PUBH6000_Assessment Brief 1

ASSESSMENT BRIEF

Subject Code and Title PUBH6000: Social, Behavioural and Cultural Factors in Public
Health

Assessment

Assessment 1: Report ‐ Social Determinants of Health

Individual/Group

Individual

Length

1,500 words

Learning Outcomes

This assessment addresses the following learning outcomes:

1. Analyse the impact of social, environmental and
behavioural factors on the health of different
populations

2. Analyse population health outcomes and the major
social, economic, political and cultural forces that
contribute to health inequalities

3. Apply theoretical frameworks to develop effective
health promotion interventions.

Submission Due Sunday Week 4 (end of Module 2) at 11:55pm
AEST/AEDT*
For Intensive class: Due Sunday Week 2 (end of
Module 2) at 11:55pm AEST/AEDT*

Weighting

35%

Total Marks

100 marks

*Please Note: This time is Sydney time (AEST or AEDT). Please convert to your own time zone (eg.
Adelaide = 11:25pm).

PUBH6000_Assessment Brief 1

Task description:
Background

Tobacco consumption in any form, lack of physical activity, a diet high in fats and sugars,
hypertension, obesity and diabetes are well‐known behavioural risk factors for heart disease.

Populations with lower socioeconomic status are more likely to have increased behavioural risk
factors for heart disease, including smoking and lack of physical activity (Australian Institute of
Health and Welfare, 2010). Although behavioural risk factors might be evident causes of diseases,
public health professionals also consider social and environmental factors that contribute to the
social gradient of health.

Instructions

Choose a population group in Australia (e.g. men/women, low socioeconomic status,
rural/remote, people with disabilities/mental illness). In 1500 words, address the following:

• Describe the burden of heart disease within your chosen population. Please describe burden

of disease in terms of any two of following: incidence, prevalence, mortality, morbidity,
survival or quality of life.

• Discuss how the social determinants of health can explain the burden of heart disease within

your chosen population.

• Propose a public health intervention to prevent heart disease in your chosen population

that addresses at least one social determinant of health (e.g. working conditions/
unemployment, social support, transport, housing conditions, education, access to
healthcare).

• Explain what other sector/s could be involved aside from the health sector (e.g education,

local government, transport, housing) in your public health intervention.

This task can be addressed by including two sections in the body of your assessment. Section 1
focuses on the burden of heart disease for your population and the social determinants relating to
this. Section 2 proposes an intervention to address a social determinant and prevent heart disease
in your chosen population. Please see the template below for more details about how to address
this task.

PUBH6000_Assessment Brief 1

Introduction

Assessment 1: PUBH 6000
Report: Social Determinants of Health.

Assessment 1 Template.

• Provide a short introduction which gives the reader an overview of the whole

assignment. Briefly introduce the public health problem (heart disease) and identify
the specific population group that your report will focus on. Explain that your report
will propose an intervention to address a social determinant of health for this
population group.

Section 1: Social determinants of Heart disease for [Chosen population]

• Burden of heart disease within your chosen population

Provide an overview here of the burden of heart disease in your chosen population:
referring to two of the following: incidence, prevalence, mortality, morbidity, survival or
quality of life. In this section, you should summarise and appropriately reference
information you have found from sources such as the Australian Institute of Health of
Welfare (AIHW).

• Discuss how the social determinants of health can explain the burden of heart disease

within your chosen population.

Here you should discuss how the burden of heart disease in your chosen population can be
explained by social determinants. Consider t health inequities and the social gradient here,
and how disadvantaged or advantaged your population is relative to the broader
Australian population. Identify any particular social determinants that are relevant for
understanding the burden of heart disease in this population group. Make sure you
support all your points with evidence from appropriate sources.

Section 2: An intervention to address social determinants of Heart disease for [Chosen
population]

• Propose a public health intervention to prevent heart disease in your chosen population

that addresses at least one social determinant of health (e.g. working conditions/
unemployment, social support, transport, housing conditions, education, access to
healthcare).

