“She’ll be right, mate!”: do Australians take their health for granted?

KEYwords: Health consciousness; health status; health-care utilization; Australia

The notion of individual responsibility for health is epitomised in the concept of health consciousness. Since the 1990s, government policies around the world have focused on specific disease risks and individual responsibilities for health.¹ This approach has relied on actively seeking to increase awareness for health and promote healthy choices through social marketing campaigns.^1,2

Health consciousness is described as ‘the degree to which an individual is conscious of his or her own health’.³ Health-related motivation plays a primary role in determining individuals’ engagement in specific health behaviours.⁴ It highlights the readiness of individuals to undertake health actions and take responsibility for their health and the health of others. Although health consciousness is often described as an individual’s willingness and responsibility to act on their health obligations, it has generally been measured in terms of specific health promotion behaviours or recall of health messages rather than underpinning attitudes or intention to act.^3–5

Consumers with higher levels of health consciousness have self-control and report higher levels of self-efficacy, are more aware of and concerned about their health and are also motivated to engage in healthy behaviours to maintain or improve their health and quality of life.^3,5–7 Health-conscious consumers value social support when they are sick; have faith in science, scientists and doctors; carefully evaluate scientific reports; believe in health promotion and a healthy diet; and consider check-ups more readily, if required.⁸ They tend to be more evaluative of health claims, more preventive in their orientations and more open to medical alternatives, whereas individuals who score lower generally consult a doctor only when they are extremely ill.⁸ Furthermore, health-conscious people are more likely to have greater commitment and social responsibility towards others and trust that this commitment and willingness to provide social support will be reciprocated in the future.⁷

The issues surrounding views on responsibilities for health are complex and can be divisive, yet until the Covid-19 pandemic, community debate has been largely absent regarding personal and collective health responsibilities. Moreover, it is not clear if and how this differs in different health services and according to different service experiences.⁹ Health consciousness can be understood regarding other constructs, populations and settings.⁵ For example, a range of socioeconomic characteristics including higher education level, income and employment status are associated with greater health consciousness.⁶ This suggests that people with different backgrounds and experiences differ in their views on responsibilities for health. A study of grocery purchases revealed that household characteristics (including income, home ownership, employment status and education level of the head of the household, presence of young children in the family and ethnicity of the household) strongly affect health consciousness.¹⁰ Furthermore, it has been argued that consumers can be segmented based on their perceptions and attitudes towards health and health care, and that different health services and programmes may be required accordingly.^6,8 Understanding the degree to which consumers believe they should be responsible for their health is therefore a primary step in forming and implementing public health policy.⁸

Health authorities have actively sought to raise health consciousness as part of efforts to encourage populations to take more responsibility for their health and reduce avoidable hospital admissions. However, this approach risks reinforcing a victim-blaming mentality, given the different determinants of health and health inequalities that exist between population sub-groups.^11,12 Some research has indicated that Australians have historically demonstrated strong egalitarianism and value accessible health care,¹³ but little is known about personal responsibilities for health in this population. This study, therefore, aimed to measure the health consciousness of a sample of Australians and explore associations with other characteristics such as sociodemographic factors, health status and health-care utilisation.

This study was undertaken as part of a larger project to engage the public in health-care decision-making.^14,15 Ethics approval was obtained from the Griffith University Human Research Ethics Committee (MED/10/12/HREC) and the Metro South Hospital and Health Service Research Ethics Committee (HREC/12/QPAH/330).

Adults from Queensland and South Australia were recruited to participate in the study by a panel company (Pureprofile, Sydney, NSW, Australia). Sample size estimates were undertaken to provide representative samples of the general population characteristics, such as state, sex and age.^16,17 Of the 3042 members of the general public who commenced the survey, 1691 (55.6%) met the quota requirements (matching the sample to the stated population characteristics). Of these, 1529 (90.4%) completed the survey and received a nominal reimbursement for their time.

The Health Consciousness Scale (HCS) was used because of its internal consistency, discriminant validity and nomological validity against a range of personal health behaviours.³ The scale measures agreement or disagreement with nine statements using a five-point Likert scale; 45 is the maximum score and nine is the minimum – lower scores indicate higher levels of health consciousness. Example items include ‘I’m very self-conscious about my health’ and ‘I’m very involved with my health’. Four sub-scales appear to equally represent the construct of personal responsibility, including health self-consciousness, health alertness, health self-monitoring and health involvement.³ The scale can be used to provide one overall measure or as four separate sub-scale measures. As Cronbach’s α was 0.91 for the nine items administered in this study, we used the HSC as an overall measure of health consciousness.

Self-reported satisfaction with health was measured using item 1 of the World Health Organization Quality of Life measure (WHOQOL-BREF). Self-reported health status was measured using a five-point scale ranging from ‘very poor’ to ‘excellent’. Quality of life was measured using AQoL-4D, a validated scale comprising 12 items to assess independent living, mental health, relationships and sensory information; Australian norms are available for this scale.¹⁸

Health-care utilisation was measured by self-reports of recent presentations to Accident and Emergency Departments, hospitalisations and visits to general practices. Response categories were ‘no use’, ‘some use’ or ‘frequent use’ of these services.¹⁹ Participants were asked to indicate if they had private health insurance (or a health concession card) and ‘hospital’ and ‘extras cover’. Other questions asked if they or a close family member had ever received medical treatment for diabetes, heart disease, asthma, other respiratory diseases, skin cancer, other cancer, depression, anxiety, other emotional problems, chronic neck or back pain, arthritis, stomach ulcer or heartburn and weight management issues.

