisions being made from the concerned party and encourages medical paternalism. (WHO,1996)
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These approach emphases on public illness rather than public health. It mainly focuses on individual or targeted groups whose social situation or behaviour at the risk of developing unhealthy lifestyle that may cause serious health problem, such as smoking, mal-nutrition problems, physical inactiveness or drug abuse. It encourages individuals to take responsibility of their own health and choose healthier lifestyle. The theory is to modify the behaviour of the small portion of the population to influence the behaviour of the majority.
This approach bases on the three assumptions. Firstly, people have to view health as a property of individuals and the major cause of morbidity and mortality are poor lifestyle choice. Secondly, correct health information being conveyed to an individual will effectively encourage people to change their behaviour and attitude. Thirdly, the provision of health services and health personnel will cause this society to achieve a better health outcome (Cockerham and Niemann, 2000).
The method is based on communication, education, persuasion and motivation. Promotion tools are health education and social marketing, for example, advertisement campaigns; websites to advocate healthier lifestyle such as “Quitnow” for smokers.
This approach takes a preventative measure to encourage a behavioural change that lead to a reduction of risk factor which benefits an individual and the society. This is a self-help strategy where an individual’s health can be managed without seeking extra professional assistant. It is also a self-care program which offers care for oneself, a family member or a friend rather than involving the traditional health care facilities. Thus it can be performed without medical intervention at a minimum cost.
This approach inclines to blame an individual for their poor health. It assumes that behaviour change is the sole responsibility of the individual who will rectify their health behaviour when the relevant health information is provided, without considering whether they are able to change. It also assumes the “victim-blaming” factor for the lifestyle is actively chosen, without considering the constraint they have to face under some environmental and social issue (WHO, 1996). It further fails to account for the social context and the underlying factors such as economic, political and social environment that led to the choice. Duff (1994). This approach is also disadvantaged by the an uneven distribution of health expenditure in public health (2%) and Community health (5%) (Duckett and Willcox2011. p.47). Therefore an individual who is at risk may not be able to receive appropriate resources. Also, as the success of this strategy can only be assessed after a long period of intervention, it is also impracticable to isolate any behaviour change as attributable to a health promotion intervention.
The aim of this approach is to minimize the inequalities in health status of all people, by taking into account of the social, economic and environment factors according to the WHO’s Ottawa Charter 1986 (Lin and Fawkes,2007). This approach seeks the amalgamation of the tradition medical, lifestyle, educational, empowerment, social change approaches a healthy public policy to create the social, economic and environmental conditions for healthy living.
Recognition of Social Determinants
It recognises the social determinant, that is, social conditions and resources for basic in improving health in population such as peace, shelter, education, food, income, stable eco system, sustainable resource and equity that impose on people’s health status.
It focuses on people and their communities, recognises the local needs of subgroups within the population, highlights the significance of multi-social sectors’ contribution to influence health in population and encourage working together for healthier environments.
Individual empowerment is based on counselling and encourage individuals to play active part in the decision making course. This empowerment can be achieved through education on health information, developing skills in recognising their need, providing a chance of expressing their opinion on the issue of health impact, encouraging them to work and communicate with health professionals through a variety of economic and social support Labonte. (1994). Community empowerment is related to promote communities in policy making, prioritising and implementing of health strategies in order increase control and improve their health.
This approach accommodates all participants of the healthcare system of public health, provides supports for disadvantaged groups, invites joint participation, and enables a better communication between an individual and the community. Therefore individuals and organisations can work co-operatively on major decisions and monitoring the outcome of some strategies (Mckie, 2007) to meet needs. Besides, it provides a framework for long term social, economic and political environment and lead to a better control of an individual’s health status within a broader social and economic framework in achieving better health outcome.
This approach has blurred the dominant mission of health promotion as it combines other promotion approach (Awofeso, 2004). Also, as empowerment is a long term process, it is difficult to evaluate the outcome and therefore the result is hard to specify and quantify. Further, this approach is disadvantaged by the historically established biomedical orientated healthcare setting. According to the 2007/08 health expenditure analysis, the majority of resources has been allocated in public hospital(39%) and medical services (19%) and Pharmaceutical (14%), leaving 2% allocated for Public health and 5% for community health and other (Duckett and Willcox2011.p 47).
In view of the new public health approach, the roles of health professionals have engaged into a broader diversity. For instance, in dealing with diabetes, a chronic condition that imposes a significant burden to the Australian society, various health professionals can appoint a leader and collaborate as a shared-care team. While the consulting doctors prescribe treatments; laboratory professional serve pathology reports on blood sugar level; medical record professionals maintain records; hospital or community or nurses take care of patients by monitoring their compliance of medication; pharmacists supply and review on medications; physiotherapists formulate physical exercises to encourage physical activities; nutritionists formulate a healthy diet plan, the psychologists evaluate the psychological impact on patients. Besides, these professionals can share and provide educational information to the patient on a healthy lifestyle through promotional programs. The role of health promote is to facilitate and catalyse their motivation. With the non-medical organisation, social workers help to liaise with different organisations for special needs. Other non-profit organisation such as Diabetic Australia helps patients to combat their conditions through self-management programs. Through the establishment of a good communication network and the active commitment of different health or non-health professionals, the patients or risk groups have the chance of improving their management skill, developing strategies and sharing illness trajectories results in building the community’s common understanding towards chronic conditions. (Patel et al. 2000).
Despite the government’s intention to reform on the current health system, impediments are expected due to uneven resources allocation; the dominance on doctor’s authority, the resistance to innovation, coupled by the political factors ever since the establishment of the health care system. Public health is not a monopolised business; it demands the leadership, cooperativeness, and responsibilities of all levels to participate. With the introduction of The Health Reform and Ration 2013 that suggested a transformation of the tradition bio-medical to the socio-economical healthcare delivery model. It is anticipated that there will be improvement on the access on healthcare services.
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