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Inequality widening in key social determinants of health in rural Australia

Introduction by Croakey: Highlighting the importance of place-based approaches to analyse and address health inequalities in rural Australia, new research has found that key social determinants of health vary in distribution between and within remoteness categories.

While an analysis by Dr Joanne Flavel, Dr Sophie GE Kedzior, Dr Vivian Isaac, Darryl Cameron and Professor Fran Baum found that premature and avoidable mortality has decreased in all socioeconomic quintiles outside of metropolitan Australia, inequality has increased for premature and avoidable mortality.

Inequality has increased in other indicators including income support, rental stress and labour force participation.

“Increasing inequality in health and social determinants of health in outer regional, rural and remote areas underscores the ways in which health inequalities strongly correlate with inequalities in social determinants of health”, Flavel and colleagues write in the Rural and Remote Health journal this week.

Below, they outline other key trends and the importance of their findings.


Joanne Flavel and colleagues write:

New research funded by Professor Fran Baum’s NHMRC Restoring the Fair Go Fellowship and the Flinders Foundation found that premature and avoidable mortality decreased in the past two to three decades for all socioeconomic quintiles outside of capital cities.

But inequality in premature and avoidable mortality in non-metropolitan areas has increased.

Inequities in other key social determinants of health are increasing in non-metropolitan areas of Australia, and social determinants of health vary in distribution between and within remoteness categories.

For example, an increase in inequality was seen for key government income support indicators, rental stress, and labour force participation in regional Australia.

We found decreases in inequality for internet access and fulltime participation in secondary education at age 16.

Our new research, recently published in Rural and Remote Health, identifies a steeper health and social gradient in rural and remote areas compared with metropolitan areas which is worsening for key measures of health and social determinants of health.

Our previous research provided evidence that health and social inequities have been increasing overall in Australia. It is also well-established that rural and remote areas in Australia have a higher average burden of disease compared to metropolitan locations.

However, less is known about health and social inequalities within rural and remote areas and how health and social determinants are distributed within regional and remote areas.

Trends in inequalities

We conducted an ecological analysis of trends in inequalities in capital cities and regional, rural, and remote areas. While ecological studies are unable to identify causal links, they are very useful in identifying patterns of health and social determinants of health particularly where individual data are not available.

Most strikingly, we found that while health and social determinants of health by local government areas were worse on average in rural and remote areas compared to metropolitan areas, there was considerable variation in premature and avoidable mortality and in key social determinants of health when outer regional, remote, and very remote areas were compared.

Some rural and remote local government areas were ranked as less disadvantaged than many major city local government areas and had lower premature and avoidable mortality.

Other rural and remote local government areas had better rates of avoidable mortality and premature mortality despite being ranked as more socioeconomically disadvantaged.

The same was true in our analyses of social determinants of health by remoteness.

Variations in health by area

Social determinants of health are vital in explaining rural and remote health inequities. Our selection of indicators was informed by the framework developed by Dr Toby Freeman – Senior Research Fellow at Stretton Health Equity – and colleagues which emphasises the importance of social determinants in determining population health and health equity.

We used data related to health and income, housing, education, employment and digital access from the Public Health Information Development Unit Social Health Atlas time series data by Quintile of Socioeconomic Disadvantage.

We analysed these data to determine trends in inequality via calculation of the slope index of inequality, and the degree of change in indicators by socioeconomic quintile.

We also categorised data by LGA into remoteness categories (major cities, inner regional, outer regional, remote and very remote) and assessed the distribution for each indicator by remoteness and by Index of Relative Socioeconomic Disadvantage.

Resources in rural areas

There have been overall improvements in health and social determinants of health in non-metropolitan areas despite regional Australia being under-resourced.

The National Rural Health Alliance released a report in 2023 that estimated a shortfall in funding for health services in rural and remote Australia at $6.55 billion compared with metropolitan Australia. The shortfall in funding for social determinants in regional Australia has not been estimated.

This under-resourcing explains at least part of the steeper social gradient in premature and avoidable mortality in non-metropolitan areas compared with metropolitan areas.

Variation in health and social determinants of health within rural and remote areas in Australia suggests it may not always be appropriate to aggregate regions together in analysis by remoteness. Understanding the variation will point to how policies to improve rural and remote health can be more effective.

It is also important to avoid a deficit lens in analyses of regional health inequalities. Rural and remote areas do have cleaner air and more access to natural spaces, health promoting community participation and stronger bonding social capital.

There are disadvantages including limited service availability and acceptability, limited educational and employment opportunities, poorer quality housing, and higher risk of social isolation but these are not generalisable to all rural and remote areas, and context and resourcing is key.

A key area for future research is determining why certain LGAs differ from others to shed further light on variation in rural and remote areas.

* The research team includes Dr Joanne Flavel and Professor Fran Baum at Stretton Health Equity, Stretton Institute, University of Adelaide; Darryl Cameron (deceased), Close the Gap Project Officer from River Mallee Coorong Local Health Network; Dr Sophie GE Kedzior of King’s College London; and Dr Vivian Isaac from the School of Allied Health, Exercise & Sports Sciences at Charles Sturt University.


See Croakey’s archive of articles on the social determinants of health.