HSC CORE 1- Health Priorities in Australia Summary

Syllabus terms:

 Self-efficacy: ability to bring about/instigate change

 Autonomy: Being independent about your level of health
 Self-sufficiency: being able to satisfy good health without the assistance of others
 Co-morbidity: Having two or more diseases
 Self-assessed health status: based on an individual’s own thoughts and mentality
 Acute/chronic disease: Short term and long term illnesses
 Social-connectedness: ability to relate and interact with others and the rest of
society. (ATSI improve the inequity of social attributes ... in turn improves their level
of social connectedness and interpersonal skills. )
 Health literacy: ability to comprehend/understand health information and the
requirements to instigate a good level of health.
 Health status: the pattern of health of a population over a period of time.
 Health conducive decisions: good for one’s own level of health
 Exacerbate/accentuate: Worsen/become worse
 Australia is an ‘Affluent’ society: general level of economic security is achieved
by most members of society.
 Social-gradient of health: the higher level of education/income the healthier you
are.
 Social hierarchy: Income decides where you stand in society.
 Degenerative disease: Progressive deterioration over time/ extent worsens over
time without sufficient treatment/alteration of risk behaviours.
 Biomedial risk factors: Genetic predisposition/hereditary factors which cause the
disease/illness development.
 Debilitating : Very serious / severe health issue
 Transgenerational: passed on one generation to the next i.e. diabetes in ATSI
families.
 Allied health professionals: Ancillary based professionals such as
physiotherapists, speech therapists.
 Out of pockets payments: In regards to the GAP between what Medicare covers.
 Partnerships promote ‘social-cohesion’.
 Capacity: The amount a single sector can do which contributes to the common goal
of all the collaborated sectors (improve health outcomes!)
 Dissuade: Discourage someone from doing something
 Lower economic quintiles: is where people from low SES reside i.e. ATSI
 Premature deaths: is the deaths before the ages of 65
 Stoic attitudes: enduring pain and hardship without complaint.
 Cycle of ill-health
Causes of CVD:

 “HERO” Atherosclerosis: – build up of plaque on the inner lining of the arteries.

 Atheroma – thickened areas of fatty deposits inside the arteries.

 inArteriosclerosis-
Good sentences to use extended responses: hardening of the arteries by fatty deposits, causing stiffness and
loss of elasticity.
 Perpetuate the cycle of death/ Perpetuates a poverty cycle
 Their health has been ‘impinged’
 This compounds serious health issues
 Allows individuals to make health conductive decisions
 The correlation between all causal factors of health inequities/determinants of health
Critical Question 1- How are the priority issues for Australia’s health
identified?

Measuring Health Status

 Role of epidemiology
Epidemiology is the study of the causes, determinants/indicators and distribution of disease
within a defined population group at a specific point in time.

It monitors the trends of health in various population groups. Through this, comparisons and
disparities can be identified. The priority groups and conditions which are experiencing
the greatest inequities are placing a massive burden on the Australian health profile, thus
must be further identified with high priority i.e. ATSI priority group and cancer as a NHPA.

 Measures of epidemiology
Morbidity: The total number of incidence/prevalence of a disease/illness within a
population group at a specific period of time.

Mortality: the total standardised death rates for given group and or given disease over a
period of time

Life expectancy: Average number of years someone is expected to live.

Infant mortality: the deaths within the first year of live per 1000 live births.

Two types:

 Neonatal- deaths within the first 28 days

 Post-neonatal- deaths within the remainder of the first year of life

*Hospital admissions and use of health care services- (Additional).

- Measures of morbidity: (i.e. Indicators of disease/illness)

Incidence: Number of new cases of disease/illness occurring over a period of time.

Prevalence: existing cases of disease/illness that exist in a defined population at a specific

point in time,

Apparent causes/indicators: what is causing and or leading to these chronic

illnesses/diseases

 Distribution
Epidemiology : the
fails to extent health
recognize of theindisease
a holistic sense as it fails to show the correlation between all the determinants
of health.
Limitations of epidemiology:
 It does not measure an individual’s quality of life achieved.

 Fails to show the effectiveness of prevention and treatment

 Fails to tell us ‘why’ health issues exist and sometimes does not accurately report on health issues i.e. mental illness.

 Since it is just raw data, it does not provide solutions to reduce health inequities and priority health issues .
Advantages of epidemiology: Who uses epidemiology?

 Identifies the areas of the greatest  Policy makers at all levels of government i.e. WHO, AIHW, ABS
concern which can further be made  Public and private health care sector i.e. Bupa, CBHS health
into priority health issues.  Individuals
 Effectively compares health status  Communities i.e. World No Tobacco Day, Jump Rope For Heart,
across various groups i.e. ATSI and Deadly Sister Fitness and Weight loss
Non-ATSI.  Manufacturers of health products i.e. Nicotine company
 It can be used to empower both  Health researchers
individuals and communities to take
action and not develop priority health
conditions i.e. CVD.
 Current trends in health data (AIHW)

Life expectancy (is increasing)

o The life expectancy at birth for males is 80.3 years compared to 84.4 years for
females
- Men have an unwillingness to seek medical attention through stoic attitudes and are
more likely to be involved in risk taking behaviour.

Infant mortality (is declining)

Due to:

 Baby health clinics and immunisation programs

 Health education and improved support service for parents and newborn babies.

Mortality (is declining)

Leading cause of death per age bracket:

Age <1 Perinatal/cognital

1-14 Injury – Land transport accidents
15-24 Injury-Suicide
25-44 Injury-Suicide
45-64 CVD-Coronary heart disease
65-74 Cancer- Lung cancer
75-84 CVD- Coronary heart disease
85-94 CVD-Coronary heart disease
95+ Circulatory- Coronary heart disease

 Overall major causes of mortality include: Coronary heart disease,

Dementia/Alzheimer’s, cerebrovascular disease, lung cancer, chronic obstructive
pulmonary disease.

