The economic dynamics and population change of Australia's regional cities

Key points This analysis is based on data from the 2011 and 2016 censuses, and does not take into account the redistributions and changes that may have occurred with COVID-19. This report can be seen as providing a baseline for subsequent analysis of the changes that have occurred and continue to occur, identifying the trends and conditions across regional Australia's urban centres prior to 2020. Populations in regional urban centres are growing overall—however, this growth is differentiated. Regional urban centre population growth is associated with proximity to major cities, and to coastal locations. Regional urban centre population decline is associated with remoteness and exposure to the resource economy. Capital cities are the main source of migration to regional urban centres, principally coastal and satellite centres with regional-to-regional-centre migration highly self-contained. International migration follows similar distribution. Commuting between regional centres and proximate capital cities increased over 2011–2016, indicating increased peri-metropolitan dependency on metropolitan interactions. Employment growth is associated with population growth, particularly for the larger metropolitan satellite and coastal regional cities—however, this is also associated with lower wage growth due to the employment mix. Health, community service, construction, hospitality and accommodation increased their share of regional employment. Industries associated with agglomeration economies are concentrating in fewer urban centres, while those associated with population services are becoming more dispersed. National economic growth factors appear to expert greater influence on employment growth in regional urban centres, while industry factors exert very limited influence. Regional effects exert greater influence than industry effects, although these are unevenly distributed. In 135 of 198 cases, a regional urban centre exhibits employment growth along with its surrounding functional economic region. For 33 regional urban centres there is positive divergence, while for 25 there is negative divergence. Four regional urban centres are declining within a declining functional economic region. Factors associated with stronger employment growth include employment factors, industry factors (especially those dependent on population growth), while income growth was less associated with employment growth. Population change exerted a strong influence on employment growth, as did human capital factors. Housing market (i.e. price) growth is strongly associated with population growth, while locational factors exhibited low associations. Cluster analysis identified nine distinctive regional urban centre groups: metro-satellites;large regional cities;medium growth cities;regional service centres;ageing population centres;agricultural centres;mining centres;industrial centres, and northern Queensland centres. Policy development should consider the following: Policy and planning measures to address the phenomenon of growth in metropolitan satellite regional urban centres, and the need to ensure coherent population, housing and employment distribution and linkages. Coordinated economic and social development approaches to emerging low-income service economies in coastal regional urban centres. Long-term transition planning to address resource-dependent regional urban centres facing cyclical economic changes based on the labour intensity of construction relative to ongoing economic activity. Opportunities and mechanisms to leverage high-wage economic development from existing regional city industry clusters. Opportunities and mechanisms for regional spatial coordination of fiscal policy to optimise development of high-wage employment in suitable regional urban centres. The study Purpose The contribution of regional urban centres to Australia's economic and population growth has been a topic of growing policy interest in the past two decades, as a result of rapid growth in the major cities and concerns for parts of regiona Australia that have experienced population decline. Associated with these trends is the distribution of economic activity and employment—particularly as traditional regional strengths such as agriculture, manufacturing and mining have declined as sources of employment in recent decades. Over the same period, metropolitan areas have prospered because of concentrations of high-skill, high-wage knowledge work, indicating diverging regional fortunes as a result of wider economic trends. The purpose of this research is to investigate patterns and dynamics of population, migration and economic change in Australian regional urban centres 2011–2016. The research is principally an empirically focused investigation identifying patterns and dynamic processes of regional change using advanced spatial analytical techniques, but provides an information base that will support future policy development efforts. Inquiry This research is part of a wider AHURI Inquiry into population growth in Australia's smaller cities. The Inquiry asks two overarching questions: First, what is the capacity of Australia's smaller cities to assist in managing national population growth, including international and national migration? Second, which policy instruments and programs are most likely to redirect population movements to these locations? Study This research investigates two overarching questions related to the Inquiry: How can we differentiate Australia's regional urban centres according to economic profile, population trajectory, industry structure and geography? What are the current mobility and settlement patterns of migrants, including those arriving from other parts of Australia and from other nations, across these smaller cities? Three further research questions are posed by this project: 1. How can a typology of smaller cities assist to understand their role in regional, state and national economies? 2. How are Australia's regional urban centres differentiated in terms of economic profile, population trajectory and industry structure? 3. What demographic, economic and spatial factors are associated with economic and population growth, and what attributes are associated with better economic performance of regional urban centres? Approach and methods For Research question 1: the project undertakes longitudinal measures of social, demographic and industry change in regional cities 2011–2016 using Australian Bureau of Statistics (ABS) census data. Next, flow analysis and mapping of migration is applied to identify key migration patterns. Migration flows are used to construct migration regions via modularity analysis. Similar techniques are used to identify journey to work flows from which functional economic regions are constructed. Shift share of employment change and location quotient analysis of employment is used to understand economic change and industry structure. For Research question 2, to understand how Australia's regional urban centres are differentiated the project applies hierarchical cluster and discriminant analysis to construct a typology of regional urban centres. This is based on a combination of economic, demographic and geographic factors. These are compiled into summary data and descriptive explanations. For Research question 3: the study applies structural equation modelling (SEM) to identify the relationships between economic, social and demographic factors affecting population change and economic growth in regional urban centres. Key findings Differentiating Australia's regional urban centres Australia's regional urban centres are heterogeneous in terms of size, location within the Australian continent and settlement structures, level of employment, industrial mix and degree of interaction with regional, metropolitan, national and international economic processes and dynamics. In 2016, there were 198 Australian regional urban centres that had populations greater than 5,000 residents. Most are experiencing population growth. However this growth is differentiated across a range of factors, including: t e existing size of the centre location relative to the coast location relative to an existing major capital city. A small number of regional urban centres are experiencing population decline. These centres are largely associated with the resource economy. They are typically positioned in remote locations in Australia. Migration Migration is a major factor in population change within regional urban centres. Migration patterns are clearly structured at the regional scale, with distinct geographies of intra-regional movement that include discernible levels of self-containment. There is a sizeable phenomenon of major city to regional urban centre migration, especially in the south-east of Australia. Beyond the major metropolitan zones, there are larger internally connected migration regions, which often involving movement between adjacent regional urban centres. Some regional urban centres lose and receive populations across long distances. For example, the Northern Territory (NT) operates as a single migration region, partly because of its relatively small population and large scale—although the volumes of movement are relatively small. © Australian Housing and Urban Research Institute Limited 2022.