Propose an intervention here to prevent heart disease in your chosen population. This
can be a completely new idea or you can draw on ideas from research you have done on
existing interventions (for example, physical activity or nutrition interventions). Either
way, it must be clearly explained how your intervention could prevent heart disease, and
how it addresses one social determinant of health. Clearly identify what this social
determinant of health is. In terms of justifying that this intervention can contribute to
reducing heart disease, and why taking action on the particular social determinant of

PUBH6000_Assessment Brief 1

health is important, make sure you support all your points with evidence from
appropriate sources.

• Explain what other sectors can be involved aside from the health sector

Identify here what other sectors could be involved in your intervention. Examples of
other sectors include (but are not limited to) education, housing, transport, local
government. Identifying one sector is fine. Clearly explain how this sector/s would be
involved in the intervention and justify why including this sector is important.
Support all your points with evidence from appropriate sources.

Conclusion

• Provide a brief conclusion which does not introduce any new information, but ‘ties

the assessment together’. It should provide a recap of the information discussed in
regard to the burden of heart disease for your population and social determinants of
this. It should also give a short overview of the intervention that was proposed. This
provides a useful overall summary for the reader.

General points

• Please use sub headings for sections 1 and 2 as per this assessment brief.

Introduction and conclusion do not need subheadings.

• Appropriate scholarly sources include peer review journal articles, subject readings,
academic books and book chapters and publications from reputable grey literature
sources. Reports from the Australian Institute of Health and Welfare (AIHW) are
likely to be particularly useful, as well as other Australian Government sources, and
reputable NGOs such as the Heart Foundation. The World Health Organisation
(WHO) is also an important source of publications.

Please look for publications from these sources such as reports, rather than relying
only upon information available on their webpages.

• Please cite at least 10‐12 scholarly sources for this assessment.
• Ensure your report is written in a clear manner, including spelling, grammar, structure,

tone and accurate referencing in accordance with the latest APA guidelines (APA 6th)

PUBH6000_Assessment Brief 1

Assessment Criteria:

• Displays understanding of the burden of heart disease within a specific population (of
student’s choice) (25%)

• Demonstrates analysis of the social determinants of heart disease within chosen Australian
population (30%)

• Proposes a suitable and appropriate intervention to address a social determinant of heart
disease for chosen population, and identifies appropriate sectors that are involved in the
intervention aside from the health sector (35%)

• Assessment Fulfills general academic standards (10%) including: :

• Provide an introduction and conclusion

• Complies with academic standards of writing, including legibility, spelling, presentation
and grammar

• Uses appropriate APA 6 style for citing and referencing research

PUBH600_Assessment Brief 1_ 6 Week Delivery

Marking Rubric:

Assessm
ent
Attribut
es

0‐34
(Fail 2 –
F2)

Unacceptable

35‐49 (Fail
1 – F1)

Poor

50‐64
(Pass ‐P)

Functional

65‐74
(Credit ‐ CR)

Proficient

75‐84
(Distinction – DN)

Advanced

85‐100
(High Distinction –

HD)

Exceptional
Grade
Description
(Grading
Scheme)

Evidence of unsatisfactory
achievement

Evidence of satisfactory
achievement

Evidence of a good
level of achievement

Evidence of a high
level of achievement

Evidence of an
exceptional level of
achievement

Displays understanding of
the burden of heart disease
within a specific population
(of student’s choice) (25%)

The assessment does not display
an understanding of the burden of
heart disease within a specific
population. There is no attempt to
describe the burden of disease by
referring to a specific indicator.

The assessment
displays a basic level of
understanding of the
burden of heart
disease within a
specific population.
One or two burden of
disease indicators are
referred to.
information
substantiated by
evidence from the
research/subject
materials.

The assessment displays a
sound understanding of
the burden of heart
disease within a specific
population. Two or more
burden of disease
indicators are referred to.
capacity to explain and
apply relevant concepts.

The assessment
displays a thorough
understanding of the
burden of heart
disease within a
specific population.
Two or more burden
of disease indicators
are referred to, and
these are well

explained.
Extended reading.
Well demonstrated
capacity to explain and
apply relevant concepts.

