Social determinants of health

Meggan J. Devery, Katie Brooker, Kitty-Rose Foley

Lucio Naccarella, Katrina Plamondon, Alison Brown, Alexandra Kent, Sana Shahram, Donya Eghrari, Nicole M. Rankin, Stephanie Best, Marlena Klaic, Zoe Fehlberg, Michelle Lambert, Sue Crengle

Saman Khalatbari-Soltani, Edward Jegasothy, Seye Abimbola, Anita van Zwieten

Rural and remote Australians experience persistent health inequities. Although randomised controlled trials (RCTs) remain the most rigorous method for establishing causal relationships and informing equitable health policy, they are challenging to conduct in rural settings, contributing to under-representation in research. When RCTs are not feasible, observational analyses using the target trial framework provide a rigorous and pragmatic alternative. Despite growing international adoption, this approach has not been applied to rural contexts. The recently published TARGET guideline offers transparent reporting standards for these studies, providing a new methodological tool to advance rural and remote health research.

Tanvir Kapoor, Harrison J. Hansford, Brooke A. Spaeth, Adam D. Irwin, Aidan G. Cashin

Mark Robinson, Gerry McCartney

Fei Zhang, Zhong Wang

Joanna Y. Gong, Emily D. Williams, Agus Salim, Spiros Fourlanos, Jonathan E. Shaw, Dianna J. Magliano

Objective To explore primary care providers' perspectives on (i) healthcare needs and barriers to care for Aboriginal and Torres Strait Islander children and adolescents; and (ii) enablers and opportunities to strengthen care. Study Design A qualitative study; interviews and open-ended survey responses. Setting Primary care providers who work with Aboriginal and Torres Strait Islander children and young people in health and education settings in New South Wales and the Australian Capital Territory. Data were collected between 23 March 2022 and 13 October 2023. Main Outcome Measures Sixteen interviews and 33 open-ended survey responses were analysed using reflexive thematic analysis with a hybrid inductive/deductive approach. Results Participants reported that some of the most important health needs for children and young people related to mental health. They recognised that the presenting complaint was not always the underlying or only concern, demonstrated an understanding of trauma-informed care and acknowledged the importance of collaborative services that engaged support networks. Barriers to care included a lack of cultural safety in mainstream services, challenging social circumstances, financial concerns, being unaware of available services and privacy and confidentiality concerns. To improve care, staff identified several areas needing change including having a package of services tailored for young people; additional training for providers in child and adolescent health, particularly for mental healthcare, trauma-informed care and communication with young people; providing a safe and engaging environment; support for staff self-care; and additional resources. Conclusions Supporting mental health needs is a key aspect of caring for children and adolescents. To provide optimal primary healthcare, service providers require specialist skills. To support adolescents and children, participants identified a need for ongoing training, professional development and organisational support to ensure best practice care is sustained. This work has informed the development of training and other resources for partner health services.

Christianna Digenis, Rachel Reilly, Peter Azzopardi, Hilina Winkenweder, Odette Pearson, Kane Ellis, Jane Fisher, Debra J. Rickwood, Choong-Siew Yong, Ngiare Brown

By quantifying the impact of geographical disparities in cancer survival, these findings highlight the need for evidence-based interventions to improve cancer survival across Australia

