Introduction

Disadvantage is a complex and multifaceted concept with varying classifications across the literature.1–3 In the context of this article, disadvantaged and marginalised groups are broadly defined as those that have less power, opportunities, rights or resources relative to others in society. These groups may also be less involved in, or excluded from, mainstream society (e.g. through under-representation in various economic, political and social activities).4,5 It is important that pharmacists are aware of patients who may fit into one or more disadvantaged groups, and that they provide support and implement strategies in their practice to optimise healthcare delivery.

Learning objectives

After successful completion of this CPD activity, pharmacists should be able to:

  • Recognise that there are health disparities in Australia
  • Discuss the supply and demand factors that influence healthcare use
  • Explain how pharmacists can implement strategies to enable equity of care in their practice.

Competency Standards addressed (2016): 1.1, 1.4, 1.5, 2.1, 2.2, 3.1, 3.5, 3.6.

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Disadvantaged groups and health disparities 

Groups that have been socially marginalised or disadvantaged in Australia include: Aboriginal and Torres Strait Islander peoples; people living with a disability or mental illness; sexual and gender minorities; and individuals experiencing poverty or low socioeconomic circumstances.6–9 These groups experience a greater burden of chronic diseases,10 have higher mortality rates,11,12 and, on average, have poorer physical and mental health than other Australians.1,13–16 

A key global indicator for population health is life expectancy.17 The health disparities in Australia’s disadvantaged populations are well documented: 

  • Australians living in the lowest quintiles of income live, on average, 6 years less than those in the highest income quintiles.12
  • Compared to Australians with 12 or less years of education, those with higher levels of education (such as with a degree or diploma) live 4.6 years longer.12
  • Aboriginal and Torres Strait Islander peoples live approximately 8 years less than non-Indigenous Australians.18
  • Men and women with mental illness experience a mortality gap of 20 and 15 years, respectively.19
  • Australians living with an intellectual disability have a life expectancy approximately 26 years less than other Australians.20

Such health disparities are partly explained by unequal distribution of health-producing factors – often referred to as social determinants of health (SDOH) – such as education, socioeconomic position, social and institutional barriers, risky health behaviours and healthcare utilisation.10 By definition, all SDOH are important in producing health. However, enabling appropriate and timely healthcare use is of particular interest as it represents a key lever through which governments can enact policy changes and attempt to bridge health disparities experienced by disadvantaged populations.

Healthcare use in disadvantaged groups

Although Australia’s universal healthcare system is designed to be equitable and accessible to all Australians, disadvantaged groups are less likely to receive appropriate and timely healthcare. On average, disadvantaged Australians use less preventive healthcare, including dental care, as well as fewer specialist services. These populations also have higher rates of preventable hospitalisations.21–23 This so-called inverse-care law, where the availability of quality medical services is inversely related to need, explains in part why preventable hospitalisations are higher among Australia’s most vulnerable populations.11,23,24

Differential effects of supply and demand 

In terms of economic theory, both demand- and supply-side factors, otherwise known respectively as ‘patient’ and ‘place’ factors, can influence healthcare use. Supply and demand can be analogously thought of as factors which are attributable to regional- and individual-level factors, respectively. 

Supply

In the context of healthcare markets, supply-side factors or interventions operate by changing the ‘supply’ of healthcare. This includes changing the accessibility, availability, quality or types of services provided. For example, training healthcare professionals to be culturally sensitive,25 or delivering services in a way that is more responsive to individuals’ needs. Another example is the expansion of vaccinations administered by pharmacists, which has led to increased uptake of influenza vaccinations.26,27

Providing healthcare professionals with incentives or guidelines on how they provide care can also change the mix and quality of what is supplied. However, it may also cause unwanted impacts, such as supplier-induced demand, where providers tell patients they need certain care (which may increase the provider’s income) even though it might be low-value or inefficient care.28 Instances of supplier-induced demand are well documented.

In the Netherlands, there was a change from a fixed payment model for general practitioners (GPs) regardless of the services provided (‘capitation’) to a fee-for-service model, where the GP receives a payment for each service provided. This increased GP-initiated utilisation of healthcare services.29 Additionally, healthcare providers that received payments, or other incentives, from pharmaceutical companies, more often prescribed those companies’ and other branded drugs.30,31

All these supply-side factors can influence what healthcare is ‘demanded.’