Demograph data included relationship status (married or partnered, separated or divorced, widowed, single); cultural backgrounds (dichotomised measures of Aboriginal and Torres Strait Islander status, a language other than English spoken at home and overseas-born); and indicators of socioeconomic status. Postcodes were also recorded to determine the state of residence and accessibility based on the Accessibility/Remoteness Index of Australia classifications (ARIA).²⁰ Employment status, education level, income and location (state and postcode) were also all self-reported.^2,12,21–23 To control for the effect of health professional perspectives, an item was included to ask if people had worked in the health system in the previous 10 years.

A pilot study with a convenience sample of 20 adults was used to determine completion time, check understanding of and difficulty completing questions, and seek feedback on the questionnaire’s language. Participants were reimbursed AU$10 for their participation in the pilot study. The main study involved a three-part computer-based survey designed in Qualtrics (Sydney, NSW, Australia) between September and December 2012. The first part comprised the HCS,³ the second part presented choices to determine preferred options for accessing emergency care (reported elsewhere) and the final part contained questions about respondents’ background, their health status and health-care utilisation to identify patterns and differences in responses among groups of participants.¹⁵

Data analysis was undertaken using SPSS (Version 21.0; IBM Corp., Armonk, NY, USA). Less than 5% of the data on participant characteristics was missing. However, as expected, there were more missing values for the measure of household annual income (14.4%). Komogrov–Smirnov and Shapiro–Wilk tests confirmed the health consciousness variable was not normally distributed (D = 0.111, P < 0.001; z = 0.976, P < 0.001, respectively) indicating both kurtosis and positive skew. Given this and the number of related variables that were measured on nominal and ordinal scales, non-parametric tests were used for preliminary analyses. However, consistent with the central limit theorem, the same pattern of results was found using parametric and non-parametric alternatives. Ordinal regression was therefore used for the multivariate analyses.

The AQoL-4D quality of life measure was scored using the algorithm in STATA²⁴ and transferred back to SPSS for analysis. The reverse-scored items of the HCS were recoded to ensure consistency of scaling.

The results of the univariate analyses (exploring associations with other factors) are presented. Multivariate analyses were undertaken using stepwise multiple regressions to explore the independence of factors associated with the health consciousness of Australians. The median score of 21 was used to dichotomise the sample into high health consciousness (HCS ≤21) and low health consciousness (HCS >21) groups. Assumptions of the final regression model were checked and there were no major violations. The stepwise modelling began with adding all eligible variables into the model, and proceeding backward (removing one variable at a time) until only variables explaining health consciousness at the P < 0.05 significance level were included.

Demographics, socioeconomic indicators, health status and health-care utilisation measures for the participants who completed the survey (n = 1529) are reported in Table 1. The overall mean HCS score was 20.9 (standard deviation [sd] 5.7), similar to the median (21; interquartile range [IQR] 18 – 25). A range of health service experiences and conditions were found to have small but statistically significant associations with HCS scores in univariate analyses (Table 2).

Table 1. Population comparisons for key individual characteristics

Table 2. Associations between individual characteristics and health consciousness

There were significant differences observed in the health consciousness of different sub-groups, as reported in Table 3. In rank order, the more health conscious group of Australians tended to be frequent users of emergency departments (mean [M] HSC score = 15.9); people hospitalised more than four times in the past 12 months (M = 16.8); people reporting very poor health status (M = 18.2), people nominating other types of employment such as a carer’s pension (M = 19.1); people who have experienced heart disease (M = 19.1) and ‘other’ cancers (M = 19.2); and people who most frequently access general practice services (M = 19.3). The less health conscious group had not attended a general practice appointment in the past 12 months (M = 24.1), were from remote areas (M = 23.8), seeking employment (M = 22.0), aged 18–24 years (M = 21.7), men (M = 21.5) and people living in areas with an accessible ARIA classification (M = 21.5).

Table 3. Differences in health consciousness levels between groups of respondents

The different trends were not uniformly linear. For example, people reporting they had very good health tended to be in the more health conscious group, with a mean score of 20.9 (typical of the overall population mean and just below the median cut-off score of 21). However, people reporting good health status were the least health conscious and people reporting the poorest health were the most health conscious, on average. There were significant differences between Queensland and South Australian residents, with South Australians tending to be significantly more health conscious (P = 0.026).

In multivariate analysis, after controlling for the influence of other variables, only a few factors predicted HCS scores (Table 4). The results suggest higher levels of health consciousness were associated with being female, single, having a health concession card, admission to hospital in the last 12 months and poorer quality of life (P < 0.000). This model has a relatively poor fit (R² = 0.105), indicating the influence of other factors not investigated in the survey.

