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The NHPAs initiative is a collaborative approach to dealing with a range of conditions which account for 70% of the burden of disease and a high financial burden in Australia. It is overseen by the National Health Priority Action Council, which was established as a sub-committee of Australian Health Ministers' Advisory Council (AHMAC) in June 2000, and comprises representatives of the Australian Government, each of the states and territories, a representative of Aboriginal and Torres Strait Islander peoples and a representative for consumer issues.
At present, seven NHPAs have been endorsed by the Australian Health Ministers' Conference covering cardiovascular health, cancer control, injury prevention and control, diabetes mellitus, mental health, asthma, and arthritis and musculoskeletal conditions. A range of program initiatives has been established aimed at improving health outcomes in these areas. More information on NHPAs, can be obtained from the Department of Health and Ageing web site and other relevant web sites, the addresses of which are at the end of this chapter.
Circulatory disease comprises all diseases and conditions involving the heart and blood vessels including high blood pressure, heart disease, stroke, and peripheral vascular diseases. Although its death rates have notably decreased over the last three decades, it is still the leading cause of death in Australia (AIHW 2002a). Because of its health and economic burden exceeding any other disease as well as the potential for prevention, it was established as one of the original priority areas in 1996.
Estimates from the 2001 NHS indicated that around 3.2 million Australians (17%) reported having a circulatory system condition as a long-term condition. The most common cardiovascular condition reported was hypertension (high blood pressure) which affected 10% of the population.
Graph 9.8 shows that the prevalence of long-term circulatory system conditions increases with age. For people aged 55 and over, the prevalence of all circulatory system conditions is 48%. The prevalence of hypertensive disease is 34%, and ischaemic heart disease (also called coronary heart disease) is 5.8%. The prevalence of cerebrovascular disease (stroke) is 2.2%.
In 2001, over 38% (49,326) of all deaths were due to diseases of the circulatory system. Ischaemic heart disease accounted for 20% of all deaths, and cerebrovascular diseases a further 9.4% (table 9.4). Between 1991 and 2001, age-standardised death rates for diseases of the circulatory system declined by 35% for males (from 469 to 304 per 100,000 persons), 33% for females (from 317 to 213) and 34% in total (from 384 to 254).
Cancer is potentially the most preventable and treatable of the common causes of death in the world. It is a disease of the genes, caused by abnormal cell division and usually presents as a solid growth tumour. It is a major cause of death in Australia.
Estimates based on information reported in the 2001 NHS show that 261,253 Australians (1.4%) reported they currently had a malignant neoplasm.
The Australian Institute of Health and Welfare cancer registry data shows there were 82,185 registered new cancer cases in 1999. The most common registrable cancers are the combination of cancers of the colon and rectum (11,637), breast cancer (10,667), prostate cancer (10,232), melanoma (8,243) and lung cancer (7,826). They together account for 59% of all registrable new cancer cases in that year. Cancer occurs more commonly in males than females. The age-standardised incidence rate in 1999 for all registrable cancers combined was 469.6 new cases per 100,000 for males and 339.2 per 100,000 for females. If the 1999 incidence rates prevailed, it would be expected that one in three men and one in four women will be directly affected by cancer before the age of 75 (AIHW 2002b).
In 2001, malignant neoplasms (cancer) accounted for 36,750 deaths, which was 29% of all deaths registered (table 9.4). There were 20,753 male deaths and 15,997 female deaths due to cancer. Overall, cancer of the trachea, bronchus and lung was the leading cause of cancer deaths (7,038 deaths), accounting for 19% of all cancer deaths. There were some differences in cancer death rates between males and females. Among males, the leading causes of cancer deaths were cancer of the trachea, bronchus and lung (22% of all male cancer deaths), prostate cancer (13%) and colon cancer (8%). Among females the leading causes of cancer deaths were breast cancer (16% of all female cancer deaths), cancer of the trachea, bronchus and lung (15%) and colon cancer (10%). Apart from age groups between 30 and 54, age-specific death rates for cancer increased markedly with age, and were generally greater for males than for females.
Mortality is influenced by the number of new cases of cancer (incidence) and the length of time lived after the initial diagnosis of cancer is made (survival). Relative survival is a measure that takes into consideration the crude survival (time between diagnosis and death) in the cancer population, and the corresponding expected survival in the general population. Expressed as a percentage, it is the cancer population that survives a specific number of years after the diagnosis divided by the general population that survives the same number of years.
