Health inequity and mental health among homosexually active men

1
Health inequity and mental health among
homosexually active men

• Gary Rogers MB, BS, MGPPsych, FACPsychMed
• Director of Health in Human Diversity Unit
• Department of General Practice
• University of Adelaide

2
Universal Declaration of Human Rights (1948)
Eleanor Roosevelt 1884 - 1962
3
Universal Declaration of Human Rights (1948)
Article 2 Everyone is entitled to all the rights
and freedoms set forth in this Declaration,
without distinction of any kind, such as race,
colour, sex, language, religion, political or
other opinion, national or social origin,
property, birth or other status.
4
Universal Declaration of Human Rights (1948)
Article 12 No one shall be subjected to arbitrary
interference with his (sic) privacy, family, home
or correspondence, nor to attacks upon his honour
and reputation. Everyone has the right to the
protection of the law against such interference
or attacks.
5
Universal Declaration of Human Rights (1948)

• Arbitrary (adjective)
• based on random choice or personal whim.
• (of power or authority) used without constraint
  autocratic.
• Compact Oxford English Dictionary

6
Universal Declaration of Human Rights (1948)
Article 12 No one shall be subjected to arbitrary
interference with his privacy, family, home or
correspondence, nor to attacks upon his honour
and reputation. Everyone has the right to the
protection of the law against such interference
or attacks.
7
Health Inequality

• Are gay-identified or homosexually active men in
  primary care subject to mental health inequality?

8
The Care Prevention Programme

• Provides integrated multidisciplinary care and
  health promotion for people with HIV and people
  who may be at increased risk
• Stated focus on homosexually active men
• Comprehensive Primary Health Care model, per the
  Declaration of Alma Ata
• Department of General Practice, University
  of Adelaide
• Commenced Jan 1998
• Participants recruited during routine GP care

9
Participants
485 gay/ homosexual

• Gender Orientation

564 males
604 participants
542
43 bisexual
31 females
22 heterosexual
9 transgender
14 something else
10
Homosexually-active men
184 (34) HIV

• HIV Status on enrolment

542 Homosexually active men
333 (61) HIV -
25 (5) untested
11
Methodology

• Comprehensive health assessment on enrolment and
  12 - 24 monthly thereafter
• Integration of multidisciplinary care, based on
  their health goals, by Nurse Coordinator GP
  working closely with participant

12
Major depressive episode at enrolment(Prime-MD,
542 homosexually active men HAM)
NS
31
28
(6)
(3.4)
Andrews G, at al. The Mental Health of
Australians. Commonwealth Dept of Health and
Aged Care 1999. Linzer M, Spitzer R, Kroenke K,
et al. Gender, quality of life, and mental
disorders in primary care results from the
PRIME-MD 1000 study. Am J Med 1996101(5)526-33.
13
Dysthymic disorder at enrolment(Prime-MD, 542
HAM)
NS
28
26
(3.9)
(1.0)
Andrews G, at al. The Mental Health of
Australians. Commonwealth Dept of Health and
Aged Care 1999. Steiner M, Bell B, Browne G, et
al. Prevalence of dysthymic disorder in primary
care. J Affect Disord 1999 54(3)303-8.
14
Suicidal ideation in two weeks prior to enrolment
(Prime-MD, 542 HAM)
NS
P0.003
(20)
17
14
(10)
Jorm A, Korten A, Rodgers B, Jacomb P,
Christensen H. Sexual orientation and mental
health results from a community survey of young
and middle-aged adults. British Journal of
Psychiatry. 180423-7, 2002.
15
Anxiety Disorders at enrolment (Prime-MD, 542
HAM)
Andrews G, at al. The Mental Health of
Australians. Commonwealth Dept of Health and
Aged Care 1999.
16
sf36 at enrolment (542 HAM and SA Male Popn Norms)
Plt0.0001
Plt0.0001
P0.0152
Plt0.0001
Plt0.0001
Plt0.0001
Plt0.0001
P0.017
Plt0.0001
Behavioural Epidemiology Unit. South Australian
population norms for the Short Form 36 (SF-36)
Health Status Questionnaire. Adelaide South
Australian Health Commission, 1995.
17
Current tobacco use at enrolment (542 HAM)
P0.004
Higgins K, Cooper-Stanbury M, Williams P.
Statistics on Drug Use in Australia 1998.
Canberra Australian Institute of Health and
Welfare, 2000
18
Probable alcohol use disorder at enrolment
(Prime-MD, 542 HAM)
NS
Andrews G, at al. The Mental Health of
Australians. Commonwealth Dept of Health and
Aged Care 1999.
19
DeathsTotal 17
35 of deaths, cf 2 in Australia generally
Australian Bureau of Statistics. Suicides
Australia 1921 1998. Publication no 3309.0
20
Death rates