Charlotte K Bainomugisa · Jessica Cameron · Paramita Dasgupta · Peter Baade

Alcohol, tobacco, ultra‐processed foods and sugar‐sweetened beverages — these are the types of harmful products that tend to spring to mind when we think about the role of commercial actors and behavioural factors in influencing health. And for good reason. In Australia, for instance, smoking is estimated to kill more than 24 000 people each year.1 Alcohol contributes substantially to a wide range of diseases, including cancer, liver disease, heart disease, and suicide and self‐harm, and overall accounts for around 4% of the nation’s total disease burden.2 Reducing the consumption of sugar via a sugar‐sweetened beverage tax is predicted to substantially reduce the number of cases of type 2 diabetes, heart disease and stroke, while also cutting the prevalence of obesity in children and adolescents.3 Traditionally, scholarship in this area has focused on industries that produce and sell products with obvious health harming impacts. More recently, the understanding of the commercial determinants of health has expanded to encompass the “pathways through which commercial actors drive health and equity”.4 This shift has enabled more deliberate exploration of how many other sectors of the economy can influence health, including gambling, social media, housing and education, to name but a few.5 This issue of the MJA illuminates our evolving understanding of the role that social and commercial factors have on health in Australia. Two articles in this issue address how rising rates of homelessness — which includes sleeping rough, as well as reliance on emergency and temporary accommodation, couch surfing, and substandard housing — demand greater consideration from health policy makers and practitioners. First, Stearn and colleagues6 explain how housing insecurity adversely affects cancer care and outcomes and put forward several possible pathways towards achieving more equitable cancer outcomes for people experiencing homelessness. Second, English and colleagues7 explore the intersection between the worsening climate crisis and homelessness. They outline the evidence on how people experiencing homelessness are more vulnerable than people with secure housing to the health impacts of extreme heat and describe emerging public health responses, including their world first co‐designed mobile cooling hub. Turning to health care, a perspective article by Murphy8 explores the rise in out‐of‐pocket costs for accessing non‐general practitioner specialists. “Doctors have, not unreasonably, had an expectation of earning high incomes, given the training required for each specialty fellow,” Murphy argues. “However, these incomes, and the fees that generate them, have created a number of challenges.” Several possible solutions are discussed, with Murphy concluding “self‐regulation is the simplest option. Given the community and government angst about this issue, specialists would do well to reflect on the impact of their fees on patients … [to] improve patient access and reduce the risk of government intervention”. Other work in this issue of the MJA includes new research by Egger and colleagues9 on trends in adolescent smoking prevalence, which suggests vaping might be slowing Australia’s tobacco control progress. In addition, a narrative review by Cortes‐Ramirez and colleagues10 examines the relatively understudied effects of mining activities on the health of Australians, and a whole of population census data analysis by Gong and colleagues11 characterises the relationship between socio‐economic position and the prevalence of ten leading chronic diseases. Despite our expanding understanding of the social and commercial determinants of health, until very recently the news media industry has attracted little attention from public health scholars.12 Writing in this issue of the MJA, Fredericks and colleagues13 make a case for establishing journalism as a health determinant and for protecting public interest journalism as a public health good. “Our increasingly unreliable and unsafe news and information environment has profound and wide‐ranging implications for the health sector and the health and wellbeing of communities”, they argue. Yet “at the same time, the capacity of public interest journalism has been greatly diminished”. Fredericks and colleagues outline how responses to the spread of health‐related misinformation and disinformation are frequently too narrow in focus. Strategies such as improving science communication or health literacy are important, but on their own will fail to address the complexity and connectivity of the issues at play. Rather, systems approaches are required that recognise the central role of public interest journalism in “hold[ing] to account the commercial and political interests undermining the safety and reliability of news and information systems”. Crucially, the authors highlight how “Indigenous knowledge systems have much to offer to systemic analyses and responses because of their dynamic, adaptive and holistic approaches with the capacity to connect diverse spheres”.

Elizabeth Zuccala

People experiencing homelessness should be prioritised in national cancer plans and policies to promote equitable access to cancer care and the health care system more broadly

Amy Stearn · Jennifer A Baldock · Julia N Morris · Joanne Flavel · Fran Baum

Journalism and independent media are important for supporting public health through contributing to a healthy information environment, fostering dialogue and respect for rights, making governments more transparent and accountable, and societies more informed, inclusive and sustainable

Bronwyn Fredericks · Neha Lalchandani · Melissa A Sweet · Alex Cramb · Carmel Williams

Australia has the means to ensure that children and young people can thrive. We are in a critical period, and failure to act risks leaving a generation behind

Georgie Frykberg · Angelica Ojinnaka‐Psillakis · Planning Saw · Kevin Kapeke · Cham Kim · Amie Furlong · Susan Maury · Anna M H Price · Peter D Sly · Taylor Dee Hawkins · Khalid Muse · Pasi Sahlberg · Prue Warrilow · Fiona J Stanley · Jordan Cory · Carolyn Wallace · Adam Valvasori · Ngiare Brown · Craig A Olsson · Yichao Wang · Sharon R Goldfeld · Rosemary Calder · Kate Lycett

By optimising existing investments and leveraging Australia’s strong universal foundation, we can enhance child and family health services and improve outcomes for all children and their families

Anna MH Price · Elodie O’Connor · Sharon R Goldfeld

Overview of lung cancer biobanking globally and in Australia, challenges such as difficulty with tissue acquisition, the usefulness of biospecimens in multi-omic analysis, as well as unique challenges faced in Australia

Sarah Yeo · Stephen Q Wong · Farzaneh Atashrazm · Andreas Behren · Anthony T Papenfuss · Natalia Vukelic · Lisa Briggs · Ashleigh R Poh · Daniel Steinfort · Natasha Smallwood · Kate Sutherland · Vivek Naranbhai · Sagun Parakh · Tracy Leong