In the general population during 1992-97, the expected proportion of males aged 60-69 years who survive for the next five years is 91%. The observed survival rate after five years for males diagnosed with lung cancer at age 60-69 is 11%. The five-year relative survival proportion for males diagnosed with lung cancer at age 60-69 is the ratio of these two percentages, that is 12% (AIHW 2001).
By convention, the proportion of people surviving is measured at one, five and ten years after diagnosis. The periods reflect different stages of management during the life of a person diagnosed. For instance, the proportion of people surviving after one year can be a measure of the success of the interventions on the immediately detectable cancer, whereas five-year and ten-year measurements are strong indicators for remission or cure.
During 1992-97, the five-year relative survival proportions for all cancers for females (63%) were higher than those for males (57%) (table 9.9). The difference in the five-year relative survival rate was 6.6 percentage points higher for females. When looking at international comparisons, Australian five-year relative survival proportions for all cancers was ranked second behind the United States of America for both males and females when compared with other Western countries for which relative survival data are available.
Injuries and deaths due to external causes
Injury and poisoning are broad terms that encompass the adverse effects on the human body that may result from events. These events may be accidental, such as falls, vehicle accidents and exposure to chemicals, or intentional such as suicide attempts and assaults by other people. Such events, and the factors involved in them, are collectively known as 'external causes' of injury and poisoning, and are a significant source of preventable illness, disability and premature death in Australia.
Males and females, and people in different age groups, experience different levels and types of risk from injury events (risk in this sense refers to both the probability of an injury event occurring and the severity of the injuries that may result). Differences in injury risk and injury outcomes are reflected in the draft National Injury Prevention Plan, a key policy response to this designated priority health area. The plan identifies four priority areas: falls among persons aged 65 years and older; falls among children under 15 years of age; drowning and near drowning; and poisoning of infants and children less than 5 years of age. Although the number of deaths from these four types of injuries is relatively small, they account for a large number of hospital admissions.
Respondents to the 2001 NHS were asked about events in the four weeks prior to interview that resulted in an injury for which they had sought medical treatment or taken some other action. Injuries data from the survey are presented in table 9.10 and highlight differences in the reporting of injury events among males and females of different age groups.
Falls have different consequences for older Australians. The 2001 NHS data show that a low fall (of one metre or less) for a person aged 65 years and over was more likely to result in them sustaining a fracture than was the case for a younger person (graph 9.11). Further, women aged 65 years and over were most likely to sustain a fracture as a result of a fall.
External causes of injury were responsible for 7,876 deaths (6% of all deaths) registered in 2001 (table 9.12). Since 1991 there has been a 12% decrease in the standardised death rate for deaths from external causes, mainly due to a 28% decrease in the rate for transport accidents. In 2001 there were 2,454 deaths attributed to intentional self harm (suicide), 4% higher than the 2000 figure, but 10% lower than the record 2,720 deaths registered in 1997. Deaths as a result of suicide account for more than one in five deaths of persons aged 25-34 years (a rate of 20.7 per 100,000 persons) and 15-24 years (12.8 per 100,000). Males consistently have higher rates of death due to external causes than females.
Diabetes is a long-term condition characterised by high blood glucose (a type of sugar) level, which results from either the body producing little or no insulin, or the body not using the insulin properly (insulin resistance). Insulin is a hormone produced by the pancreas that helps the body cells use glucose.
Diabetes is a costly disease, associated with substantial morbidity and mortality, primarily from cardiovascular complications, eye and kidney diseases, and limb amputations. In 1996, diabetes became the fifth NHPA in recognition of the increasing prevalence of the disease, its seriousness and its cost to the community.
Types of diabetes
There are three major types of diabetes mellitus. Type 1 diabetes is marked by extremely low levels of insulin. Type 2 diabetes is marked by reduced levels of insulin, or the inability of the body to use insulin properly. Gestational diabetes, which occurs in about 4-6% of pregnancies of females not previously diagnosed with diabetes, is not usually long-term. However, for women diagnosed with gestational diabetes, there is an increased risk of developing Type 2 diabetes later in life (AIHW 2003e).
National Diabetes Register
In 1999, the National Diabetes Register was established at the AIHW as part of the National Diabetes Strategy. The register holds information on people with insulin-treated diabetes who started using insulin since January 1999. Between 1 January 1999 and 31 December 2001, 22,575 people began to use insulin, and consented to be on the register (AIHW 2003e).