Morbidity: (Decreasing for some diseases but also increasing for others)

o Prevalence of diabetes is increasing.

o Increasing incidence/prevalence of arthritis, hypertension and osteoporosis.
o Cancer death rates may be decreasing but there is a rising incidence of new cancer
conditions.
o Kidney disease, obesity and mental health problems are increasing
 - 0-44 years: Mental health conditions, Asthma, Back
problems, CVD, Arthritis
- 45-64 years: CVD, Arthritis, Back problems, Mental
health conditions, Asthma
- 64+: CVD, Arthritis, Back problems, Mental health,
Diabetes
- Overall: CVD, Mental health conditions, Back problems,
Arthritis, Asthma

Reasons for the improvement in some health conditions/diseases

- Deaths are declining due to education and greater awareness of diseases through health promotion
campaigns.
- Road accidents amongst the 15-24 age bracket has also fallen, due to tougher laws on speeding and
the P-plate system.
- Early detection through breast screening and prostate examinations increases an individual’s chance
 Identifying priority health issues
of survival.

5 point criteria (‘Some People Practice Picking Cherries’)

 Social Justice Principles

 Priority Population Groups
 Prevalence of condition
 Potential for prevention and early intervention
 Costs to the individual and community

Social Justice Principles

 The principles of equity, diversity and supportive environments aim to reduce
health inequities existent within the Australian population. This can be achieved
through resource allocation and funding, catering for all Australians regardless of
cultural/social barriers/backgrounds and the promotion of inclusivity by developing
supportive environments through programs and incentives. In turn, the aim is to
increase an individual’s own accountability for their level of health, so they can make
health conducive decisions.

Equity: Providing the fair allocation of funding and resources to all Australians,
regardless of socio-economic/socio-cultural/environmental barriers.

 Two Types:
 Horizontal equity: the distribution of resources/funding to all Australians.
(everyone)
 Vertical equity: the distribution of resources/funding to the groups most at
need. (priority groups)

Equity: Supporting the whole population by directing extra resources to those resonating
from the priority population groups.

Examples:
1) The Close the Gap Campaign is an multi-faceted program initiated by the
Australian Government, that aims to reduce the severe health inequities
present with ATSI people by 2030 i.e. Year 12 educational attainment.
 2) Medicare is Australia’s universal health insurance scheme; it provides access
to basic healthcare for all Australians, regardless of religion, socio-economic
status, location and or cultural background.

Diversity: Since Australia is an extremely multicultural country it has a diverse population

with diverse health needs. All health services/programs must recognise this by being
culturally sensitive and feature strategies to cater services for all- regardless of barriers i.e.

Examples:

1) The Breast Screen NSW incentive offers free mammograms to all Australian’s with a
Medicare card (equity). To cater for all, their service pamphlets are written in over 30
languages and they also have translating services available. (diversity)
2) Rural Women’s GP service – providing culturally sensitive and appropriate services
by women for women.
3) Hospital translators available in a range of languages

Supportive environments: Environments must be inclusive and supportive to all

Australians in the environments where they live, work and play. Through a versatile range of
opportunities and provisional facilities that empower individuals to take control of their level
of health. Furthermore, access and people’s rights must be recognised.

Examples:

1) Community based fundraisers such as World No Tobacco Day

2) Implementation of ramps and lifts for wheelchair accessibility

2) ATSI Campaign- Quit Smoking ‘break the chain’ “if I can do it, I reckon we all can”.

3) NSW legislation National Tobacco Strategy - No smoking in Public Areas

4) Royal Flying Doctors Service providing primary medical services in R&R areas where
there is limited access to services and facilities.
5) Speeding cameras, school zones, zebra crossings, and rest stops/shoulders near
freeways as incentives for drivers to reduce their speed/revive before driving again.
Stop, revive, and survive- rest stops/shoulders reducing driver fatigue and the
chances of being involved in driving accidents.

Priority Population Groups

When identifying priority health issues, the diseases/illnesses which are of the greatest
burden to the Australian health status are more so detrimental to certain sub-groups that
do not have equal access to merely enough resources/facilities as normal Australians.

The 6 groups that suffer the greatest burden include:

 Aboriginal Torres Strait Islander’s (ATSI)

 Socio-economically disadvantaged
 Rural and Remote communities (R&R)
 People born overseas
 The disabled
 The elderly
Through the correlation between all the determinants of health (socio-cultural, socio-
economic, environmental and individual determinants) these sub-groups suffer severely
adverse health outcomes, thus have been regarded as priority population groups.

Prevalence of condition
The conditions/illnesses that are most common and have a high rate of diagnosis and
prevalence within Australia place a great burden to the Australian health status. For
example, CVD is the leading cause of death within Australia with over 45,000 individuals
dying from this condition annually. Thus, must be regarded with high priority.

 Another condition is injury including self-harm (suicide) which is the leading

cause of mortality for young Australians from the ages of 15-24.

Potential for prevention and early intervention

When identifying the heath priority issues the policy makers/government must consider if
funding/resource allocation will be effective or not. Since, most NHPAS’s are highly
preventable for example CVD which is a lifestyle disease, they have a high potential to
reduce in effect on the Australian health status. Through, various preventative measures
such as breast screening (cancer), adopting a holistic lifestyle i.e. changing diet (CVD)
the priority health issues can be prevented and in turn, reduce in terms of incidence
rates.

Costs to the individual and community

A range of costs are associated with being diagnosed with a chronic illness, this can
have a drastic effect on many stakeholders. The conditions/diseases that hold great
costs must be prioritised.

Individual costs:

Direct costs

-Financial costs- the condition/illness can be costly in terms of GP consultations,

medication/treatment, ancillary services such as X-rays/radiology, surgeries, travel fees.

- Physical costs- Loss of mobility/normal bodily functioning

Indirect costs

- Social costs- a range of illnesses/conditions have an adverse effect on relationships

with both family and friends. I.e. a wife has to drive a husband to work as a result of a
heart condition.
 -Emotional costs – may include the physical pain associated with the condition and or
illness, loss of quality of life.

Community

Direct costs

 Expensive to treat all patients with this disease

 A range of medical facilities/services are required to be widespread all over the
country.

Indirect costs

 Absenteeism, loss of potential earnings, retraining in the workplace

 Premature loss of contributing as valuable members of society

Critical Question 2- What are the priority issues for improving

Australia’s health?
 Groups experiencing health inequities

Inequities: A lack of fairness and equality in regards to the opportunities and

biomedical factors that contribute to instigating a good health status. There is currently
an unfair distribution and allocation of resources, in accordance with people’s needs and
requirements. For example, people in R/R have a limited access to preventative and
curative health services such as GP clinics therefore suffer poor health outcomes, whilst
people in metropolitan areas have a range of services and facilities available to them,
therefore have better health outcomes.

