Introduction

The Loddon Mallee is 50,000 sqkm of Murray River basin and Central Highlands in the Northwest quarter of Victoria. 90% of the population is in regonal centres². The estimated population is approximately 320,000. Of this, approximately 1.7% is of Aboriginal and Torres Strait Islander descent.¹

LMM has one of the most consistently warm climates in the State.³ As such it is a major food-producing area, with other main economies in tourism, viticulture, equine, horticulture, crops, cattle, manufacturing and wool production. 71% of the land is classified as under rural use. The Bendigo Bank, a major Australian financial institution, is also headquartered in this area. Despite this, the region faces significant social and economic disadvantages, with average personal and household incomes all lower than state averages for both Victoria and NSW.¹ This is reflected in high rates of disability, chronic disease, hospital usage, mental health problems, and drug and alcohol related morbidity.Although the most urbanized parts of the region (Bendigo, Castlemaine and Echuca) enjoy the highest overall socioeconomic and health status, the rural areas and smaller towns in the region have declining populations, more aged populations, and higher levels of socioeconomic disadvantage – all mirrored by higher levels of chronic disease. As populations continue to decline in rural areas and small towns, the services are gradually becoming centralized in larger townships and regional centers.¹

Figure 1: Map of the Loddon Mallee Administrative Region

Demographic Characteristics

As stated, the estimated population of the (LMM) catchment area is approximately 320,000 (6% of the population of Victoria) with 90% of this population residing in regional centers.²  The population is expected to rise by a further 13% by 2022.  Loddon Mallee has higher percentages of 0-14 and 65 plus population that the Victorian average and lower percentages of the other age groups.⁴ 16.2% of the population is aged 65y or over, and the median age is higher compared to both Victoria and regional Victoria medians.

Figure 2: Regional Population by age group

Overall the LMM region is aging, and this pattern is projected to continue to 2022 with the percentage aged 65 plus increasing from 16.2% to 21%.²Another demographic shift is being seen due to baby booms in the regional centres. With relatively low property prices, a population of mainly younger people with low socioeconomic status is migrating to the area, however this is not projected to translate into higher proportions of younger demographics.^1,5

The population dependency ratio (proportion under 14y and over 65y i.e. not of working age) is comparatively high: 56.1% for LM compared to 47.2% for Victoria, and this is projected to rise from 56.1% to 65.5% by 2022.² Some rural areas have dependency ratios greater than 80%.

Cultural and linguistic diversity in the region is low.  86% of residents were born in Australia, while only 4.5 per cent of the population were born in non-English speaking countries (NESCs) and the same number speaks a language other than English (LOTE) at home, mostly Italian, Turkish or Greek.⁶ 1.7% of the population identifies as Indigenous and Torres Strait Islanders – the largest proportion of any Victorian region.² There is a 17 year age gap in life expectancy between Indigenous and non-indigenous residents. There is a large number of transient workers in the casual labour force in the horticulture industry.⁷ The immigration rate of LM is well below the Victorian average, however the percentage of new settler arrivals that are humanitarian arrivals is higher than the Victorian average (10.1% to 7.3%).²

Epidemiological Characteristics

Life expectancy at birth on 2007 data is 78.6y for males and 83.4 years for females, well below the Victorian averages.^2,5 The indirect standardized death rate for LM is 6.25, also significantly greater that that for Victoria (5.7).²; Average annual death rates by cause are higher for LM in all categories (see Table 1).

Table 1: Avoidable Mortality by Cause, 0-74 years, 2003-2007²

Poor health determinants (education, employment, income) across the region result in the highest rate of overweight or obese persons within Victoria and close to double the NSW rate of high-BMI-attributable admissions. The region has worse rates of smoking, alcohol consumption, asthma, physical activity and chronic disease.^1,2 Compared to Victorian averages, LM has higher rates of hypertension, diabetes, cardiovascular disease, high cholesterol, respiratory disease, and musculoskeletal disease.^1,4 Dental health is poorer with long public system waiting times. In terms of mental health, LM has higher rates of mood and behavioural disorders but lower reported levels of psychological distress. There are higher percentages of mental health service clients, and higher levels of prescriptions for antidepressant and anti-dementia medication. Levels of drug abuse and drug-related crime are lower, but alcohol-related presentations are proportionately higher than average.

