Many socioeconomic factors influence health, including education, employment, income and wealth, family, neighbours, housing, access to services, migration and refugee status and food security. Socioeconomic disadvantage, and its detrimental effects on health, is common in Australia.
Social and economic circumstances are recognised determinants of access to health care and of healthcare outcomes, including for colorectal cancer (CRC). Between 2009 and 2013, Australians living in the most disadvantaged areas had the highest age-standardised incidence for CRC.
Apart from access to health services related to distance or transport, the cost of services is an additional factor, related to socioeconomic status (SES) that influences the care people receive. In 2015–2016, one in 12 (8%) Australians who needed to see a medical specialist delayed or did not attend because of the cost. Those with a long-term health condition were more likely to delay seeing or not see a medical specialist due to cost than those without (9% compared with 5%). People living in the areas of most socioeconomic disadvantage were more likely to delay seeing or not see a medical specialist due to cost than those living in areas of least disadvantage (9% compared with 6%).
Many socioeconomic factors are beyond the capacity of individual clinicians to address. This section focuses on those modifiable SES-related factors which impact on surveillance in three settings:
- following adenoma detection;
- post curative resection for CRC;
- in the setting of dysplasia surveillance in inflammatory bowel disease.
Strategies for reducing socioeconomic inequality in surveillance colonoscopy
Clinicians can address three key areas linked to SES to improve the success of surveillance, by:
- communicating information in a way that is meaningful and actionable for the patient
- sharing decision-making with the patient and their support people
- improving their own cultural competency to support effective communication with patients from different cultural groups and belief systems.
The goal should be to ensure that all patients' decisions, including whether or not to participate in surveillance colonoscopy, are well informed and freely made.
Literacy is low in Australia. In 2011, only 56% of people had the general literacy needed to cope with everyday life and work.
Health literacy is defined as the skills, knowledge, motivation and capacity of a person to access, understand, appraise and apply information to make effective decisions about health and health care and take appropriate action. Poor health literacy is associated with low SES and is relevant to surveillance. Almost 60% of adult Australians have low health literacy. In 2006, among those whose first language was English, 44% had a level of health literacy described as adequate or better but amongst the almost 3 million Australians aged 15–74 years who spoke English as a second language this level fell to only 25%. Low health literacy is associated with low levels of knowledge and poorer health outcomes.
Since 2011 all hospitals and day facility services in Australia have been required to meet the National Safety and Quality Health Service Standards for accreditation. A specific standard (the Partnering with Consumers Standard) requires demonstration of actions to improve consumer understanding and participation in decision making about their care. With the introduction of the second edition of the National Safety and Quality in Health Care Standards, health service organisations will be required to communicate with consumers in a way that supports effective partnerships, in this way specifically addressing issues related to health literacy. A number of useful resources are available to assist clinicians, managers and other health professionals working outside the hospital or day facility to support improvements in health literacy and to develop information to meet the needs of patients with low health literacy. These resources are readily accessible on a number of sites, including the National Health and Medical Research Council and Cancer Australia websites.
People who are supported to make an informed decision by a healthcare professional may have better outcomes, better experiences, and less regret about their decisions. Disadvantaged groups may benefit most. Patient decision aids, decision support and navigation tools have been shown to increase CRC screening participation, but have not been trialled in the surveillance setting. Larger studies are needed to identify which features of navigation are most effective in patients ongoing participation in CRC surveillance, particularly those from lower SES backgrounds.
Cultural competency is the capacity to interact with people across different cultures and requires cross-cultural communication skills. This competency is particularly important in Australia where 1 in 4 Australians is born overseas, and just under 3% identify as Aboriginal or Torres Strait Islander Australians. Action at all levels of the health system is required to reduce the health inequalities that exist for many culturally and linguistically diverse background communities. An important first step to reduce this source of health inequality is to ensure that environments provide a sense of cultural safety so that people feel sufficiently comfortable to discuss their cultural identity. This then enables information and discussions about treatment options to be undertaken in a culturally sensitive manner. A number of services are available to support health services and providers including translation services, cultural guides, social services and patient advocacy groups. Online and face-to-face training in cultural competence for health professionals and the broader health workforce is also available and is now considered by many professional bodies essential training for clinicians.
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