Aboriginal and Torres Strait Islander’s (ATSI)

-Nature and extent of health inequities:

o ATSI individuals suffer a life expectancy that is approximately 10 years less than
non-ATSI individuals.
o High levels of CVD, diabetes, cancer and obesity
o High infant mortality rates due to low sanitation/immunisation programs, health
literacy and knowledge.
o High morbidity rates in terms of mental illnesses, diabetes, kidney disease,
respiratory disease, circulatory disease and communicable diseases.

o Socio-cultural determinants (family, peers, media, religion, culture )

 ATSI mothers suffer a low level of health literacy, therefore involve themselves in
a range of risk factors such as consumption of alcohol, tobacco smoking. As a
result, underdeveloped young’s health is already impinged. They may develop
 Fetal alcohol syndrome and or suffer withdrawal symptoms later on in life and or
have abnormalities.
 ATSI individuals believe in traditional approaches to healthcare, thus may not
access mainstream services.
 ATSI people live in tribal humpies/small houses with many family members, this
may further exacerbate a range of health issues such as infectious diseases i.e.
tuberculosis, Otis media (middle ear infection).
 Family and friends may influence involvement in risk behaviours such as tobacco
smoking, consumption of a high fat diet, illicit drug use.
 Media places a range of generalisations and stereotypes on ATSI individuals
such as they are “doll bludgers, criminals” etc, therefore ATSI people may feel a
sense of social-exclusion and disempowerment, leading to severe health
deficits i.e. suicide.
 Colonisation from the arrival of the early Europeans/first fleet  dispossession
and assimilation which further made them consume white foods i.e. bread,
mutton and jam. As a result, they now have a transgenerational susceptibility to
diabetes.

o Socio-economic determinants (education, employment, income)

 ATSI individuals suffer low educational attainment rates- only 46% complete year
12 or obtain an equivalent certificate.
 Due to limited education levels ATSI individuals have a low level of health
literacy and low qualifications. This leads to the involvement in a range of risk
behaviours without knowing the harmful consequences it places on their health
i.e. tobacco smoking, illicit drug use.
 Low qualifications leads to limited employment prospects and opportunities,
therefore ATSI individuals have to satisfy work in high risk labour jobs such as
coal mining, where there is a constant exposure to the carcinogen asbestos.
Also, heavy machinery can also cause health risks.
 Low levels of income, deems an individual unable to purchase resources to attain
a healthy lifestyle such as fruit and vegetables. Since fruit and veg is expensive
an ATSI person will have to rely on cheaper fatty foods such as junk food,
canned foods.

o Environmental determinants (access to facilities/services and geographical location )

 ATSI individuals mostly reside in the lowest economic quintiles, as they mostly live
in R/R areas/low SES areas.
 Due to their location away from the metropolitan areas they suffer a limited access to
preventative and curative health services such as GP clinics, breast screen
mammograms, pap smears, and MRI machines.
 Unsanitised drinking water and garbage disposal/recycling may not be available,
compounding serious health issues.
 Limited availability of fresh food and vegetables. Therefore, having to consume fatty
foods/canned items.
  Limited infrastructure / built roads, therefore making it hard to access hospitals and
schools in the city areas.
 Many ATSI individuals live in overcrowded dwellings/humpies where there is a lack of
sanitation and garbage disposal systems.
- This leads to poor hygiene and increased risk of communicable diseases i.e. Otis
media, cholera and tuberculosis.

Role of individuals Role of communities Role of governments

Individuals have the responsibility to Empower others and Government has a role to create effective
participate and access all health create a range of health policies and provide funding for a
programs made available to them. They support range of health care facilities such as state
also have the role to disseminate this services/programs hospitals. They also have a role in
information to others and advocate for available to all reducing inequities by implementing
health needs in behalf of the wider community members. universal health care schemes such as the
community. This enables Medicare/PBS.
community members to
instigate good health Additionally, they have a role in
practices. initiating/funding multi-faceted health
promotion campaigns such as the Two
i.e. Deadly sister fitness Ways Together Program.
program

- All sectors must work in an intersectoral approach where everyone has equal
accountability and responsibility to improve health outcomes.

Rural and Remote communities (R/R)

o Nature and extent of health inequities:

 -Health worstens as an individual moves away from the city/metropolitan

areas.
 Poor access to services and facilities
 High prevalence and incidence of CVD, cancer and mental illnesses.
- High injury rates i.e. self-harm such as suicide and occupational hazards.

o Socio-cultural determinants (family, peers, media, religion, culture )

 Stoical attitudes such as “It will be alright” leads an individual not accessing
GP services and thus suffer severe health issues due to accessing medical
attention when it is too late.
 Involvement in a range of risk behaviours due to peer pressure
 A lack of support networks due to geographical location may lead to mental
illnesses and self-harm i.e. suicide.
  People residing in R/R areas are often forgotten in terms of media coverage,
therefore may feel left out  leading to disempowerment.
 Family may be poorly educated thus involve themselves in risk behaviours,
these behaviours will be further passed down to the next generation.

o Socio-economic determinants (education, employment, income)

 A lack of access to schools/universities may lead to individuals having low education

 Limited employment choices and opportunities leading an individual having to
pursue in the only available jobs such as farming, trade labour. These jobs impose
great health risks i.e. heavy machinery and exposure to carcinogens.
 Due to low employment opportunities and education levels, an individual will have
low income levels. As a result, they may not be able to purchase fresh food and
vegetables and may have to resort to cheaper fatty foods.

o Environmental determinants (access to services/facilities and geographical location)

 Limited access to health services and facilities such as GP clinics, hospitals.

 Reduced access to schools/universities/colleges and fresh food
supermarkets/shopping centres.
 Low infrastructure/ connecting roads to the city areas, thus limiting access to
services and facilities.
 Natural disasters such as flooding can cause an issue and destroy any fresh
food/veg crops.
 Due to residing away from city areas an individual may feel isolated and thus
can result in mental illnesses such as depression or self-harm such as
suicide.

Role of individuals Role of communities Role of governments

Individuals have the responsibility to Empower others and Government has a role to create effective
participate and access all health programs create a range of support health policies and provide funding for a
made available to them. They also have the services/programs range of health care facilities such as state
role to disseminate this information to others available to all community hospitals. They also have a role in reducing
and advocate for health needs in behalf of members. This enables inequities by implementing universal health
the wider community. community members to care schemes such as the Medicare/PBS.
instigate good health
practices. Additionally have a role in initiating/funding
i.e. Rural Women’s GP service multi-faceted health promotion campaigns
i.e. R/R Beyond blue such as The Royal Flying Doctor service.
men’s shed.
 - All sectors must work in an intersectoral approach where everyone has equal
accountability and responsibility to improve health outcomes.