Table 4. Multivariable regression analysis: relationship between individual characteristics, health status and health-care usage with health consciousness

The health consciousness of the Australian population is important to health professionals and policymakers working to promote health and prevent illness and injury. Apart from being a strategic imperative as part of efforts to reduce avoidable hospitalisations and improve population health outcomes, the current study demonstrates that health consciousness influences decisions to access care and be influenced by previous experiences of health care.¹⁴ Health consciousness is a distinct health attitudinal measure and the merit of including it in health research alongside other measures of individual characteristics of care has been established.¹⁴ Nevertheless, the health consciousness of Australians has not previously been reported. Gender, marital status, health concession cardholder status, previous hospitalisation and quality of life were individually associated with health consciousness, but the poor model fit and the influence of key demographic factors such as gender, health concession card status and relationship status suggest that other social factors that were not considered in this study may be additional drivers of health consciousness.

In this Australian study, small yet statistically significant differences were observed between different population groups. In general, higher levels of health consciousness were observed for more frequent users of emergency and general practice services, people admitted to hospital in the previous 12 months, concession cardholders and people with major morbidities or poor health. Many structural factors were also associated with lower health consciousness, such as being unemployed, younger, married and male. Small but statistically significant differences were observed between Queensland and South Australian residents, demonstrating a need to further explore the existence of and the reasons for any jurisdictional differences. Although there are limited survey administrations with comparable adult populations, HCS scores in this Australian population are somewhat less favourable than reported for other studies that have administered this scale.^3,8 For example, the mean Australian score of 20.9 (±5.7), compares to the mean of 20.0 (±8.5) observed for 349 adult New Yorkers in 1990.³ Whether the results of this study are anomalous or accurately reflect that Australians may be more inclined to take their health for granted (ie until they encounter a serious health problem), warrants further investigation.

In contrast to previous findings, this study found that personal health consciousness is most strongly influenced by proximal circumstances of ill-health or structural determinants (eg gender, socioeconomic status such as a concession card, and marital status). These findings may reflect higher morbidities in the sample than the general population.^14,15 However, this study consistently indicated that significant health problems are associated with higher levels of health consciousness, as expected, because people who are ill are likely to be more attuned to health information and open to receiving help and support. HCS scores for people with low self-reported health status may reflect health anxiety that could negatively affect quality of life, as indicated by the associations between health consciousness and quality of life, depression, anxiety and health service use. Nevertheless, previous research has indicated that health-conscious consumers are open to collaborative decision-making in health care and trust clinicians’ advice, suggesting it is an important precursor of self-management and health promotion.⁸

It may be counterintuitive that people in poor health were more health conscious. However, other results indicate that people who have worked in health care are more health conscious, suggesting that many Australians may not think about health unless their circumstances demand it. These findings require clarification and may raise concerns for public health professionals if they indicate that the general public does not think about their health unless they have to.

We acknowledge limitations to this study. Despite being matched to state demographics for age and sex, the respondent sample included a higher proportion of lower socioeconomic groups, who have greater burden of disease than generally noted in population studies. This may also reflect over-diagnosis of morbidity. We did not use probability weighting in the study. There were also insufficient numbers of Aboriginal and Torres Strait Islander participants to enable further analyses for this population group. The results are based on a cross-sectional study and further investigations are required to identify causalities. Objective measures of health status could yield additional insights that we could not explore in the current study.

Further research is needed to clarify the implications of these findings for health promotion and social marketing campaigns in the short term, and to inform population health approaches and health service planning and programming in the longer term. More targeted research may be needed to better inform mass health communication activities and target population strategies to improve health literacy and health consciousness.^3,25,26 The results of the current study nevertheless appear to support health promotion programmes that seek to better equip and support people to overcome sociodemographic barriers to their health (which were also associated with lower levels of health consciousness) and to increase community capacity for health promotion more broadly.

In highlighting the need to raise health consciousness, population health professionals may empower individuals (enhancing responsible and action-oriented people) and communities (accessing health information and local and community health facilities). The population’s general compliance with recent Covid-19 measures is promising to this end. Nevertheless, the findings that most Australians are not actively engaged or conscious of their health suggests a need to improve interpersonal or mass health communication activities.²⁷ Strategies could include targeting individuals and community groups with higher levels of health consciousness to garner their support to create more favourable conditions for community-based interventions,²⁶ targeting at-risk populations with low health consciousness with tailored interventions⁷ or a combination of both.²⁸ The results also demonstrate the need to consider specific demographic and societal factors (cultural and social factors) because of the significance of population differences.²⁸

Although a diverse range of factors is associated with health consciousness at the population level, the experience of a significant health condition is most likely to alter the degree to which people think about their health and take responsibility for their wellbeing. The Australian attitude of ‘she’ll be right, mate’ may prevail until a change in an individual’s health status or exposure to the health system demands otherwise. Further research is required to clarify the findings and their implications for health services, including the need to better understand the drivers of health consciousness among Australians as part of efforts to increase personal responsibility and engage more of the public in health-promoting actions.

The authors declare no competing interests.

This study was funded by the Australian Research Council (ARC).