Chronic Conditions and Risk Factors

Chronic conditions are the leading cause of illness, disability, and death in Australia (66) The increasing burden of chronic conditions, is placing greater demands on the health care system, and requires a consistent and integrated approach for effective prevention and management to improve health outcomes for all Australians (66)

Key Points

• 73.3% of the population in country SA are estimated as being overweight or obese

• High potentially preventable hospitalisations for chronic conditions

• High rates for diabetes across most country SA region

Identified Needs

1. Chronic disease multidisciplinary care and prevention.

2. Reduce potentially preventable hospitalisations

3. Access to health care services and preventative care.

Health Needs

In 2021, it was estimated that almost half of Australians (47%) had one or more of 10 selected chronic conditions (67).

The 2021 Census was the first Census to collect data on long-term health conditions in Australia. In the Country SA PHN region, the age-standardised rate having one or more long-term health conditions was 30.1 per 100 persons, exceeding the SA average (29.5 per 100 persons) SA3 regions with the highest rate were Gawler - Two Wells, Mid North, Yorke Peninsula, Lower North and the Barossa (8)

Potentially Preventable Hospitalisation hot spots for chronic conditions are more than 1.5 times higher than the state average in in Port Augusta, Berri, Renmark, Port Pirie, Millicent, and The Coorong (68)

Rates for Aboriginal people experiencing chronic conditions are extreme compared to other population demographics in the Country SA PHN region and likely driving the high rates across the Outback (69). Analysis of chronic conditions experienced by Aboriginal people in country SA have been incorporated in the Aboriginal Health sections of this Needs Assessment Report.

Conditions of Significance

Diabetes

The Country SA PHN region has a higher age-standardised rate of self-reported diabetes (excluding gestational) (5.1 per 100 persons) than the national average. Risk of diabetes increases with age, with prevalence reaching 1 in 5 by age 75 (8). SA3 regions with the highest age-standardised rate of diabetes (excluding gestational) are Outback - North and East, Mid North, Gawler - Two Wells, Eyre Peninsula and South West, and the Yorke Peninsula (8)

Outback North and East more than double the proportion of SA population reporting a diagnosis of diabetes, and nearly double the proportion of country SA population with diabetes (70). This region is also the highest for diabetes complication hospitalisation (3.2 per 1,000).

Despite Barossa SA3 having one of the lowest diabetes prevalence for the Country SA PHN region, it is the second highest area diabetes complication hospitalisation (3.1 per 1,000)(70)

Cardiovascular Disease (CVD)

Circulatory system diseases include a range of cardiovascular and cerebrovascular conditions. Deaths due to cardiovascular disease were 50% higher in the lowest socioeconomic group compared with the highest (6). The

Country SA PHN Needs Assessment Report 2022-2025 (November 2021) prevalence of CVD increases with growing remoteness and double the proportion of men (4%) than women (2%) have a diagnosis of CVD (6)

SA3 regions with the highest age-standardised rate of self-reported heart disease (including heart attack or angina) are Gawler - Two Wells, Outback - North and East, Mid North, the Yorke Peninsula, and Fleurieu - Kangaroo Island (8).

Respiratory Disease

SA3 regions with the highest age-standardised rate of self-reported asthma are Gawler - Two Wells, followed by the Yorke Peninsula, Mid North, Lower North and Barossa (8)

Outback North and East had the highest age-standardised rate of potentially preventable admissions for asthma, followed by Fleurieu – Kangaroo Island (71)

Nationally, chronic obstructive pulmonary disease (COPD) was the 5th leading cause of death for non-Indigenous Australians and the 3rd highest for Indigenous Australians from 2016-2020, with 1 in 20 Australians over the age of 45 reporting being diagnosed with COPD (72, 73).

The Country SA PHN region has a high age-standardised rate self-reported lung conditions (including COPD or emphysema) of 1.9 per 100 persons, compared to the SA and national average (1.8 and 1.7 per 100 persons, respectively). SA3 regions with the highest rate are the Mid North, Gawler - Two Wells, the Yorke Peninsula, and Murray and Mallee (8)

The highest rates for Potentially Preventable Hospitalisations related to COPD are in Berri, Port Augusta, Quorn-Lake Gillies, Ceduna, The Coorong, Port Pirie, Renmark, Naracoorte and Murray Bridge at least 1.5 the average state rate (68)

Arthritis and Osteoporosis

SA3 regions with the highest age-standardised rate of self-reported arthritis are Gawler – Two Wells, followed by Mid North, Yorke Peninsula, the Lower North and Murray and Mallee (8)

Highest proportion of the population reporting osteoporosis were in Gawler - Two Wells followed by Yorke Peninsula and the Mid North; all other areas were below both the SA and Country SA PHN proportions (6)

Chronic Kidney Disease

SA3 regions with the highest age-standardised rate of self-reported kidney disease are the Outback - North and East, Mid North, Gawler - Two Wells, and Lower North (8).