The assessment displays
a highly sophisticated
understanding of the
burden of heart disease
within a specific
population. Two or more
burden of disease
indicators are referred
to, and the relevance of
these for understanding
heart disease in the
chosen population is
very clearly explained
Mastery of concepts and
application to new
situations/further
l

PUBH600_Assessment Brief 1_ 6 Week Delivery

Demonstrates analysis of the
social determinants of heart
disease within chosen
Australian population (30%)

The assessment does not contain
any analysis of how the burden of
heart disease within a specific
population relates to social
determinants of health

The assessment contains
some basic
analysis of how the
burden of heart disease
within a specific population
relates to social
determinants, but this is
overly descriptive The
relationship between social
determinants and heart
disease is not clearly
explained and needs better
links to evidence

The assessment contains a
good analysis of how the
burden of heart disease
within a specific population
relates to social
determinants. The analysis
is reasonably well
explained and justified by
credible evidence.

The assessment contains a
thorough and detailed
analysis of how the
burden of heart disease
within a specific
population relates to
social determinants.
The analysis is very well
explained and justified
with relevant & credible
evidence

The assessment contains
a highly sophisticated
analysis of how the
burden of heart disease
within a specific
population relates to
social determinants.
The analysis is expertly
explained and well
justified by relevant &
high quality evidence
from credible sources

Proposes a suitable and
appropriate intervention
to address a social
determinant of heart
disease for chosen
population, and identifies
appropriate sectors that
are involved in the
intervention aside from the
health sector (35%)

The assessment does not propose
an intervention to address a social
determinant of heart disease for a
specific population, and does not
identify any sectors that would be
involved in an intervention.

The assessment provides a
basic description of an
intervention to address a
social determinant of heart
disease for a specific
population. Some aspects of
the intervention are unclear.
Other sectors that could be
involved in an intervention
are identified, but how they
would be involved is not
clearly explained.

The assessment provides a
good, clear proposal for an
intervention that addresses
a social determinant of
heart disease for a specific
population. Other sectors
that could be involved in
this intervention are clearly
identified.

The assessment
provides a clear,
through and detailed
proposal for an
intervention n that
addresses a social
determinant of heart
disease for a specific
population. Other
sectors that could be
involved in this
intervention are
identified, and their
role is clearly
explained

The assessment provides
a highly sophisticated and
creative proposal for an
intervention to address a
social determinant of
heart disease for a specific
population. Other sectors
that could be involved are
clearly identified, and
their role in the
intervention is well
justified.

PUBH600_Assessment Brief 1_ 6 Week Delivery

Assessment Fulfills general
academic standards
(10%)including:

Provide an introduction
and conclusion

Complies with academic
standards of writing,
including legibility, spelling,
presentation and grammar

Uses appropriate APA 6 style
for citing and referencing
research

Poorly written with errors in
spelling, grammar.

The assessment has no
introduction or conclusion.

Demonstrates inconsistent use of
good quality, credible and
relevant research sources to
support and develop ideas.

There are mistakes in using the APA
style.

Is written according to
academic genre (e.g. with
introduction, conclusion
or summary) and has
accurate spelling,
grammar, sentence and
paragraph construction.

Demonstrates consistent
use of credible and
relevant research sources
to support and develop
ideas, but these are not
always explicit or well
developed.

There are no mistakes in
using the APA style

Is well‐written and
adheres to the
academic genre (e.g.
with introduction,
conclusion or
summary).

Demonstrates consistent
use of high quality,
credible and relevant
research sources to
support and develop
ideas.

There are no mistakes in
using the APA style

Is very well‐written
and adheres to the
academic genre.

Consistently
demonstrates expert
use of good quality,
credible and relevant
research sources to
support and develop
appropriate arguments
and statements. Shows
evidence of reading
beyond the key reading

There are no mistakes in
using the APA style.

Expertly written and
adheres to the
academic genre.

Demonstrates expert
use of high‐quality,
credible and relevant
research sources to
support and develop
arguments and
position statements.
Shows extensive
evidence of reading
beyond the key
reading

There are no mistakes in
using the APA Style

• Task description: Background

Instructions
Introduction
Assessment 1: PUBH 6000 Report: Social Determinants of Health.

• Section 2: An intervention to address social determinants of Heart disease for [Chosen population]

Assessment Criteria:
Marking Rubric:

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.

References

Australian Institute of Health and Welfare. (2011). Cardiovascular disease: Australian facts

2011. Canberra, ACT:

AIHW.

Australian Institute of Health and Welfare. (2012). Risk factor trends: Age patterns in key

health risks over time. Canberra, ACT: AIHW.