Group 3: Socio-economically disadvantaged

General notes:

 Social gradient of health (the lower level of education/income the less healthier
you are).

The nature and extent

 High morbidity rates i.e. diabetes, asthma, coronary heart disease, lung cancer,
and stroke.

Incentives/programs reducing the inequities:

- Medicare/PBS
- Father Chris Riley’s Youth off the streets

 High disease
1) Cardiovascular levels of preventable chronic disease, injury and mental
health problems.
Nature of the problem

- CVD is a class of several diseases affecting the heart and associated blood vessels i.e. veins, arteries and
capillaries.
 Types of CVD: Coronary heart disease, Cerebrovascular disease (stroke), Peripheral vascular disease
(blood supply to the extremities is lost).
- Common symptoms of CVD: stroke, myocardial infarctions/coronary occlusion/thrombosis, angina.
 Causes:
- Atherosclerosis is the underlying cause of CVD build up of fatty deposits on the inner lining of the
arteries. (Reduces the supply of oxygenated blood).
- Atheroma is the thickened areas of fatty deposits within the arteries.
- Arteriosclerosis is the hardening of the arteries  leading to loss of elasticity and artery function.

Extent of the problem (trends)

- Highest burden of disease in Australia  it is the leading cause of death for many groups.
- Over 1 million Australians were affected by CVD in 2011-2012
- It was the leading cause of death in 2012  affecting 1/3 Australians.
Risk factors and protective factors
Risk factors:
- Non-modifiable: Family history of CVD, gender (higher in males), the risk of CVD increases with age.
- Modifiable: Physical inactivity, tobacco smoking, hypertension, obesity/overweight conditions.
Protective factors:
- Regular physical activity, smoking cessation, reduced blood pressure levels, maintaining a healthy weight
range and consumption of a balanced diet i.e. fresh fruit and vegetables.
Groups at risk:
- People who smoke/consume a high fat diet, People over the age of 65, People with high blood pressure
- Priority groups: ATSI, Socio-economically disadvantaged and Rural/Remote.

Determinants of health:
Socio-cultural:
- A family who has low levels of health knowledge/who has a CVD is likely to pass it on to the next generation.
- People with a family history of CVD are at greater risk.
- Growing up in a family that binge eats, has a lack of physical inactivity and smokes  likely to impart these poor health
behaviors to their young who will them develop CVD.
Socio-economic:
- Unable to participate in organised sport due to low income levels
- A low level of health literacy and knowledge leads to a likelihood of developing CVD.
- Office jobs/ ongoing sedentary behaviour increases CVD susceptibility. (Higher rates of CVD in white collar jobs)
- Low levels of income  inability to consume fresh foods and join gyms/sports clubs.
Environmental
- Lack of access to preventative and curative health services such as GP’s, doctors, clinics
- Lack of access to sporting/recreational facilities such as local parks, gyms i.e. people in R/R areas and or socio-
economically disadvantaged areas of Australia.

2) Cancer (skin, breast and lung)

Nature of the problem

 Cancer is an uncontrollable growth of the body’s cells that may spread to other parts of the body. It involves
a mutation and is caused by a carcinogen.
 The process of cancer involves the mutated body cells dividing and multiplying uncontrollably, transferring
its genetic material to nearby cells.
 A tumour develops (group of abnormal cells) and continues to affect cells  causing neoplasm’s (abnormal
mass of cells).
 Metastasis refers to secondary/new tumours  it involves the spreading of cancers to other parts of the
body. The tumour can either be spread locally by moving into nearby tissue and or regionally, where it
travels through lymph nodes, tissues, organs and it further spreads to different parts of the body. (Skin
cancer).
 Cancers are classified based on the body part in which they began:
 Carcinoma: is the cancer of general body cells i.e. mouth/throat.
 Sarcoma: is the cancer of bones/muscles/cartilages.
 Leukaemia: is the cancer of blood/bone marrow.

Extent of the problem (trends)

 2nd largest cause of death in Australia and largest disease burden in Australia.
 There is a high incidence for people aged 65-74 (this is expected to increase). It is also the leading cause
of death for people aged 65-74.
 It accounted for 30% of all Australian deaths in 2010
 Mortality rate is decreasing  due to more people accessing preventative/curative health services such as
mammograms and increased knowledge/skills i.e. smoking cessation, being sun smart, being self-sufficient
through regular mole checks/noticing any deformities.
 Incidence increasing of new cancer conditions.

Determinants of health
Socio-cultural
Non-modifiable:
- Family: through second hand smoke within the family household an individual has a high risk of
developing lung cancer.
- Blue eyes/fair skin/red hair
- Family history of breast cancer
Peers: peer pressure  to look cool and ‘fit in’ individuals may smoke/tan i.e. (ladies/bronze complexion)
- Media: advertisements and media campaigns that raise awareness and promote protective behaviours in
order to lower the chances of developing cancer.
I.e. Quitline campaign and ‘tanning is skin cells in trauma’
Socio-economic
- Low levels of health literacy and understanding of how cancer develops can constitute to the development
of skin, breast and lung cancer.
- Low income levels unable to afford sunscreen and other protective measures to avoid diagnosis to
cancer/s.
- Unsatisfactory occupations that lead to exposure of chemicals, pollution, and radiation can be carcinogens
in the development of lung cancer/skin cancer.
 Environmental determinants

 Lack of access to media campaigns/anti-smoking TV advertisements and preventative health services such
as free mammograms, can further lead to susceptibility.
 Limited curative health services such as hospitals and primary GP’s, can exacerbate the issues even further
(once treatment is received it may be too late).

Groups at risk
 Lung: tobacco smokers, blue collar workers, men and women over the age of 50
 Breast: women who have never given birth, obese women, women over the age of 50, women with early
menstruation and late menopause.
 Skin: people with blue eyes/fair skin, people who spend too much time in the sun without protection.

Injury

The nature of the problem:

 An injury is an adverse affect on the body resulting from an event. For example, falls, transport accidents, drowning and
self-harm such as suicide.
 Injury has a high contribution to mortality and morbidity within Australia.
 The consequences can be both short term such as loss of physical function and long term such as permanent disability or death.