Of those registered, 60% were found to have Type 2 diabetes; 29% had Type 1 diabetes and 7.3% had gestational diabetes. Additionally, 62% of registrants were aged over 45 years; 4.9% were aged less than 10 years, 4.8% aged 10-14 and 29% aged 15-44 years. In 2000 and 2001, 1,565 new cases of Type 1 diabetes among children 0-14 years were recorded on the register, an average annual rate of 20 new cases per 100,000 population for boys and 19 per 100,000 for girls.
Estimates from the 2001 NHS indicate that over half a million Australians (around 3%) have reported having diabetes as a long-term condition. Results from the three successive National Health Surveys show that diabetes is a growing health problem in Australia. The prevalence of diabetes has risen from 1.2% in 1989-90 to 2.0% in 1995, and to 2.9% in 2001.
After adjusting for age differences, Indigenous Australians were almost four times as likely as the non-Indigenous population to report some form of diabetes (11% compared with 3%). Graph 9.13 shows age-standardised rates of diabetes among the Indigenous and non-Indigenous population in Australia in 2001.
In 2001, diabetes mellitus was the underlying cause of death in 3,078 deaths, 2.4% of all deaths registered. Of these, 1,639 deaths were males and 1,439 females (table 9.4). The age-standardised death rate due to diabetes was 16 per 100,000 persons (20 for males and 13 for females per 100,000 persons).
There were a further 7,247 deaths where diabetes was not the underlying cause but was an associated cause. Where diabetes was mentioned as an associated cause, the main underlying causes were acute myocardial infarction (heart attack), chronic ischaemic heart disease, cerebrovascular disease and malignant neoplasms (particularly of the digestive organs and the respiratory and intrathoracic organs).
Although approximately 80% of the population enjoy 'good' mental health free of mental disorders, it has been estimated that mental disorders caused 13% of the total disease burden in 1996. Although mental illness is not a major direct cause of death, it is associated with a proportion of deaths due to suicide and some other conditions, and is an important cause of chronic disability. For males, substance use disorders (from alcohol or other drugs) accounted for 33% of the mental health burden, while for females affective disorders such as depression accounted for 39% of the mental health burden (AIHW 1999).
In the 2001 NHS, information on long-term mental and behavioural problems was collected from all respondents. A long-term condition was defined as one which the respondent regarded as having lasted or was expecting to last six months or more. Respondents in the survey were not specifically asked if they had been diagnosed with any mental disorders, so the information they provided could be based on self-diagnosis rather than diagnosis by a health professional.
In 2001, 9.6% of the Australian population reported that they had a long-term mental or behavioural problem. Proportionally more females (11%) than males (8.5%) reported these problems. The most commonly reported problems were classified into two groups: anxiety related problems and mood (affective) problems such as depression and bipolar disorder; each were reported by approximately 3% of all males and 6% of all females.
In the 2001 NHS, information on mental health was collected from adult respondents using the Kessler 10 Scale (K10), a 10-item scale of current psychological distress. The K10 asks about negative emotional states in the four weeks prior to interview. The results from the K10 are grouped into four categories: low (indicating little or no psychological distress), moderate, high, and very high levels of psychological distress. Based on research from other population studies, a very high level of psychological distress, as shown by the K10, is likely to indicate a need for professional help.
In 2001, 3.6% of the adult population reported a very high level of psychological distress. Women were more likely than men to report high (11% of women and 7.2% of men) and very high (4.4% of women and 2.7% of men) levels of distress. The greatest sex difference was between young women and men aged 18-24 years, with 5.4% of women having very high levels of psychological distress compared to 2.7% of men in this age group (graph 9.14). A higher proportion of both males and females aged 45-54 years reported very high levels of psychological distress compared with any other age group.
Use of medication for mental wellbeing by adults
In 2001, 18% of adults used medication for their mental wellbeing in the two weeks prior to the survey interview. People may have used more than one type of medication for their mental wellbeing. Use of pharmaceutical medications was reported by 9.6% of adults overall, use of vitamins or mineral supplements by 7.8% and use of herbal or natural medications by 5.4%.