Demand

Demand-side factors change the ‘demand’ for healthcare. A key demand-side factor
is ‘need’ or, in other words, health status. Naturally, those in poorer health have greater need for healthcare and therefore use of healthcare greater than those in better health. 

Risky health behaviours are a demand-side factor that could influence healthcare use by leading to adverse health outcomes.32 For example, smoking, excessive drinking and obesity can cause chronic medical conditions that, in turn, are associated with increased healthcare costs.33,34 Other demand-side factors that influence healthcare use include health literacy, level of education, socioeconomic position, age, sex, cultural and sexual identity, and patient preferences.28 For example, young people may be more likely to turn to friends for mental health support rather than engaging directly with healthcare services,35 and higher levels of education may increase individuals’ health literacy. Research has shown that policies which mandated an increase in education led to ‘treated’ individuals getting more regular health checks, thus increasing preventive healthcare use.36 However, a similar empirical study in Australia found that an increase in schooling was not associated with increased preventive healthcare use.37 It was, however, associated with better health habits, such as an improved diet. How education affects utilisation of acute care services and medication adherence among Australians remains an important question for future research. 

Looking at changes in income, researchers in Queensland showed that area-level increases in unemployment led to reduced demand for both primary and secondary healthcare services in people with cardiovascular disease.38 Here, the authors argue that individuals experiencing unemployment had more time to invest in healthier behaviours (e.g. exercise, healthy diet), which led to reduced healthcare utilisation.

Influence of supply- and demand-side changes and interventions

Interventions can influence healthcare use through both the supply and demand side. At times, the relative importance of these factors can be difficult to disentangle. Economic evaluation, including those applied in drug health technology assessments, do not explicitly explore how these factors vary across different groups and ultimately impact equity.39 

Intuitively, the relative importance of demand- and supply-side factors is expected to vary across different groups. For example, consider if a primary practice finds it more costly to retain its staff and decides to initiate a co-payment so that all individuals receiving care at that practice need to pay more. In a sense, this is a supply-side change, as the practice is changing the cost of delivering care in that specific place. However, this change can also impact the demand for healthcare, and certain individuals may be less willing, or able, to pay. Subsequently, low- versus high-income individuals may have different responses to price; naturally, those with better financial means may be less affected by an extra cost and not alter the way they seek care at the practice. However, poorer individuals may avoid or delay seeking care as a result of the price change. Indeed, Australians in low socioeconomic households spend proportionally less on healthcare than other households,40 and those living in the lowest socioeconomic areas are more likely to avoid, or delay, seeing a dentist due to cost.41 The costs associated with healthcare are also more likely to deter poorer individuals from adhering to medicines and accessing specialist care.42,43 Delaying or avoiding such care may lead to deterioration of health and increase costs in the future. For example, in the US, reduced utilisation of prescription medicines stemming from co-payment increases was offset by subsequent increases in outpatient care and hospitalisations.44,45 Similarly in the US, reduced patient costs for healthcare saw improvements in overall survival.46

Different interventions will target different population groups. For instance, supply-side factors, such as cultural inclusivity, are likely to be more important for culturally and linguistically diverse populations. Immigrants that live in areas with more doctors that speak their language have been shown to use more healthcare services.47 Further, embedding Aboriginal health workers in remote community health centres and point-of-care testing have improved doctor-patient relationships and adherence to diabetes services for Aboriginal and Torres Strait Islander peoples.48,49

Supply, in terms of access, is also important. Availability of good public transport to healthcare has been shown to be particularly important for Australians living with disabilities. For example, some people living with disabilities face greater mobility barriers compared with people without disabilities.50 Access to telehealth services may also be particularly important for those living in remote and rural areas where there is less availability of specific services.51,52

More broadly, social and institutional factors can drive demand and supply of healthcare. For example, social exclusion, where individuals and groups are excluded from institutions and wider society, can induce individuals to be less willing to engage with healthcare professionals.53