The extent of the problem (trends):

 Injuries are the highest cause of death for those under the age of 35 such as self-harm and road traffic
accidents. Also, the main cause of premature death (deaths under 65 years of age).
 The rates for external injuries such as suicide, transport accidents and drowning are slowly declining.
 Due to the growing and ageing population the hospitalisation from falls is increasing (40% of all injuries is falls).

Risk factors and protective factors for injury:

Falls

 Risk factors include: being elderly, working in high risk jobs such as trade labour. Some falls can be prevented
through harnesses and WHS safety regulations.
Socio-cultural, Socio-economic and Environmental determinants
Transport
 Risk factors include: speeding, drink driving, not wearing seatbelts and driver fatigue. Protective measures
Socio-cultural:
include
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is very andamongst
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Self-harm
 ‘It won’t happen to me’ attitudes amongst the youth.
 Risk factors
Healthinclude:
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as ‘Don’tdrug
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 Socio-economic:
 People from Low SES are likely to be unaware of the consequences of speeding/drink driving and
may have a low understanding of car safety ratings.
 Blue collar workers such as builders/construction site workers are at great risk of injury.
 Environmental:
 Those from R&R areas may have limited understanding about the consequences.
  People from R&R areas are more at risk of suicide due to limited access to support
networks

Groups at risk

- The elderly, children, youth and the R&R priority group

 A Growing and Ageing population

 One of the biggest health issues facing our economy  it places immense
pressure and burden on many stakeholders.
 The GAAP is due to a declining mortality rate and an increased life expectancy.
 13% of Australia’s population is over 65 years of age.
 90% of the population is 70 years or older, this is expected to increase by 13
percent by 2021 and to 20 per cent in 2051.

Healthy ageing

 Healthy ageing refers to the behaviours (protective behaviours) and activities that
prevent the development of a disease/illness. It is concerned with the quality of life
not just the years lived by the individual. It is achieved through the maintenance of a
holistic lifestyle regardless of the ageing process.

Benefits:

 It allows elderly people to contribute to the workforce longer  leading to greater

economic growth and development.
 Individuals who employ healthy ageing can give back to society/retain their skills and
expertise i.e. carer or volunteer.
 Improves an individual’s quality of life and DALY rates which are used to measure
disease burden.
 Allows individuals to be autonomous and self-sufficient in instigating their own good
health status.
 Healthy ageing can improve an individual’s life expectancy by up to two decades.

Increased population living with chronic disease and disability

 The incidence/prevalence of chronic disease/disability i.e. stroke, CVD, dementia,

Alzheimer’s increases with age.
 More people are living with highly preventable chronic diseases such as CVD and
Cancer due to a better access to curative and preventative health care
services/facilities i.e. primary GP’s.
 There is more health literacy and awareness and thus, more people are aware of the
modifiable risk factors causing disease and illness.

Impacts:
  The rise in chronic disease and disability is pushing a greater demand and
requirement for health services and workers in public hospitals, medical clinics,
retirement care and palliative care units.  Health care workers will have to provide
care for a greater amount of people which will further reduce the quality and quantity
of time that each patient receives from a health care professional.

Demand for health services and workforce shortages

 There is a limited amount of medical practitioners i.e. GP’s and increasing hospital
admissions from the GAAP.
 The Government have increased residential facilities/ training for aged care workers
and funding for dementia care in aged care.
 The Aged Care Education and Training Incentive has been successful in
attracting more people to aged services  reducing workforce shortages.

Availability of carers and volunteers

 As carers/volunteers are ageing with the rest of the population  there is a low
availability.
 Allows individuals to retain their skills/expertise and make a meaningful contribution
to society.
 They also allow elderly Australians to remain in their own homes  reducing the
burden on aged care services.
 Due to the limited availability of volunteer organisations the federal government have
implemented a range of Home and Community Care Reform Packages such as the
Living Longer, Living Better package which features means tested pension and
volunteer/support services provided to those who need it most.

Students learn to: Assess the impacts of a GAAP:

Health system and Health service workforce Carers of the elderly Volunteer organisations
services
Health care workers will Utilising their
The great demand will have to provide for a skills/expertise to assist The baby boomer
result in services becoming greater amount of people elderly individuals i.e. generation is ageing with
more expensive and based  reducing the retired dieticians can more skill and
on socio-economic status quality/quantity of time provide advice to elderly technological ‘know how’
rather than the priority of each patient receives. whilst in the caring role. than previous generations
care needed.  the baby boomer
Increased hours that health generation may remain in
Strong bonds can form
Increased treatment costs professionals may work  administrative employment
between the volunteer and
due to chronic disease and reducing job satisfaction. much longer reducing the
the old aged individual,
disability  increasing amount of volunteers.
positively impacting social
health expenditure for the As the retirement age has health.
GAAP. increased health workers
now have to work even
Increased waiting times, longer.
demand for hospital beds
and nursing homes.
 Critical Question 3- What role do health facilities and services play in
achieving better health for all Australians?
 Health care in Australia
 Range and types of health care facilities and services:
 Diverse range of health care facilities and services which focus on prevention, treatment, diagnosis,
rehabilitation,early intervention, health promotion and primary care for patients.


Rehabilitation Health-related services

institutions Non-institutional
Institutional
 Ancillary i.e. speech
therapy/physiotherapy.
Medical services i.e. GP’s

Public and private hospitals Nursing homes Community supports (creating health conducive environments).

Pharmaceuticals  Food service industry, food safety standards, gym equipment

i.e. PBS in parks/sports fields.

Public hospitals: Private hospitals:

 Operated by state and federal governments 

Owned and operated by individuals and
community groups.
 Provide specialised and complex surgeries i.e. lung
 Provide same day surgery and more short-
transplants
stay surgeries.
 Same day surgery and take most non-admitted patients.
 Provide elective surgeries.
  Available to all Australians,
Responsibility for healthlong
carewaiting times,
facilities andfree bed and
services :  Undergo less complex procedures.
no choice of doctor.
Commonwealth government  Patients pay for the service  including
benefits like choice of doctor.
 Providing funding to the state and territorial governments for the running of health facilities and services i.e.
public hospitals and community funding grants.
 Run universal health care schemes such as Medicare/PBS which aim to promote equity.

 Create national health legislation and policies such as drink driving laws to promote good health outcomes.