• Death rate
• 17 deaths among ...
• 476 men still in touch an average of 1799 days
  after enrolment
• 7.4 per 1000 per annum
• Mean age at death 45 (NS different from cohort)
• 3x the death rate for Australian males aged 45
  2.2/1000
• Suicide rate
• 2.6 per 1000 per annum
• 7x the peak suicide rate for Australian males
  0.37 at 25-44 yrs
• Despite any beneficial effect of the Programme

Australian Bureau of Statistics. Australian
Historical Population Statistics. Publication no
3105.0.65.001 Australian Bureau of
Statistics. Suicides Australia 1921 1998.
Publication no 3309.0
21
Suicidal Ideation Prior Two Weeks, (repeated
measures, N 228)
Plt0.001
Plt0.001
22
Health Inequity

• Margaret Whitehead, WHO Europe, 1991
• The concepts and principles of equity and health
• Not all health inequality is health inequity
• Inequity has a moral and ethical dimension
• Health inequity
• Differences in health profiles that are
  unnecessary and avoidable but, in addition, are
  also considered unfair and unjust.

23
Health Inequity

• Distinguish between
• Inequities in level and quality of health between
  groups
• Equity in health implies that ideally everyone
  should have a fair opportunity to attain their
  full health potential
• Inequities in the provision and distribution of
  health services
• Equity in health care is defined as
• equal access to available care for equal need
• equal utilisation for equal need
• equal quality of care for all

24
Health Inequity
Are gay-identified or homosexually active men in
primary care subject to mental health inequity?
25
Income (542 HAM vs SA males aged 35-44)
Median SA Males
Median HIV
Median HIV -/?
Australian Bureau of Statistics. South
Australian Basic Community Profile 2001.
Publication no 2001.0
26
Correlates of Major Depressive Episode
No longer significant when income controlled
for.
27
Correlates of Dysthymic Disorder
No longer significant when income controlled
for.
28
Correlates of Panic Disorder
29
Correlates of Generalised Anxiety Disorder
No longer significant when income controlled
for.
30
Correlates of Tobacco Use
No longer significant when income controlled
for.
31
Bullet-proof myth
32
Health Service Inequity
This Programme and clinic is non-threatening.
There is never ever any worry about the fact of
my sexuality. I feel comfortable coming here. I
feel a great sense of privacy when I am here. I
am pleased to know that there is a holistic gay
service here in Adelaide. Run by gay men and
women or those who are absolutely relaxed about
it all. This is an important element knowing
that one can feel absolutely comfortable coming
here.
33
Health Service Inequity
There is a comfort about O'Brien St. One is
comfortable that being a gay male is the norm
here and for all of us this is not an unusual
thing. Being gay is not the thing that makes us
unique. Being a brilliant Accountant, or Tennis
Player, or Judge is the quality that makes us
unique not our sexuality. At O'Brien St, we can
comfortably put our sexuality in the background
and get on with our health care matters.
34
Health Inequity
Can Primary Health Care make a difference?
35
A Primary Health Care approach

• challenges the society to address the
  socio-economic causes of poor health and makes
  provision for basic health needs
• encourages community empowerment
• provides comprehensive quality health care
• demands concerned and accountable health worker
  practice
• prioritises the people who are most disadvantaged
  ensuring that health care is accessible,
  equitable and affordable to all
• recognises the importance of integrated service
  provision from primary to tertiary levels of care
  within a coherent health system
• promotes inter-disciplinary, multi professional
  and intersectoral collaborative teamwork for
  development

The (South African) National Progressive Primary
Health Care Network. Definition of progressive
primary health care, 2000.
36
Change in Overall sf36 Profile, (repeated
measures n 228)
37
Major Depressive Episode Prevalence, (repeated
measures, N 228)
Plt0.001
Plt0.001
38
Major Depressive Episode Prevalence, (repeated
measures, N 235, suicides assumed MDE)
Plt0.001
Plt0.001
39
Dysthymic Disorder Prevalence, (repeated
measures, N 228)
Plt0.001
Plt0.001
40
Dysthymic Disorder Prevalence, (repeated
measures, N 234, suicides assumed DD)
Plt0.01
Plt0.001
41
Conclusions

• Homosexually active men do appear to have
  differences in their health status compared with
  men in the general community
• Some of these health differences appear to be
  associated with markers of injustice and
  unfairness and so may be examples of health
  inequity
• A specialised, targeted, culturally appropriate
  comprehensive Primary Health Care programme is
  associated with mitigation of health inequity
• Reconciliation?

42
The Health in Human Diversity Unit is funded
by The South Australian Department of Health
and supported by unrestricted grants from Glaxo
SmithKline Boehringer Ingelheim Abbott
Australasia Roche Products
gary_at_careandprevention.org