Prevalence is shown to increase with age and is more common in females than males. The prevalence of end stage kidney disease requiring dialysis is twice as high in remote areas compared to metropolitan areas (74)

Post-COVID-19 Syndrome

Post-COVID-19 syndrome, commonly known as ‘long COVID’, is characterised by a range of symptoms extending several weeks or months after infection with COVID-19. Knowledge of this condition, including its definition and impact to the primary health care system, is still evolving. Current evidence estimates that the national incidence of post-COVID-19 syndrome is between 10-35% of people who test positive for COVID-19, and that incidence increases with age, number of comorbidities and severity of the acute illness (75, 76) Country SA PHN is monitoring the evolving evidence on postCOVID-19 syndrome and will continue to respond to emerging health and service needs in the region.

Chronic Condition Risk factors Tobacco Smoking

An estimated 15% of South Australians over 18 years are current smokers, with the exception of Gawler – Two Wells which was equal to this, and Adelaide Hills which was below, all other areas in the Country SA PHN region had agestandardised rates of smoking above the rate for SA (1)

Alcohol consumption

An estimated 15% of South Australians over 18 years consume more than two standard alcoholic drinks a day on average, with the exception of Gawler – Two Wells which was slightly below (1).

All other areas in the Country SA PHN region had age-standardised rates of alcohol consumption above the rate for SA (39).

Nutrition

In general, rates of fruit and more specifically vegetable consumption are very poor throughout country SA region with the exception of the Adelaide Hills which was the highest in the region for consumption of recommended daily serves of fruit and vegetables.

Yorke Peninsula SA3 had the lowest consumption of recommended serves of vegetables. Eyre Peninsula and South West, Lower North, Gawler – Two Wells, and the Mid North were also below the state average (77)

Gawler – Two Wells SA3 had the lowest proportion of respondents consuming the recommended serves of fruit per day (77)

Weight

34.3% of South Australians reported as being overweight with 29.5% being in the obese category (60). It is estimated 73.3% of the population across the Country SA PHN region as overweight or obese, and above the national average of 63.4% (78). In country SA region, 78.6% of Outback North and East surveyed had a BMI placing them in the range for being overweight or obese (60) With the exception of Gawler – Two Wells which were lower, all other SA3 regions in country SA were above the state average for being overweight and/or obese (70)

High Blood Pressure

Approximately a quarter of the population over 16 years in the Yorke Peninsula, Eyre Peninsula & South West, Outback North & East, and the Murray Mallee report having high blood pressure (70).

Service Needs

Patient-centred care approaches facilitated by the GP, including regular contact, individualised care plans, multidisciplinary shared care and patients being involved in decision making about their care have identified as effective for improving the health outcomes of patients with chronic conditions.

Three quarters (73%) of general practitioners reported care coordination activities post-hospital discharge and 87% reported coordination of care with social services and community providers (79)

People in Outer Regional and Remote/Very Remote areas face barriers in this approach to chronic care management, being least likely to have a usual GP or place of care, to facilitate a coordinated approach to care. This is further limited with lack of access in regional areas to specialists or faculties for medical testing (80) In addition, information sharing between health providers is reported by heath care users as decreasing as distance to metro areas and remoteness increases (80)

Population Health

There are a wide range of indicators that describe the health of a community and individual including where people live, what culture they are born into, socioeconomic status across life, health status and risks, and ability to access required services that are close to home. Other factors include living in a healthy community with access to clean water and sanitation, where government supports health preventative measures such as screening, immunisation against common communicable diseases and promotion of a healthy lifestyle.

Key Points

• Childhood vaccination rates below 95% across most of region

• Lack of access to oral health care

• High levels of disadvantage experienced in areas of region

Identified needs

1. Improve immunisation and vaccination rates

2. Access to oral health services

3. Access to health care services and preventative care

Health Needs

Immunisation and vaccination

Childhood immunisation

The National Immunisation Program (NIP) Schedule is a series of immunisations given at specific times ranging from birth through to adulthood.