State and territory governments

 Oversees the provision of public hospitals and other health services i.e. GP’s, dentists, optometry, mental
health, aged care, family health centres.
 Funds community health services and public hospitals.
 Develop health incentives/programs i.e. preventative health care programs  vaccinations in schools.
 Health promotion

Local governments
 Implementing sanitation and garbage disposal systems
 Creating health promoting environments free gym equipment in parks/sports fields.
 Running services such as Meals on Wheels  allowing elderly individuals to remain in their own homes.

Private sector
 Privately owned and operated services i.e. private hospitals, dental, physiotherapy and chiropractic
services.
 Some received funding from both the Commonwealth and state/territory governments
Community groups
 Organisations that target specific health priority issues i.e. Cancer Council, Heart Foundation.
  Equity of access to health facilities and services
- The Australian health care system aims to provide a broad range of services to all Australians that is readily
available however inequities arise due to certain issues.

 Socio-economic status: Affluent individuals achieve good health status however people with low SES
such as ATSI and the socioeconomically disadvantaged cannot access services due to low health literacy
and low income levels.

Strategy: Medicare is available  however due to low levels of health literacy/knowledge they are unaware that
this service exists  therefore the disparity remains based on SES.

 Geographical location: Many services and facilities are available for those residing from the city
counterparts. However, there is a limited adequacy and access for those from Rural and Remote areas.
- Basic medical checkups/GP consultations are not available  health issues worsen. I.e. Benign tumours
turn malignant.

Strategy: Royal Flying Doctor Service  Allows R/R based communities to access a wide range of health
facilities and services i.e. first aid courses, health field days, GP checkups  allowing R/R people to achieve good
health.

 Waiting lists and times: Individuals with higher SES have private health insurance have reduced waiting
times for GP checkups and surgeries. Those with low SES have to rely on public health insurance schemes
such as Medicare.
- Extreme shortages of health service workers in public hospitals leads people on Medicare to experience
long waiting period’s as medical attention is given based on the severity of a injury/illness conditions may
worsen overtime i.e. Arteriotherosis to Atherosclerosis.
- Priority is also given to those with private health insurance.

Strategy: Living Better, Living Longer training reform program  aiming to attract more health professionals
as there is not enough workers to meet the growing demand of patients (mostly the aged).

- An individual’s health insurance decides the amount of time it takes to see medical practitioners 
unequitable for those of priority population groups.

 Cultural backgrounds/languages  diversity can be achieved through translator services and brochures
in many different languages.

How much responsibility should the community assume for individual health problems?

- Health is not solely an individual’s responsibility therefore equal accountability must be provided by all
sectors i.e. individual, communities and governments (intersectoral approach).

 Health care expenditure VS expenditure on early intervention and prevention

- Expenditure refers to the allocation of funding for the provision of a range of health services i.e. medical
services and pharmaceuticals.
- Currently, a majority of health spending is on curative services i.e. public hospitals/surgeries.
- ‘Prevention is better than cure’  however less than 2% on expenditure is on prevention/health promotion.
- Preventative measures include health education programs/campaigns  K-10 PDHPE curriculum,
community programs i.e. World No Tobacco Day and legislation/taxation i.e. No Smoking in public areas.

Benefits of health spending on prevention:

- Reduces morbidity and mortality rates

- Increases life expectancy and longevity
- Enhances an individual’s quality of life
- Reduced burden on health system/services/workforce
- Prevention is also cost effective/allows for substantial savings to made
- Preventative services empower individuals to exert greater control over their own health/make good health
choices.
- Inexpensive preventative services allow for equity of access ATSI and R&R can access.
Limitations of expenditure on early intervention and prevention:

- It takes many years for prevention measures to reduce incidence/prevalence of life styled related conditions.
- It is difficult to take funding away from curative services as they are already stretched to the limit i.e. hospital
usage by the elderly.

 Impact of emerging new treatments and technologies on health care

 Key hole surgery: involves a small incision for surgery  laparoscope/endoscope is used for viewing inside
the body.
- This method is non-invasive allowing for a faster recovery through the small incisions.
- There is also less pain, quicker surgical procedures and shorter hospital stays (same day surgery and return
home).

Limitations: it is a very expensive procedure (not provided by Medicare), does not provide equity and access for ATSI
and R/R (only available in city counterparts).

 MRI scans: medical imaging procedure using magnetic field/radio waved to take images of the body’s
interior.
- It is a non-invasive procedure that is useful in providing information and allows for early detection for a range
of health issues/problems  improving individual health outcomes.

Limitations: it is a very expensive procedure (not provided by Medicare), does not provide equity and access for ATSI
and R/R (only available in city counterparts).

 Health insurance: Medicare and Private

 Medicare is Australia’s tax funded universal health care scheme providing basic medical services to all
Australians regardless of age, gender, culture and socioeconomic status.
- It is funded through taxation  1.5% on taxable income and 2.5% on individuals with higher income and who
have not opted for private health insurance.
- There is a Medicare levy surcharge for individuals/families that meet certain income thresholds but have not
opted for private health insurance.

Advantages: Disadvantages:

- Free treatment as a public patient in a public - No choice of doctor in hospitals

hospital. - Usually no access to ancillary services i.e.
- Free or subsided treatment for a range of Chiropractic, Osteopathy.
services through bulk billing/subsidised costs - Increased waiting times in hospitals/medical
i.e. GPs clinics
- Access to the Medicare Safety Net and - ‘Gap’ payments may need to be paid due to
Pharmaceutical Benefits Scheme (PBS). the 85% scheduled fees.
- Access to the Medicare Safety Net

 Private health insurance

- Individuals have access to private hospitals and ancillary benefits.
- The Lifetime health care incentive in 2000  provides lower lifetime premiums for people who join private
health insurance earlier in life and maintain it, compared to those who join after the age of 30.
- There is an increasing amount of Australians covered by private health insurance since 2009.

Advantages Disadvantages

- Shorter waiting times for treatment/medical - Premiums need to be paid

services in public hospitals. - Already paying for Medicare
- Choice of doctor in hospitals - Private health insurance is highly expensive
- Ancillary benefits i.e. dental, physiotherapy. - Issues of equity and access
- Peace of mind
  Complementary and Alternative health care approaches

 Reasons for growth of complementary and alternative health products and services

CAM services have risen in popularity within Australia due to:

- A global recognition by the WHO deeming CAM services as beneficial to one’s health.
- Greater acceptance of cultures and religions within Australia due to the growing rate of migration and
globalisation.
- These services promote the holistic health care approach
- Providing a range of services when mainstream medicine may be ineffective
- There are now formal qualifications in the fields of complementary and alternative health care approaches
which have enhanced the credibility of these fields such as university degrees.
- Persuasive marketing campaigns have promoted the feel good elements i.e. using natural and organic products
to connect the mind, body and spirit.

