Original Research

Regional health inequalities in Australia and social determinants of health: analysis of trends and distribution by remoteness


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Joanne Flavel
1 PhD, Research Fellow * ORCID logo

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Sophie GE Kedzior
2 PhD, Research Associate ORCID logo

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Vivian Isaac
3 PhD, Senior Lecturer ORCID logo

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Darryl Cameron
4 MPH, Close the Gap Project Officer

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Fran Baum
5 PhD, Professor of Health Equity ORCID logo


1, 5 Stretton Health Equity, Stretton Institute, Napier Building, North Terrace, University of Adelaide, SA 5001, Australia

2 Faculty of Life Sciences and Medicine, King’s College London, Strand, London, WC2R 2LS, United Kingdom

3 School of Allied Health, Exercise & Sports Sciences, Faculty of Science and Health, Charles Sturt University, Albury, NSW 2640, Australia

4 River Mallee Coorong Local Health Network, SA Health, Murray Bridge Office, 96 Swanport Road, Murray Bridge, SA 5253, Australia

ACCEPTED: 10 November 2023

early abstract:

Introduction: Rural and remote areas have a higher burden of disease leading to inequalities in health between regional and urban areas. This paper compares trends in health status and social determinants of health in capital cities and rest of states/territories in Australia and examines the distribution of health and social determinants between metropolitan, inner regional, outer regional, rural, and remote areas.
Methods: We conducted an ecological analysis of Public Health Information Development Unit data for capital cities, rest of states/territories, and Local Government Areas. Trends in inequalities in capital cities and rest of states/territories (regional, rural, and remote) from 1986 to 2018 were assessed using the slope index of inequality. Data for 538 Local Government Areas were classified into remoteness categories and scatterplots produced to assess differences in health and social determinants of health both between and within remoteness categories.
Results: Our analysis of trends found that premature and avoidable mortality and infant mortality decreased in all socio-economic quintiles outside of capital cities. However, inequality in socio-economic area disadvantage increased for premature and avoidable mortality. There were mixed trends in terms of social determinants of health: higher  increases in full time participation in secondary education and internet access in the most disadvantaged quintiles led to decreases in inequality in urban and non urban areas. .
Inequality increased outside capital cities for income indicators, rental stress, and labour force participation due to higher proportional gains for areas within the least disadvantaged quintile of area disadvantage. Inequality was higher in capital cities compared to rest of states/territories in 2016 for rental and mortgage stress, welfare dependent families, and participation in tertiary education.  It was higher in rest of states/territories compared to capital cities for premature and avoidable mortality, labour force participation, and internet access. We found that while rural and remote areas had worse health and SDH on average, there was heterogeneity in premature and avoidable mortality and SDH for outer regional, remote, and very remote LGAs.
Conclusions: Increasing inequality in health and SDH in outer regional, rural, and remote areas underscore the ways in which health inequalities are strongly correlated with inequalities in SDH. Variation in health and SDH within non-metropolitan areas suggests it may not be appropriate to clump regions and towns together when conducting analysis in Australia. Policies to improve rural and remote health need to enhance existing provisions of social and health infrastructure with context specific measures to reduce these health inequalities.
Keywords: health inequalities, social gradient, social determinants of health, regional inequality, rural health