Australian Institute of Health and Welfare. (2014). Cardiovascular disease, diabetes and

chronic kidney disease: Australian facts – Prevalence and incidence. Canberra, ACT:

AIHW.

Australian Institute of Health and Welfare. (2015). What are cardiovascular diseases?

Retrieved 9 February, 2015, from http://www.aihw.gov.au/cardiovascular-health/about/

Amster, L. E., & Krauss, H. (1974). The relationship between life crises and mental

deterioration in old age. International Journal on Aging and Human Development, 5, 51-

57. doi:10.2190/JA32-3VFR-29X4-D3Q7

Australian Bureau of Statistics. (2012). Australian Health Survey: First results, 2011-12.

Canberra, ACT: ABS.

Australian Department of Health. (2015a). Cancer screening. Retrieved 16 February, 2015,

from http://www.cancerscreening.gov.au/

Australian Department of Health. (2015b). Medicare Benefits Schedule: Health Assessments.

Retrieved 16 February, 2015, from

http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A25&qt=noteID&criteria=

701

Australian Department of Social Services. (2014). Immunising your children. Retrieved 16

February, 2015, from http://www.humanservices.gov.au/customer/subjects/immunising-

your-children

Baum, F. (2008). The new public health (3rd ed.). South Melbourne, VIC: Oxford University

Press.

Cancer Council Victoria. (2012). Tobacco in Australia: Facts and issues (4th ed.). Carlton,

VIC: Cancer Council Victoria.

Cimarras-Otal, C., Calderón-Larrañaga, A., Poblador-Plou, B., González-Rubio, F., Gimeno-

Feliu, L., Arjol-Serrano, J., & Prados-Torres, A. (2014). Association between physical

activity, multimorbidity, self-rated health and functional limitation in the Spanish

population. BMC Public Health, 14, 1170. doi:10.1186/1471-2458-14-1170

Havari, E., & Peracchi, F. (2014). Growing up in wartime: Evidence from the era of two

world wars. Italy: Einaudi Institute for Economics and Finance.

Hostinar, C. E., & Gunnar, M. R. (2013). The developmental effects of early life stress: An

overview of current theoretical frameworks. Current Directions in Psychological Science,

22, 400-406. doi:10.1177/0963721413488889

Kannel, W. B. (2002). Coronary heart disease risk factors in the elderly. American Journal of

Geriatric Cardiology, 11, 101-107. doi:10.1111/j.1076-7460.2002.00995.x

Karwalajtys, T., & Kaczorowski, J. (2010). An integrated approach to preventing

cardiovascular disease: Community-based approaches, health system initiatives, and

public health policy. Risk Management and Healthcare Policy, 3, 39-48.

doi:10.2147/RMHP.S7528

Klieman, L., Hyde, S., & Berra, K. (2006). Cardiovascular disease risk reduction in older

adults. Journal of Cardiovascular Nursing, 21(5 Suppl), S27-S39. doi:10.1097/00005082-

200609001-00007

Lang, T., Lepage, B., Schieer, A.-C., Lamy, S., & Kelly-Irving, M. (2000). Social

determinants of cardiovascular diseases. Public Health Review, 33, 601-622.

Lauder, W., Mummery, K., Jones, M., & Caperchione, C. (2006). A comparison of health

behaviours in lonely and non-lonely populations. Psychology, Health & Medicine, 11,

233-245. doi:10.1080/13548500500266607

Lin, V., Smith, J., & Fawkes, S. (2014). Public health practice in Australia: The organised

effort (2nd ed.). NSW: Allen & Unwin.

McEwen, B. S., & Stellar, E. (1993). Stress and the individual: Mechanisms leading to

disease. Archives of Internal Medicine, 153, 2093-2101.

doi:10.1001/archinte.1993.00410180039004

Mendis, S., & Banerjee, A. (2010). Cardiovascular disease: Equity and social determinants.

In E. Blas & A. Sivasankara Kurup (Eds.), Equity, social determinants and public health

programmes (pp. 31-48). Geneva, Switzerland: World Health Organization.