 Range of products and services available

Iridology: The patterns and Acupuncture: Inserting fine

colours of the iris can be needles into specific points of
examined to determine the skin. This restores balance
information about someone’s and promotes the body to heal Chiropractic: The manipulation
health. itself. of the spine and joint adjustment
 The iris is divided into to treat disorders in the
zones which correlate to Neuromusculoskeletal system
different parts of the
body.

 How to make informed consumer choices

A consumer must consider:

- The purpose which is what they want to achieve from a product or service
- Research the nature and type of product/service check for qualifications/credentials of the practitioners,
research the service and its effectiveness.
- Consider questions such as: What are the benefits? Is this safe? Are there any side effects or risks I should
know about?
- The qualifications and credentials must be checked by a regulatory authority. Ask questions such as:

Where did you get your training? How long have you been practising? How long was your training course?

- Gather other opinions from your GP, friends/family, and internet reviews/ratings.
- *Is the service reputable?
- Talk to the service provider!
- Evaluate by weighting the benefits/limitations and contact your medical practitioner before engaging in any
complementary or alternative health care approach.
- After these considerations the consumer is in the best position to make a health conducive decision.
 Critical Question 4- What actions are needed to address Australia’s health
priorities?
 Health promotion based on the 5 actions areas of the Ottawa Charter

Developing personal skills Creating supportive environments

Focuses on enhancing an Focuses on the provision/creation of health

individual’s knowledge and skills promoting environments where individuals live, work
and increasing ones control over and play.
The Ottawa Charter
their own health.
i.e. No smoking in public areas such as sports fields,
i.e. K-10 PDHPE curriculum in pubs/clubs.
schools, cooking classes for CVD
prevention.

 Improving an individual’s health

literacy. - . Building health public policy
Reorientating health services
Involves fiscal measures, policy development,
Focuses on the new public legislations, taxation and organisational change to
Strengthening Community Action
health approach shifting the promote good health outcomes.
Involves community emphasis of health from
input/deliberation targeted for the curative to preventative health I.e. K-10 PDHPE curriculum, No smoking in public
care services. areas, plain packaging for cigarettes  over the
needs of specific communities.
counter and increased prices for cigarettes 
I.e. World No Tobacco Day, Pink  Valuing health dissuading an individual from smoking.
Ribbon Day fundraisers holistically
for Breast for health
 Levels of responsibility promotion
cancer.
- An intersectoral approach  each sector has equal accountability to ensure health promotion success.
 Commonwealth government
- Provides funding for a range of government interventions i.e. Royal Flying Doctors Service
- Funds health promotion campaigns i.e. Go for 2 and 5.
- Creates national health policies/legislation i.e. Mandatory K-10 PDHPE curriculum
- Uses taxation to fund national health schemes i.e. Medicare and PBS.
 State government
- Manages the running of a range of services i.e. hospitals and education in schools
- Implementing legislations/regulations i.e. pool fencing, immunisation programs
 Local government
- Hygiene practises/garbage disposal/sanitation
- Maintenance of parks/sporting fields
- Managing community services i.e. Meals on Wheels
 NGO’s
- Setting up health campaigns i.e. National Heart Foundation- Heart week
- Undergoing research into many priority health issues i.e. cure for cancer
 Individuals
- Participating in all health promotion programs available to them/becoming autonomous in order to instigate
good health status. Also, employing in protective behaviours and reducing risk behaviours.
 Private sector
- Production of healthy foods, UV clothing
 Communities
- Creating health promoting environments  i.e. World No Tobacco Day, fun runs
 The benefits of partnership in health promotion
- A multifaceted intersectoral approach allows for social cohesion.
 When one single sector does not have the capacity to take action in certain ways they are able to be
backed and supported by other sectors that have the capacity. I.e. Governments can provide funding
to local communities for programs/fun runs.
 Allows for a pooling of resources to be shared i.e. expertise and funding.
 Empower individuals/communities to participate in health promotion incentives
 The inclusion of individuals/communities in health promotion initiatives ensures their diverse health
care needs are met/allows for cultural appropriateness.
 The prospect of success is also increased as more people are working towards a common goal.
 There is a greater potential to solve complex health issues that individual health sectors cannot
achieved by themselves.
 How health promotion based on the Ottawa charter promotes social justice
 Developing personal skills: focuses on enhancing an individual’s health literacy/knowledge and skills.
- Equity: K-10 PDHPE curriculum, Diversity: Breast cancer pamphlets in a range of languages, Supportive
environments: Quitline/smoking infographics.
 Creating supportive environments: focuses on creating health promoting environments where individuals
live, work and play.
- Equity: Royal Flying Doctors Service – health field days for ATSI/R&R, Diversity: translator services in
hospitals, Supportive environments: smoke free environments and gym equipment/bike tracks in parks.
 Building health public policy: involves legislation, policy development, organisational change and fiscal
measures.
- Equity: Close the Gap campaign, Medicare (available to all Australians), Diversity: Abstudy supporting
ATSI whilst they study, Supportive environments: No hat No play/ Road safety education.
 Reorientating health services: reflects the new public health approach shifting the emphasis from curative
to preventative health. (Breast screen example)
- Equity: free mammograms available to all women over the age of 40, Supportive environments: Breast
screen vans travelling to a range of communities, Diversity: Breast screen pamphlets are available in a
range of languages.
 Strengthening community action: involves community voice and deliberation/planning for health promotion
initiatives.
- Equity: lobbying councils to make changes i.e. lighting, bike tracks, Supportive environments: Gym
equipments/bike tracks/garbage collection, Diversity: ATSI peak body members advocate/raise a range
of ATSI health inequities.