The key health issues for the main population groups are as follows:

• Males are significantly more likely than females to have high-risk health behaviours or characteristics (such as smoking or obesity) and to have many chronic diseases. Life expectancy is much lower compared to the Victorian average and there are significantly higher admission rates for COPD, congestive cardiac failure and angina, and complications of diabetes. Males make up a higher proportion of total new cancer cases and of total cancer deaths, compared to females and to the Victoria average - mostly cancers of the bowel, kidney and lung. Males were significantly less likely to have seen a GP than the Victoria average and significantly less likely than females to have seen a GP in 2009/10.^4,8,9,10
• Females. Compared to the Victoria average, LM had a significantly higher rate of teenage pregnancies in 2008, higher rates of smoking and obesity, a higher proportion of all cancer deaths from breast, liver, lymphoma and pancreatic cancer, and a higher proportion of all new cancer cases that were cancers of the bowel, kidney and melanoma.  Breast and cervical cancer screening rates are lower.  Females in LM are more likely than males to have mental and behavioural problems (self-assessed data), and the rate of family incidents (76% of aggrieved parties are women) where charges are laid or an intervention order was applied for is substantially higher than the Victorian average.^4,8,9,10
• Children Compared to the Victoria average, the rate of hospital admissions per 1000 children aged 0–8y was slightly higher in 2008-2010. LM has higher proportions of children who are developmentally vulnerable or at risk. Immunization rates were lower than the Victorian averages for the 12-15 month immunisation stages, and there are lower participation rates for all of the key age visits except the 3.5 year check. Breastfeeding rates are lower for all key ages and there are more babies born with low birth weight (<2,500g). Infant death rates (number of deaths before 12 months of age, per 1000 live births) were 5.5 in LM compared to 4.6 in Victoria.² There is a higher proportion of Child & Adolescent Mental Health Services clients, and the rate of substantiated child abuse is up to 3 times the Victorian average in some areas.^4,8,10
• Young People Compared to the Victorian average, a higher proportion of young people had left school and were disengaged (i.e. not involved in any work or study), higher proportion of population aged 15-24 were receiving the Youth Allowance, there is a higher teenage pregnancy rate and a higher hospitalization rate for intentional self-harm.  50.6% of adolescents reported being recently bullied.^4,8,10
• Indigenous/ATSI. Generally speaking, the LM catchment’s Indigenous population had a much lower income, was significantly less likely to have completed year 12, was significantly less likely to be employed or participating in the labour force (seeking employment), and had higher rates of chronic disease and preventable mortality than the non-indigenous population.^4,8,10
• Older Population. Compared to the Victorian average, LM has a higher proportion of lone person households, a higher proportion of population aged 65y plus earning a low income, and decreased labour force participation figures. Certain health conditions appear to be more prevalent. There is a higher proportion of the population living in both high and low residential aged care, reflecting the age structure of the population as well as availability of aged care places at various levels.  Significantly higher rates of people aged 70 years and over were receiving HACC services.^4,8,10

Health Services

Within the LM region, there are regional health services in Greater Bendigo and Mildura, and district health services in smaller regional centres.  There are private hospitals in Greater Bendigo, Mildura and Sea Lake, registered community health centres in Bendigo, Castlemaine, Kyneton, Kerang and Mildura, while community health services are provided at a number of other locations in the region.²

The health services are working for a changing community with changing needs: a growing, ageing and significantly 'at risk' community that has increasingly high expectations of their healthcare providers.¹¹

The health workforce is well supplied with GPs and nurses/midwives, but the rate of specialists, pharmacists and physiotherapists is comparatively low (Table 2).  Lack of availability of services means substantial workloads for local professionals and long wait lists for patients.¹ The health workforce is ageing, representative of the ageing population of the region.^1,12  GP attendances are below state average overall for both males and females, with high regional variation. 

Table 2: Health Professional Workforce- Practitioners per 100,000 pop²

The rate of emergency department presentations in LM (318.3 per 1,000) is 20% higher than the Victorian average, with higher rates of primary care type presentations to EDs (46.6%).  Inpatient separation rates are slightly higher than the Victorian average for the public system, but lower for private hospitals.  Length of hospital stay is longer.  Ambulatory care admissions are a higher percentage of total hospital admissions than the Victorian average, and there is higher utilization of Home and Community Care services.  The regional rate of both mental health and drug and alcohol clients is higher than average.²

Geographical and environmental characteristics

The Loddon Mallee community is spread out geographically and in some cases is extremely isolated.¹¹   Public transport is limited or not available in a large number of the small towns and rural areas – only 40% of the population is near public transport compared with the Victorian average of 72.3% - worsening access and usage of services.^1,2  Outside of the regional centres, access to specialists is very limited, placing a travel burden on patients in need.¹  In the rural areas there is a high reliance on community nurses for primary care services.  The region has no cardiothoracic or neurosurgical units, meaning patients requiring care beyond the capabilities of the regional base hospitals must travel or be transported to the state capital Melbourne for definitive care.  A statewide retrieval service, as well as e-health and telehealth practices, is frequently utilized.