This is in line with studies showing that experiences of racism, discrimination and stigma have negative effects on health status as well as medication use (see Case study 1).54,55 Social exclusion, racism and discrimination of particular individuals/groups might also lead to supply-side issues for accessing healthcare. Some regions might have a less diverse healthcare workforce, as minority-status individuals may select to migrate out of discriminatory regions. Groups of people may also feel discriminated against if they believe they are being treated with disrespect from healthcare professionals, not believed, or are left waiting to receive care.56 

Several policy initiatives have aimed to reduce health disparities in Australia. On the demand side, there is bulk billing and reduced medication co-payments for individuals with low income.57 Reduced medication co-payments are also available for Aboriginal and Torres Strait Islander peoples diagnosed with, or at risk of developing, chronic conditions.58 On the supply side, there are healthcare services available specifically for Aboriginal and Torres Strait Islander peoples, such as through Aboriginal Community Controlled Health Organisations. Mobile screening services are also available to help to facilitate access to breast cancer screening for those living in regional and remote
parts of the country. 

Case study 1 – Structural stigma and sexual orientation disparities in healthcare use

Research question and context

Discrimination and stigmatisation at the institutional and societal level – conceptualised as ‘structural stigma’ – have been linked to adverse health outcomes among sexual and gender diverse populations.14,54,59–62 

This stigma is theorised to contribute to these health inequalities by inducing stress, risky health behaviours and reduced healthcare seeking.59

In the context of economic theory, structural stigma is expected to moderate both demand and supply of healthcare.

For example, gender and sexually diverse populations living in more stigmatising environments might experience more heterosexist harassment or abuse. Subsequently, sexual and gender diverse individuals in these regions may be exposed to more stressors and be in poorer health. However, individuals may also delay or avoid healthcare if they anticipate they will receive stigmatising treatment within healthcare settings.60,63 Further, if people in these minority groups do seek healthcare, they may be more hesitant to disclose their status or discuss their sexual behaviour or gender identity, and therefore their specific health needs, with healthcare providers.64,65 

In terms of ’supplying’ healthcare, it could be that regions with more stigma also have fewer LGBTIQ+ specific healthcare providers and services (such as the Gender Centre and sexual health clinics).

Therefore, structural stigma may lead to poorer health but reduce healthcare seeking. A growing body of research in Australia aims to explore the stigma’s association with healthcare use among sexual and gender minorities in Australia. 

Overview and results

As a proxy for structural stigma, the authors used the responses from the 2017 Australian Marriage Law Postal Survey.14,15 Specifically, the measure of stigma used was the regional percentage of votes against legalisation of same-sex marriage. The variation in these responses across different regions of Australia is shown in Figure 1, where the darker areas represent regions with more votes against same-sex marriage (‘no votes’).*

This measure of structural stigma was then linked to two datasets:

  1. Census-linked administrative data (aggregated Medicare records), including 83,519 individuals in same-sex relationships (data on other sexual/gender minorities was not available).
  2. Gay community periodic surveys which contained self-reported information on sexual health outcomes (STI/HIV diagnoses) as well as sexual health service use (STI/HIV tests, pre-exposure prophylaxis [PrEP], post-exposure prophylaxis [PEP] and HIV-related clinical visits) for gay, bisexual and other men who have sex with men (GBM) in Australia, including gender diverse populations. 

Controlling for both supply-side (access to healthcare, rurality) and demand-side (e.g. age, income, education) factors, these studies investigated whether regional variation in stigma (percentage of votes against legalising same-sex marriage) was associated with health outcomes and healthcare use in regard to:

  • GP visits
  • mental health medicines (antidepressant and anti-anxiety medicines)
  • sexual healthcare (pathology services and anti-infectives, STI/HIV diagnoses, HIV-related clinical services, combination therapy for HIV)
  • awareness of PrEP and PEP.

