Social Determinants of Health

Addressing Social Determinants of Cardiovascular Health among Older Australians

Cardiovascular or heart disease contributes one of the greatest burdens to the Australian

health system (Australian Institute of Health and Welfare [AIHW], 2015). The term ‘heart

disease’ is inclusive of such conditions as coronary heart disease, stroke, atherosclerosis,

oedema and cardiomyopathy (AIHW, 2015; Australian Bureau of Statistics, 2012). National

statistics show older Australians are one of the population groups at highest risk for these

conditions, with Australians aged 65 and above recording higher hospitalisation and death

rates related to cardiovascular health than any other age groups (AIHW, 2011). In 2011-12

approximately 51% of Australians aged between 65 and 74 had self-reported heart disease,

with rates among those aged over 75 as high as 64% (AIHW, 2014). Higher rates of heart

disease have been recorded among men, with the differences in gender-based prevalence

increasing with age.

There is extensive evidence highlighting risk factors for heart disease among older adults

(e.g., Kannel, 2002; Klieman, Hyde, & Berra, 2006); the majority of which relate to proximal

determinants of health or lifestyle factors including smoking, alcohol consumption, weight

and exercise (AIHW, 2012). When compared to subsequent generations, older adults had

much higher rates of smoking in their youth (Cancer Council Victoria, 2012). These types of

generational comparisons also demonstrate differences in nutrition. Younger generations

illustrate more healthy eating behaviours compared to older adults who often record poor

fruit and vegetable intake (AIHW, 2012). Similarly, older adults are more likely to be

sedentary or participate in minimal exercise in comparison with younger age groups.

Physical activity is an effective preventive strategy for heart health yet the multimorbidity

faced by many older adults restricts activity (Cimarras-Otal et al., 2014).

While tackling individual factors is valuable, consideration of upstream factors

influencing morbidity and mortality for heart disease may allow for understanding of context.

For example, early life challenges have been shown to have a negative impact on adult health

outcomes (Havari & Peracchi, 2014; Wilkinson & Marmot, 2003) and many older

Australians grew up during the World War II years. At this time many families were without

fathers, brothers and uncles; women and children were engaged in the workforce; incomes

were low and resources were limited.

Stress is a critical social determinant of health. There are biopsychosocial theories

which suggest the experience of chronic stress, or the cumulative effect of daily stressors can

have damaging long-term effects on wellbeing (McEwen & Stellar, 1993). These stressors

may include the aforementioned early life challenges; occupational stressors among a

population who have spent multiple decades in the workforce; or stressful life events specific

to older adults (e.g., retirement, changes in family roles) (Amster & Krauss, 1974; Hostinar &

Gunnar, 2013; Lang, Lepage, Schieer, Lamy, & Kelly-Irving, 2000). Stressors such as low

socioeconomic status, education and income have also been linked to increased heart disease

mortality and high levels of alcohol and tobacco use (Mendis & Banerjee, 2010). Additional

stressors relate to social isolation and loneliness, both of which have been recorded at high

rates among older adults and may contribute to heart disease and morbidity (Lauder,

Mummery, Jones, & Caperchione, 2006).

It has been suggested that heart disease may be underdiagnosed and undertreated

(Karwalajtys & Kaczorowski, 2010). Employing a social determinants approach encourages

a proactive and preventive method (Williams, Costa, Odunlami, & Mohammed, 2008) which

emphasises early intervention and education about risk factors as vital to reducing incidence

of cardiac events (Baum, 2008). One method for achieving this is through public health

interventions with epidemiological approaches such as screening (Lin, Smith, & Fawkes,

2014). Typically screening is carried out in primary care settings by health professionals

such as general practitioners (GPs). However, access to health services is a key social

determinant of health. Access relates to financial resources and the availability of bulk

billing; physical access based on location and practice opening hours; and willingness to

attend and health literacy (Baum, 2008). There are financial incentives for GPs to conduct

cardiovascular screening (Australian Department of Health, 2015b) yet barriers to access

remain. To address this problem, a public health intervention could see the introduction of

free heart screening in local pharmacies. The geographical distribution of pharmacies and

their co-location with supermarkets improves options for physical access. Further, over 85%

of Australians aged over 50 take a prescribed medication and thus already access pharmacy

services (Morgan et al., 2012). For those individuals unable to physically access a pharmacy

but who have their medications delivered, screening could be conducted when the

medications are administered.