 Ottawa charter in action

1) National Tobacco Strategy 2009: aims to reduce the high incidence/prevalence rates of lung cancer
within Australia.
 Developing personal skills: K-10 PDHPE curriculum  raising awareness and increasing knowledge of the
harmful effects tobacco smoking can cause i.e. lung cancer, Quitline.
- Also, ensuring the unglamorous effects of tobacco smoking are highlighted.
 Creating supportive environments: No smoking in public areas and parks  reducing the incidence of second
hand smoking and children do not pick up bad behaviours. Frightening messages and media campaigns
through a lifestyle behavioural approach  “every cigarette is doing you damage”.
 Strengthening community action: World No Tobacco Day, Cancer council fun runs.
 Reorientating health services: the Royal Australian College of General Practitioners and ‘Lifescripts’
becoming more assertive/assisting tobacco smokers to quit  referring them to nicotine patches/Quitline
programs.
- GP’s are now more intimate and will initiate conversations to promote smoking cessation.
 Building healthy public policy: increased cigarette prices and cigarette plain packaging/over the counter 
extra burden as smokers have to ask for cigarettes (dissuading them from purchasing).
 2) Breast Screen Australia: is a free screening program that aims to achieve early detection of breast
cancer.
 Developing personal skills: K-10 PDHPE curriculum  teaching risk factors/protective factors for breast
cancer i.e. self-sufficiency through checking oneself for moles/deformities.
 Creating supportive environments: Free Breast screen vans around Australian communities
 Strengthening community action: raising awareness  Pink Ribbon Day, Cricket Australia 3rd pink test,
pink socks in soccer clubs.
 Reorientating health services: Free mammograms to allow for early detection, Royal Australian College of
General Practitioners  GP’s referring women over the age of 40 to mammograms/ raising awareness
about breast cancer and how to reorient lifestyle to prevent it.
 Building healthy public policy: Free mammograms/assessments for women of the ages of 40-50  national
breast screening policies.
 Ancillary care

- complements the services of conventional physicians i.e. radiology, speech therapy.

Palliative care- improving the quality of life for patients with incurable diseases/illnesses

Neural strategy – hydrotherapy and relaxation

ATSI -> Suffer language barriers as for many ATSI individuals English is their second
language. As a result, this affects their ability to be able to access preventative health care
such as general practitioner consultations.

ATSI- Role of community- Australian community controlled health services. (ACCHS)

Operated by the local community to deliver holistic, comprehensive and culturally

appropriate health care.

Services include clinical care, health education, screening, immunisation and specific
programs.

Diabetes e.g.

Reinforcing factors (junk food adverts)

Enabling factors (lack of support)

Predisposing factors (the family has diabetes )

Government

Aboriginal and Torres Strait Islanders (ATSI)

 Role of the individual, community and government

 The Two Ways Together Program which provides equal accountability

between communities, ATSI peak bodies and government levels. All parties
deliberate on key health inequities and targeting strategies i.e. low income
levels and educational attainment.
 The Office of Aboriginal and Torres Strait Islander health provides
funds/grants to 245 organisations to support improved health initiatives.
  Aborginal Health and Medical Research Council of NSW controls over 60
ATSI organisations of NSW, they work with other government departments to
deliver a range of health care initiatives/develop policy and evaluate progress
made in health reforms and healthcare.

 National Aboriginal Community Controlled Organisation work with other

departments such as the department of housing/community
services/indigenous affairs to provide a range of health and welfare services
for ATSI communities.

 Northern Territory Emergency Response (Howard government) – address

the immediate needs of ATSI people living in the NT. A range of initiatives
including the provision of health care services, educational, social, welfare
reforms and laws that hinder access to alcohol and welfare payments. The
response was aimed to initiate health care checks for children under 16
years, as a means for identifying common health concerns and plan for a
coordinated delivery of services to treat these illnesses.

 ATSI role models/Individuals empowering others:

 Cathy Freeman
 Greg Inglis
 Adam Goodes

Health promotion campaigns and interventions

 Healthy schools canteen policy (Fresh food tastes @ school( – labelled foods with
stickers indicating their nutritional value. For example, fatty foods such as Sausage
Developing personal skills
Rolls are given red stickers. In turn, students can make informed consumer choices
by avoiding
Honingthe
the allocated red sticker
skills necessary to foods.
develop a sense of autonomy within.
This is achieved by improving ones
health literacy. In turn, individuals
are able to make good health
choices.

Enabling an individual to emphasise

greater control and autonomy over
their own health.

I.e. a cooking class to learn healthy

recipes that involve fresh fruit and
vegetables. In turn, lowering junk
food intake and enabling the
chances of developing a lifestyle
disease such as CVD or type 2
Diabetes.
Sample Exam Questions HSC Core 1:

 Define the role of epidemiology and list how epidemiology is measured.

 Examine how the priority health issues are identified in Australia’s health.

 Outline two socioeconomic determinants that contribute to health inequities experienced by

Aboriginal and Torres Strait Islander peoples.

 Identify the groups experiencing health inequities in Australia.

- Aboriginal Torres Strait Islanders (ATSI)

- Overseas born people
- People with a disability
- Socioeconomically disadvantaged people
- People in rural remote areas
- The elderly
  Describe the roles that individuals, communities and governments have in address health
inequities experienced by Aboriginal and Torres Strait Islander peoples.

 Outline the preventable chronic diseases and provide two ways individuals could reduce
their risk of chronic disease.

 Assess the impact of a growing and aging population on the health system and services.

 Evaluate health care in Australia in relation to social justice principles.

 Describe two actions of the Ottawa Charter

The developing personal skills section of the charter refers to the notion that individuals
are able to employ the skills necessary to evoke the sense of autonomy within. In turn,
individuals are more likely to be self-sufficient in improving their overall health status.
For example, attending a cooking class to learn healthy recipes involving fresh vegetables
and fruit. In turn, this will allow individuals to eat healthy and further lower the possibility of
developing an incidence of a preventable lifestyle disease such as CVD.

The reorientating health services section of the charter recognises health in a holistic sense.
Thus, this notion pushes the implementation of preventative health programs and initiatives
such as the Close the Gap campaign and Breast screen – Free mammograms to determine
whether breast cancer has formed and or intervene early on to reduce the chance of death
( before condition worsens ) etc. In turn, this notion aims to reduce the
incidence/prevalence of a range of chronic and acute illnesses/diseases.

 Argue the benefits of applying the Ottawa Charter to one health promotion initiative.

National Tobacco Strategy 2009/2010

The Ottawa Charter sets an effective framework in providing a direction to health promotion
campaigns. Through this, a variety of health promotion campaigns can be viewed in a holistic
sense, recognising the values of the new public health approach. In turn, programs and
interventions are more likely to be successful.

number of cigarette purchases per day. Furthermore, this has reduced the incidence of lung cancer.