Limited vaccination rate coverage exists for key age groups across several Country SA PHN regions (81):

Age SA3 Regions with vaccination rates at or above 95%:

1 Year Barossa, Yorke Peninsula, Limestone Coast

2 Year Nil

5 year Eyre Peninsula South & West, and Limestone Coast

Influenza vaccination

General practice is the primary provider for flu vaccinations. Vaccinations for influenza for SA in 2021 (March to October) were reported as totalling 757,678. With 273,206 administered to people aged 65+, and 455,031 aged 5-64 years old (82)

Vaccine preventable Potential Preventable Hospitalisation (PPH) conditions include hospitalisations due to diseases that can be prevented by vaccination, such as influenza, measles and whooping cough. Port Augusta has been an identified as a continual hotspot for vaccine preventable hospitalisations 2004 to 2018 (68)

COVID vaccination

At October 2021, 6 Commonwealth vaccination clinics (through general practice clinics), 9 Aboriginal Community Controlled Health services and 41% of pharmacies in the Country SA PHN region were administering COVID-19 vaccinations (83). Ninety percent of Country SA PHN residential aged care staff are fully vaccinated with a COVID-19 vaccine, with the exception of Barossa SA3, which has 80%-89% of staff fully vaccinated (84)

Country SA PHN Needs Assessment Report 2022-2025 (November 2021)

Japanese Encephalitis

In March 2022, Japanese encephalitis was declared a Communicable Disease Incident of National Significance. As at October 2022, the first nine cases of the virus have been detected in people living in SA Presence of the virus in mosquitoes and animals has been confirmed in the SA3 regions of Murray and Mallee, Gawler-Two Wells, the Barossa and the Lower North Vaccinations are being rolled-out to high risk and vulnerable populations (85)

Monkeypox

In July 2022, monkeypox was declared a Communicable Disease Incident of National Significance. As of September 2022, two cases of the virus have since been confirmed in people living in SA. Vaccines are being provided to persons at high-risk of contradicting monkeypox, including confirmed close contacts, vulnerable populations and people whose occupation may put them at increased risk (86)

Sexual Health

Sexual health includes having access to contraception, awareness of preventative behaviours to protect self and partners from sexually transmissible infections and access to testing and treatment(87).

Aboriginal and Torres Strait Islander populations have higher rates of blood borne virus and sexually transmissible infections, including HIV, Hepatitis C, Hepatitis B, gonorrhoea, chlamydia, and syphilis (refer to section: Aboriginal Health of this report)

Syphilis

In South Australia there is an ongoing infectious syphilis outbreak, first declared in the Far North and Western & Eyre regions from November 2016 (18)

As of March 2022, 169 cases of infectious syphilis have been notified in SA, marking a sharp increase over the last three years Of these, 157 (93%) cases were Aboriginal and Torres Strait Islander persons, and 67% were persons aged 15-34 Three cases of congenital syphilis have been reported in SA since the start of the outbreak (19)

Chlamydia

Chlamydia is the most commonly notified STI in South Australia. The notification rate of chlamydia in 2018 for South Australia was 360 per 100,000 population, and has been stable over the past five years, with a similar number of notifications in 2019 and 2020 (88)

Gonorrhoea

Rates of gonorrhoea were stable over 2017 and 2018 with a rate of 74 per 100,000 population in SA or just under 1,300 notifications (88). This increased to just over 2,000 notifications in 2019 and slightly reduced from that to just under 1,700 in 2020 (88).

Cancer Screening

In 2017, in South Australia, people aged over 65 accounted for 62.7% of all cancers and 78.9% of all cancer deaths, with a lifetime risk of being diagnosed with cancer (calculated to age 75) at 1 in 3 for males and 1 in 4 for females (89). In the Country SA PHN region, the age-standardised rate of self-reported cancer (any type, including remission) is slightly below the state and national average at 2.8 per 100 persons (8).

The most common reported cancers in South Australia (2017) (89):

Male Female

• Prostate 28.5%

• Colorectal 10.6%

• Lung 9.1%

• Melanoma of skin 7.8%

• Non-Hodgkin lymphoma 5.5%

These accounted for 61.1% of all newly diagnosed cancers among males in 2017.

• Breast 29.2%

• Colorectal 12.0%

• Lung 9.8%

• Melanoma of skin 6.8%

• Uterine 4.8%

These accounted for 62.7% of all cancers among females in 2017.

Country SA PHN Needs Assessment Report 2022-2025 (November 2021)

Cancer screening programs are evidenced to increase detecting cancer early, to support improved outcomes for treatments, while awareness of and avoidance where possible of associated risk factors associated can help to reduce chances of getting cancer (90).