As would be expected, when comparing adults who reported having a mental or behavioural problem with those who did not, proportionally more adults with these problems also reported using medication for their mental wellbeing. Approximately 50% of adults with a mental or behavioural problem used medications, of which 14% used pharmaceutical medications for mental wellbeing; 18% used vitamin or mineral supplements for mental wellbeing; and 14% used herbal or natural medications for mental wellbeing.
More women with a mental or behavioural problem reported using medication for mental wellbeing compared with men (54% and 45% respectively). With the exception of the 55-64 year age group, the proportion of women with these problems and using this medication was higher than the comparable proportion of men in all age groups (graph 9.15). The greatest differences between sexes were recorded in age groups between 25 and 44 years. Medication use was most frequently reported by women aged 35-44 years (60%), followed by those aged 25-34 (59%) and 75 years and over (58%). For men, medication use was most commonly reported by those aged 45-54 years (55%), followed by those aged 55-64 (53%) and 65-74 years (50%).
The most frequently reported types of medications taken for mental wellbeing were the same for both men and women with mental and behavioural problems: antidepressants, followed by vitamin or mineral supplements, herbal or natural medications, sleeping tablets or capsules, tablets or capsules for anxiety or nerves, tranquillisers, and mood stabilisers.
Asthma is a chronic inflammatory disorder of the lung's air passages which makes them narrow in response to various triggers. This leads to episodes of shortness of breath and wheezing. Asthma can begin at all ages, including the very young. The disease can start as a mild chronic cough and lead to mild or severe wheezing, and sometimes even to respiratory arrest.
Although asthma has low associated mortality, people with asthma can experience reduced quality of life and require a range of health services, from general practitioner care to emergency department visits or hospital in-patient care. It was one of the most frequent reasons for hospitalisation among children aged 0-14 (AIHW 2002a). The management of asthma is an important public health issue because of the personal burden it places on those with asthma, often with onset in childhood, and the financial burden it places on the health system.
The prevalence of asthma in Australia is one of the highest in the world, with more than two million Australians (12%) reporting the disease in 2001. Asthma is more prevalent in young people than older age groups. For people under 25 years of age, the prevalence of asthma is 15%. Up to 14 years of age, asthma was more common among males than among females. In older age groups, however, asthma was more common among females than among males (graph 9.16).
Asthma was identified as the underlying cause of 0.3% of deaths registered in Australia in 2001, when 175 males and 247 females died from the disease. The most recent peak in asthma deaths occurred in 1989, and standardised death rates for asthma have been declining since then (graph 9.17). Most asthma deaths occur in older age groups.
Arthritis and osteoporosis
In July 2002, AHMAC announced arthritis and musculoskeletal conditions as a new (seventh) NHPAs in recognition of the major burden these diseases place on the community. Osteoarthritis, rheumatoid arthritis and osteoporosis are the most commonly occurring musculoskeletal conditions. Although they are not immediately life threatening and have low associated mortality, they have substantial influence on the quality of life and impose a heavy economic burden on the community.
Osteoarthritis is one of the most common types of arthritis and affects the cartilage in the joints. Cartilage cushions the ends of bones where bones meet to form a joint. In osteoarthritis this cartilage degenerates. Osteoarthritis is most commonly found in the knees, neck, lower back, hip and fingers.
Rheumatoid arthritis is the most common form of inflammatory arthritis. Inflammatory arthritis is characterised by joint swelling and destruction. In rheumatoid arthritis the immune system attacks the tissues lining the joints. As a result of this attack, inflammation occurs causing pain, heat and swelling. The disease can also cause inflammation of connective tissue, blood vessels and organs.
Osteoporosis is not a form of arthritis but is another type of musculoskeletal disorder. Osteoporosis (porous bones) is a disease where bone density and structural quality deteriorate, leading to an increased risk of fracture. The most common sites of fracture are the bones of the spine, the hip and the wrist. However other bones are commonly affected, including the shoulder, ribs and the pelvis.
Estimates based on information reported in the 2001 NHS show that over 2.5 million Australians (14%) had some form of arthritis and over 299,000 Australians (1.6%) had osteoporosis. The prevalence is greater in females at nearly all ages. The prevalence of arthritis is 16% for females compared to 11% for males, while the prevalence of osteoporosis is 3.0% for females and 0.6% for males. Graph 9.18 shows that the prevalence of arthritis and osteoporosis increases sharply with age. For people aged 65 and over, the prevalence of arthritis is 47% and the prevalence of osteoporosis is 8.0%.