Research has found benefit in advancing the roles of community pharmacists to include

health prevention and promotion activities (O'Loughlin, Masson, Déry, & Fagnan, 1999). In

this screening intervention, individuals could visit their local pharmacist and receive blood

pressure testing and education around lifestyle factors affecting heart health, including

encouraging referral to GPs if required. Policy makers understand the value of such

screening methods, as seen by their funding of cancer screening programs for certain age

groups (Australian Department of Health, 2015a). The funding to support pharmacy

screening for heart health could come from the savings that would be made by intervening

early and reducing spending on hospitalisations and acute treatment.

Encouraging attendance at local pharmacies would require incentives, similar to the

policies which encourage immunisation of children (Australian Department of Social

Services, 2014). Given the age of the target population, and issues related to the social

gradient of health, it seems that linking the pharmacy heart health screen with applications for

the Age Pension might be plausible. There are approximately 2.4 million Australians

currently receiving the pension, with predictions that 80% of older Australians are eligible for

the payment (National Commission of Audit, 2013). To receive this payment, coordinated by

the Department of Social Services, individuals must be aged over 65, Australian residents,

and have met the requirements of an income and assets test. For those individuals not

accessing a pension due to the result of means testing, Commonwealth Seniors Health Cards

are available (currently held by approximately 300,000 Australians). To apply for a card or

the pension, individuals must complete a range of forms. A public health approach to heart

disease might see the inclusion of an additional form, citing a cardiovascular screening test.

A local (specially trained) pharmacist could conduct the screen and submit a report to the

Department of Social Services. This type of model would address the social gradient by

ensuring that as many Australians as possible have access to screening, regardless of their

ability to pay.

Limitations of this approach relate to the exclusion of those individuals who continue to

work past pension age, however it is possible that screening could be offered to all

individuals aged over 65 but only incentivised through the pension scheme. It is also possible

that introducing a screen may be perceived as paternalistic; however, the establishment of

such a program provides great opportunity for early intervention to reduce prevalence of

heart disease. The value of such an intervention is not only in its efforts to address social

determinants such as access to health services and income, but in the surveillance data which

would result. The majority of older Australians receive a pension and if there was

cardiovascular screening data made available for each of these individuals, it would provide a

national database of cardiovascular health for Australians aged over 65. This would enable

the mapping of particular geographical risk areas, providing a body of evidence to inform

future interventions. For example, selecting the most appropriate regions for additional

health services, or highlighting areas which would benefit from a reduction in fast food

outlets.

Conducting such an intervention could not be done in isolation. Any attempt to address

social determinants of health requires an integrated approach, across and within sectors

(Baum, 2008). At a macro level the pharmacy heart screen would require horizontal

integration between the health and community sectors, in particular between the Australian

Government Departments of Health and Social Services. Information recorded in the

national database (coordinated by the Department of Social Services) could be used in

collaboration with Departments of Planning and Infrastructure to inform future urban design

and establishment of services. At the meso level it would be important to have vertical

integration with local pharmacy systems working closely with social services offices (i.e.,

Centrelink). At a micro level pharmacists would need to be trained in heart screening and

lifestyle counselling, hence encouraging coordination with the education sector. Further, any

decisions would need to be made in partnership with community members (i.e., end users)

(Mendis & Banerjee, 2010); it is important that older Australians’ voices are heard in any

attempts to target social determinants affecting their cardiovascular health.

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