Morgan, T. K., Williamson, M., Pirotta, M., Stewart, K., Myers, S. P., & Barnes, J. (2012). A

national census of medicines use: A 24-hour snapshot of Australians aged 50 years and

older. Medical Journal of Australia, 196, 50-53. doi:10.5694/mja11.10698

National Commission of Audit. (2013). Age Pension. Canberra, ACT: Australian

Government.

O’Loughlin, J., Masson, P., Déry, V., & Fagnan, D. (1999). The role of community

pharmacists in health education and disease prevention: A survey of their interests and

needs in relation to cardiovascular disease. Preventive Medicine, 28, 324-331.

doi:10.1006/pmed.1998.0436

Wilkinson, R., & Marmot, M. (Eds.). (2003). Social determinants of health: The solid facts

(2nd ed.). Denmark: World Health Organization.

Williams, D. R., Costa, M. V., Odunlami, A. O., & Mohammed, S. A. (2008). Moving

upstream: How interventions that address the social determinants of health can improve

health and reduce disparities. Journal of Public Health Management and Practice,

14(Suppl), S8-S17.doi:10.1097/01.PHH.0000338382.36695.42

Introduction

Research shows that coronary heart disease (CHD) is preventable and that the

prevalence of heart disease (including heart attack and angina) in South Australia (SA) is

currently higher than in urban areas (O’Connor and Wellenius, 2012 and Clark, Eckert, et

al 2007). This paper will explain heart health in rural SA and examine patterns within this

population. Furthermore, an explanation of the social determinants of health (SDH) in

relation to rural heart health will be offered.

A public health intervention will be proposed which will utilise the principles of

The Ottawa Charter for Health Promotion (WHO, 1986) to encourage physical activity

(PA) in rural populations. Community members will be invited to attend sporting clubs

using a SDH model (WHO, 2003). The concept of the social gradient of health will be

addressed by encouraging other sectors to become involved with this intervention such as

local government, sporting clubs, fitness groups, local education facilities and volunteers

in service organizations.

Heart health in rural South Australia

According to the World Health Organisation (WHO, 2012) heart attacks are

avoidable. They can be prevented by addressing risk factors such as reducing the use of

tobacco, eating a healthy diet and by increasing physical activity (PA). In South Australia

(SA) research shows that in 2010, 23 % of deaths were as a result of cardiovascular

disease (AIHW, 2015). The Heart Foundation (Heart Foundation, 2014) maintains that,

unless current trends are not addressed, life expectancy is likely to fall in the next

generation. Rural populations are very much at risk of poorer health outcomes as shown

in research by Dixon and Welch (2000). Clark, Eckert et al. (2007) concur with this view

and discuss heart disease and chronic heart failure in rural locations in Australia. Further

to this, The Heart Foundation’s Mary Barry notes that Australians who live outside urban

areas are at “significantly greater risk of the nation’s biggest killer, cardiovascular disease”

(Heart Foundation, 2014, accessed online 14 February 2015).

How does SDH impact on this data?

The social determinants of health (SDH) are extensively described in The Solid

Facts (WHO, 2003), and include ten themes to explain differences in health outcomes: the

social gradient, stress, early life, social exclusion, work, unemployment, social support,

addiction, food and transport. This comprehensive publication encourages all countries to

make structural and policy changes at all levels of government. Moreover, it encourages

accountability by public and private sector agencies to address these determinants to

improve population health. As Rose (in Marmot, 2005) points out, an examination of the

‘causes of the causes’ is required in order to address health inequities.

Dixon and Welch (2000, p. 254) note “the health status of rural people is inferior”.

Their research examines poorer health outcomes using a social determinants of health

(SDH) framework. Burnley (in Dixon and Welch, 2000) states that studies show that the

incidence of health disease is higher for people living in small rural towns and better for

people living in the coastal areas. Additionally the data shows that men in particular had

poorer health outcomes. Dixon and Welch (2000) discuss this occurrence and question if

the poorer outcomes could be as a result of inadequate health services in rural towns.

O’Connor and Wellenius (2012) examined the prevalence of diabetes and coronary health

disease in USA and noted that risk factors such as poverty, obesity and the use of tobacco

products may contribute to the higher prevalence of heart disease in rural communities.