Breast screening

Participation in breast screening for the eligible population (50-79 years) in 2018-19 for Country SA PHN is 58%. The regions which are below the Country SA PHN participation rate are the Lower North, Limestone Coast, Outback North & East, with the lowest being the Mid North with 48% participation (91).

Cervical screening

Outback North and East were below 40%, followed by the Murray and Mallee, Mid North, Limestone Coast, Yorke Peninsula, Gawler – Two Wells, and Eyre Peninsula and South West were also below the Country SA PHN overall participation rate of 48.5% (91)

Bowel screening

For persons invited to participate in bowel screening in 2018-19 in all areas of Country SA PHN except for Outback North & East (40.6%) had a greater participation rate than the overall national average (43.5%)(91).

Skin cancer

Melanoma and non-melanoma are the highest diagnosed types of skin cancer in Australia and rank in the top 5 causes of cancer overall. Melanoma is the third most common type of cancer and data is routinely collected by cancer registries regarding its prevalence. Comparatively, non-melanoma statistics are not collected by cancer registries. In South Australia, the age-standardised rates for melanoma were highest in;

• Mid North (0.51 per 1,000)

• Yorke Peninsula (0.48 per 1,000)

• Eyre Peninsula and South West; and

• Fleurieu – Kangaroo Island (both 0.46 per 1,000)(92)

Similarly, the highest rate ratios for non-melanoma compared to South Australia were (92, 93);

• Mid North (1.31 times higher than SA)

• Eyre Peninsula and South West (1.26 times higher than SA)

• Lower North (1.26 times higher than SA)

• Yorke Peninsula (1.23 times higher than SA)

• Fleurieu – Kangaroo Island (1.18 times higher than SA)

These findings correlate with MBS data showing higher rate ratios in agricultural and coastal areas of South Australia. Rates of skin cancer increase with age, with males having higher age-specific rates across all age brackets (93)

Oral Health

Essential to general health and wellbeing, oral health impacts quality of life. Oral health can be considered as a “state of being free from mouth and facial pain, oral diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking and psychosocial wellbeing.”(94)

As an identified Potentially Preventable Hospitalisation, acute dental condition hotspots across country are: Renmark, Barmera, Nuriootpa, Tanunda, Berri, Ceduna, Goolwa-Port Elliot, Port Pirie and Port Augusta (68). Renmark has the highest admission rates for South Australia at a rate of 2.6 that of the state average.

Renmark and Berri have been hot spots for Dental conditions for 15 and 14 years, followed by Port Pirie and Port Augusta which have been hot spots for 13 years (68)

For children living remote or very remote areas in South Australia, there is a higher prevalence and severity of untreated dental decay and total decay experience (95). For adults, decay experience is disproportionate across the social gradient and for specific populations including: rural and remote populations, Aboriginal people, frail older people, people with disabilities, those living with mental illness and culturally and linguistically diverse people (95)

Disadvantage

Socio-economic factors are universally recognised as key in determinants of health for population groups. Communities where groups of people experience socio-economic disadvantage are generally identified as being of greater risk of poorer health with higher rates of illness, disability and death than those from higher socioeconomic groups (96).

AIHW (2015) national analysis found overall burden of disease at 1.5 times higher for people located in low socioeconomic areas in comparison to than those in high socio-economic areas, with estimates for specific diseases at:

• 2.5 times as high for type 2 diabetes

• 2.0 times as high for lung cancer

• 1.4 times as high for stroke (97)

Concentration of disadvantage are experienced by communities in the APY lands, Maralinga Tjarutja, Peterborough, Coober Pedy, and Port Pirie (40).

Nationally, locational disadvantage is experienced in remote and very remote communities, with burden of disease being 1.4 times as high as major cities and potentially preventable hospitalisations being 2.5 times as high (98)

Service Needs

Local access to GP and specialist health professionals is limited across region, often requiring travelling long distances to access services. Community consultation across the region identified only half of respondents accessed a GP within their own suburb, and only 5% accessed other health professionals in this same area (99). 48% of respondents travelled over 450kms to access a specialist health professional. Time, cost and access to transport were highlighted barriers to accessing care outside local area (Refer to: Health Workforce section of this report)(99)

Outreach programs administered by the Rural Doctors Workforce Agency and Royal Flying Doctor Service contribute to closing local services gaps in rural and remote locations across country SA (99)

Access to dental services in Country SA are limited with limited availability of dentists and private dental services in regional and remote areas (95)

Country SA PHN Needs Assessment Report 2022-2025 (November 2021)