The LM catchment has experienced prolonged and devastating drought conditions in the last decade.  In 2011, parts of the area experienced major flooding and this has had substantial impacts upon several small towns, as well as on farms and communities.⁴  There is a high yearly risk of bushfires, with the potential to cause mass casualty situations and traumatise affected populations.

The state boundaries between Victoria, NSW and South Australia do not necessarily match the natural geographic distribution of the population, based as it is around the area’s river systems.  This has led to some overlap in different levels of administration of the area, as well as difficulties in cross-border coordination of services between two state health systems.

Social determinants of health

The socio-economic and health status of residents varies considerably, however the rural areas and small towns of the catchment are typified by relatively high levels of socio-economic disadvantage⁴. LM has a higher than average percentage of low income individuals and households as well as persons experiencing food insecurity.²  The percentage of social housing is 4.9% in LM compared with 3.9% for Victoria.  Regional unemployment is equal to the Victorian average, but the percentage of the LM population with high school or tertiary qualifications is significantly lower.  The percentage of persons with private health insurance is lower than average in almost all LM districts.  The overall crime rate is lower than average for Victoria and people report feeling safer on the streets at night, but the rate of violent crime and family violence is higher than the Victorian average.  In terms of community strength, LM rates above average on most indicators.²

Many of the health challenges faced by the LM community are preventable, or can be effectively managed with support, information and advice. Poor health literacy and a low socioeconomic population in the region leads to reduced access to services in the first instance, as well as reduced prevalence of preventative behaviours.¹ Many stakeholders find the system ‘complex and hard to navigate’¹.

Conclusion

The Lodden Mallee is a large, rural region in Victoria with multiple demographic, geographic and epidemiological issues affecting the current and future health of its population.  Comparatively, LM is poorer than average for Victoria in terms of socioeconomic status and the socioeconomic determinants of health, with lower rates of education, income and healthy lifestyle.  This implies a low level of health literacy in the region and also places greater pressure to provide affordable services.⁴  There is a higher burden of disease, with higher than average rates of chronic disease, mental health, dental health and preventable mortality.  This is seen with more prevalence in the districts with more relative socioeconomic disadvantage.  The population is also rapidly ageing, and as populations continue to decline in rural areas and small towns, the services are gradually becoming centralised in larger townships and regional centers and this perpetuates the cycle of population and local services decline.⁴

References

1. Loddon Mallee Murray Medicare Local. Whole of region and after hours needs assessment: outcomes to date. March 2013 http://www.lmmml.org.au/needsassessmentresources (Accessed 21/08/2013)
2. Victorian Government Department of Health (March 2012).Loddon Mallee region health status profile 2011. http://docs.health.vic.gov.au/docs/doc/EE1D37A445A06155CA2579F80011DD15/$FILE/LMR Regional Health Profile 2011.pdf (Accessed 25/08/2013)
3. Regional Development Victoria website.http://www.rdv.vic.gov.au/victorian-regions/loddon-mallee (Accessed 21/08/2013)
4. Bendigo Loddon Primary Care Partnership Population Health Profile - November 2012, Bendigo Loddon Primary Care Partnership, Bendigo, Victoria. (Accessed 21/08/2013)
5. Australian Bureau of Statistics.  Community profiles. http://www.abs.gov.au/websitedbs/censushome.nsf/home/communityprofiles?opendocument&navpos=230 (Accessed 25/08/2013)
6. Victorian Multicultural Commission. http://www.multicultural.vic.gov.au/regional-advisory-councils/regions/loddon-mallee(Accessed 25/08/2013)
7. Medicare Lodden Mallee Murray website. http://www.lmmml.org.au/index.html (Accessed 21/08/2013)
8. Rural Health Australia – Medicare Local information. http://www.ruralhealthaustralia.gov.au(Accessed 25/08/2013)
9. Cancer Council Victoria.  http://vcrdata.cancervic.org.au:8082/ccv/#regional (Accessed 25/08/2013)
10. Public Health Information Development Unit (2011). A Social Health Atlas of Australia [Second Ed] – Volume 3: Victoria.http://www.publichealth.gov.au/publications/a-social-health-atlas-of-australia-%5bsecond-edition%5d---volume-3%3a-victoria.html(Accessed 25/08/2013)
11. Bendigo Health.  Strategic Plan summary 2008 – 2013. http://www.bendigohealth.org.au/aboutus/strategicplan.aspx‎ (Accessed 21/08/2013)
12. Health Workforce Australia 2012: Health Workforce 2025 – Doctors, Nurses and Midwives – Volume 1. https://www.hwa.gov.au/sites/uploads/FinalReport_Volume1_FINAL-20120424.pdf (Accessed 25/08/2013)