Introduction

What are the key equity issues and who is at risk?

Cardiovascular disease (CVD)

Socioeconomic disadvantage is associated with higher rates of CVD. Aboriginal and Torres Strait Islander peoples, people living in rural and remote areas, and people in lower socioeconomic groups, all have an increased risk of cardiovascular disease.⁶Minority groups have high risk factor rates of cardiovascular disease globally.^6,7

Type 2 diabetes (T2D)

There is a higher prevalence of T2D among Australians in the lower socioeconomic groups.⁸ T2D is more than twice as common in the most disadvantaged communities.⁹ Certain ethnic groups are more at risk.¹⁰Aboriginal and Torres Strait Islander peoples are three times more likely to have diabetes than non-Indigenous Australians, and T2D is a direct or indirect cause for 20% of Aboriginal and Torres Strait Islander deaths.¹¹

CVD risk factors

Biological and behavioural risk factors play a role in increasing cardiovascular risk (refer to Chapter 7. Prevention of chronic disease). However, while smoking, nutrition, alcohol and physical activity (SNAP) risk factors exhibit clear socioeconomic gradients,^10,12 the higher prevalence of vascular and metabolic disease is only partly mediated by behavioural risk factors and is more consistently observed in women.¹³ Diabetes and CVD are more common in rural populations, and this is exacerbated by poorer access to healthcare.¹⁴There is evidence that men from socioeconomically disadvantaged backgrounds may be less likely to be offered statins.¹⁵

Chronic kidney disease (CKD)

Disadvantaged groups have higher rates of CKDfor which type 2 diabetic nephropathy is a common cause.^16,17 Over the past 25 years, the number of Aboriginal and Torres Strait Islander peoples commencing renal replacement therapy was 3.5 times greater than the majority of the population. CKD has an earlier onset in Indigenous peoples.^18–20 Aboriginal and Torres Strait Islander peoples are 10 times more likely than non-Indigenous Australians to be hospitalised for CKD, and, from 2008 to 2012, CKD was responsible for or associated with 16% of Aboriginal and Torres Strait Islander deaths.¹¹

What can GPs do?

• Inequities in diabetes care can be ameliorated using a structured systems-based approach to care targeting at-risk and minority populations using diabetes registries.²¹
• Social disadvantage may be a factor in poor medication adherence in patients with chronic disease.^22,23 Interventions that can help improve medication adherence include those that target the barriers created by socioeconomic status (SES) and the treatment itself.²³ Underuse of cardiovascular medications is common in older adults at high risk of CVD, and may be a factor in inequity in cardiovascular outcomes.²⁴
• Effective chronic disease interventions are likely to be those that address the determinants of behavioural risk factors that arise from root social causes such as poverty and low health literacy.⁶Interventions delivered in community settings that target families and are multifaceted to incorporate the social context are generally the most successful.^25,26
• Trust is an important element in the delivery of culturally competent health service to patients with chronic diseases, particularly Aboriginal and Torres Strait Islander peoples. Key ways to improve healthcare delivery are to respond to social complexity; promote empowerment, trust and rapport; and reduce discrimination and racism. To do so requires not only practice-system change but also Aboriginal and Torres Strait Islander cultural training of health professionals to build culturally safe environments.^27,28 Continuity of care and patient-centred care are also important. Culturally specific interventions are needed and there are ongoing initiatives to develop these.^29–33