Figure 1 – Regional percentage of votes against legalising same-sex marriage out of eligible voting population by postcode

Results and implications

In regions with a higher share of ‘no votes’, individuals in same-sex relationships visited the GP less often but used more medicines for mental health conditions than their heterosexual counterparts.14 Men in same-sex relationships as well as GBM in more stigmatising regions also used fewer pathology services, were less likely undergo HIV/STI testing, receive HIV/STI diagnoses, and be taking, or aware of, PrEP and PEP.14,15 GBM living in more stigmatising regions were also less likely to be aware of their HIV status, and those living with HIV used less HIV-related clinical care and were less likely to be on combination therapy.15 

This research echoes previous work theorising that sexual minorities in stigmatised regions have reduced healthcare seeking but poorer mental health,59,66 as well as previous work showing that sexual minority males experiencing stigma were less aware of, and used fewer, HIV-related medicines.54

This research found that although sexual minorities in regions with more stigma are in poorer health and have greater ‘demand’ for care, they use less primary healthcare. Altogether, this research suggests that structural stigma is likely an important moderator in sexual minority health and healthcare disparities and further suggests that broader stigmatisation is undermining efforts to adequately manage HIV infection among GBM in Australia. These findings suggest more inclusive practices in healthcare and ongoing policy efforts to reduce the stigmatisation of sexual and gender
diverse populations would be beneficial.

* While this measure explicitly uses the terminology as described in the Postal Survey, the authors recognise and acknowledge that these represent views towards marriage equality more broadly. The authors recognise that biological sex and gender are distinct concepts.

Knowledge to practice

Pharmacists can support patients from different disadvantaged populations to access appropriate healthcare in many ways, including:

  • Providing education to patients to increase health literacy and discuss the importance of medicine adherence. Language may need to be tailored to the patient’s level of literacy and understanding. Private counselling rooms can be used during discussions to make the patient feel more comfortable. If language is a barrier to communication, consider using interpreting services where appropriate.
  • Creating a welcoming and inclusive space. Have signs, pamphlets and symbols that represent cultural competence or LGBTIQ+ friendly services. Ensure individuals feel comfortable about disclosing ethnicity or other information which could help with their care. Consider whether a patient is eligible for, and could benefit from, any services – including MedsChecks, HMRs, dose administration aids, the Closing the Gap (CTG) PBS Co-payment Program or a concession card – and provide information on these available services.
  • Undertaking cultural awareness training and using respectful communication (e.g. correct use of pronouns and asking respectfully if unsure). Engage with local community groups/organisations that represent people who are disadvantaged to discuss how to create a friendly environment. 
  • Offering delivery services to patients who find it difficult to go to the pharmacy.
  • Undertaking health promotions for particular conditions/topics relevant to minority groups.  

Conclusion 

Supply- and demand-side factors affect healthcare use and, in turn, health outcomes. The relative importance of these factors varies across different disadvantaged groups. In addition to access and affordability, inclusivity and diversity are important considerations for enabling healthcare utilisation among socially disadvantaged groups. Understanding how, and the extent to which, these factors influence equity is vital to designing interventions and optimising allocation of resources. The research highlighted in this article underscores a particular need to reduce the stigmatisation of sexual and gender diverse populations. Inclusive practices in the primary care setting and, more broadly, affirmative action could be used to address inequalities. Pharmacists need to be aware of the barriers to healthcare faced by different minority groups and should consider strategies that can be implemented to improve access to pharmacy services. Pharmacists can undertake various training modules (i.e. cultural awareness or gender and sexual diversity training), and access resources and guidelines to assist in closing disparities in health and healthcare use.

Key points:

  • Pharmacists will encounter people in their practice who are in disadvantaged groups and at greater risk of poorer health compared to the general population.
  • Groups that have experienced social disadvantage include, but are not limited to, Aboriginal and Torres Strait Islander peoples, those living with a disability or mental illness, and people with a low socioeconomic status.
  • Demand- and supply-side factors can influence healthcare availability and use by people in disadvantaged groups. Adjusting these factors can improve access to healthcare for different patient groups.
  • Pharmacists should be aware of barriers faced by people in accessing healthcare and should implement strategies to increase the use and acceptability of pharmacy services
    for people in disadvantaged groups. 

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KARINNA SAXBY BEng(Hons), BSc, MSc is a research fellow and PhD candidate at the Monash University Centre for Health Economics. She has a special interest in healthcare utilisation and policy evaluation.

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