For populations living away from major urban centres, access to health services may be

limited. The cost of travel to major towns to access health services can be prohibitive

resulting people not attending hospitals for support or education regarding their health

problems. In addition, social exclusion has been shown to lead to poorer health outcomes

(WHO, 2003). As noted in The Solid Facts (WHO, 2003), the longer people spend

excluded from their community the greater their risk of developing chronic disease,

“particularly cardiovascular disease” (WHO, The Solid Facts, p.16).

Physical activity in rural areas – a pilot program

The Ottawa Charter for Health Promotion framework (WHO, 1986) will be used to

advocate for free physical activity programs in rural SA. According to WHO (2003)

public health interventions that reduce social exclusion at a community level, as well as at

an individual level, are required in order to reduce inequities and promote better health

outcomes. Increasing daily physical activity has been shown to improve health outcomes

and encourage social connectedness in communities (Brownson, Housemann, et al., 2000).

Jackson, Howes, et al, (2005) agree with this notion and note that not only has physical

activity been shown to have benefits to physical health but can also lead to improvements

in mental health and personal development.

A pilot program is proposed which will encourage people living in rural SA to

attend local sporting clubs on a regular basis that will improve general fitness levels and

encourage social connections.

The ‘come and try’ events will be piloted in a major rural town initially and then

rolled out across South Australia. Funding and support will be sourced from local

governments, local businesses (cycling/sporting shops, local major employers, farming

machinery companies, mining companies) as well as local service organisations (Rotary,

Probus). The location of the events will be the local primary school or the area high

school. The equipment will be either at the school or funded by local service clubs. The

program will initially be simple and will be developed in consultation with community

leaders and local community groups. Suggestions of activities to ‘come and try’ may lead

to sports such as soccer, netball, cricket being offered. However, some non-traditional

activities may be offered such as tai chi, yoga, fencing, etc. An offer of 6 free sessions

may also be of interest and keep people attending for at least six weeks. Family

memberships could be funded to get the whole family involved. Media advertising will

be necessary – with local community radio stations becoming popular there may be an

opportunity to seek free publicity. E-mentoring has been suggested as a method of

supporting public health campaigns (McNab, 2009) and could prove successful in this

instance. People could be mentored and supported online or via social media to encourage

attendance and offer support – this could be facilitated by trained volunteers (thus

developing their skills).

The social gradient of health

According to The Solid Facts (WHO, 2003. p. 10) people who live “further down

the social ladder usually run twice the risk of serious illness and premature death as those

near the top”. Physical activity has been shown to reduce the social gradient in some

instances (Vyncke, De Clercq, et al. 2013). The rural physical activity pilot project will

address the social gradient of health by offering a six week ‘come and try’ sporting

activity to rural populations for free, thus reducing the cost for individuals. Funds to cover

fees and equipment will be sourced from local businesses, local service groups and

through sponsorship. Volunteers (local community members) will be recruited and trained

consequently enhancing skills in the community. In addition, this experience may benefit

those who are unemployed as they will gain valuable skills that could lead to entry into the

paid workforce. In order to attend the sessions, some individuals may require assistance

with transport which is poor in rural areas. Volunteers may be called to assist with

transport, but to address the overall problem of rural transport community members will

be encouraged to advocate for improvements in bus timetabling and better routing

systems. Social exclusion is an important SDH and will be addressed by the rural physical

activity program by encouraging people to be involved in the sporting clubs. By attending

the come and try sessions, it would be hoped that people feel more comfortable joining

social events and thus reduce social exclusion.

Conclusion

The prevalence of heart disease in rural Australia poses a major problem for public

health practitioners. This paper examines how a social determinants of health framework

could be used to address this issue, and the notion of the social gradient of health was

explored. In addition, the principles of The Ottawa Charter for Health Promotion (WHO,

1986) have been considered.

A ‘come and try’ pilot program is proposed which will encourage community

members to attend a free 6-week trial at a local sporting club. Transport will be provided

by volunteers with funding provided by a collaborative group comprising local businesses,

local government and local education authorities. Costs will be kept to a minimum by

having the support of trained volunteers who will run the classes. This will also enhance

the skill set of the volunteers and may lead to employment. Social exclusion will be

addressed by reducing the barriers to becoming involved in the community (reduction of

costs, improved transport). Effective and efficient community engagement will enhance

this proposed pilot program and ensure success for the final roll-out across South

Australia.

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