Growing Australia's smaller cities to better manage population growth

Key points This report examines the capacity of Australia's smaller cities to accommodate a larger percentage of the nation's population growth. It finds that: In the absence of purposeful action, a growing percentage of Australians will live in our largest cities in 20 years. Most immigrants move to the largest metropolitan areas, and a fundamental reshaping of our immigration system is needed if this pattern is to be reversed. Change, however, is possible. Many moving to smaller cities come from other parts of non-metropolitan regions, although the processes of sea change and tree change have reshaped this pattern over the past 20 years. Young people commonly leave smaller cities and regional areas for education and employment opportunities. There is a weak link between employment growth in smaller cities and population growth and the direction of the relationship varies from place to place. Much of the employment growth in these places has been in low paid employment, and there is a need to reverse this trend and increase the mix of industries growing in these places. Policies to attract more Australians to smaller cities need to focus on the Aspirational Changers segment of the population (21 per cent of the total) and the Lifestyle Maximisers (54 per cent). There are viable policy options for governments seeking to promote the growth of smaller cities, including place-based policy frameworks that concentrate investment and quality of life gains in a defined set of centres, further development of these localities as retirement destinations and their growth as education and research hubs. Key findings In broad terms the research found smaller cities experienced a range of processes shaping their populations over the period 2011–2016. ] Absolute population growth was highest amongst smaller cities located in coastal regions next to the two major cities in south-east Australia, indicating population concentration in regional Australian settlements. By contrast, population decline was concentrated in inland and remote towns, particularly in centres associated with resource industries. The processes of population concentration in fewer and larger regional settlements evident in the 20th century appears continued (BITRE 2014). International migration was largely similar, with most relocating to larger regional urban centres. Smaller cities are the first destination of few international arrivals. Many internal migrants relocating to smaller cities come from other parts of non-metropolitan Australia. ‘Sunbelt' cities have fared better than regional centres in southern Australia over recent decades, but this growth may be a product of population, rather than economic, processes. There is a long standing pattern of accelerated growth amongst coastal cities on the eastern seaboard. Growth is also more pronounced in smaller cities closer to a major metropolitan region. In some regions, larger regional centres are growing as nearby smaller settlements decline. COVID-19 had a muted impact on the movement of population to smaller cities, with the greatest impact in Victoria. Importantly, fundamental change is possible but a definitive conclusion on likelihood cannot be reached at this stage. The research categorised population change into three main groupings: Larger regional cities that are close to a major (state capital) cities grew more (by count) than other regional areas. Coastal urban centres gained more population than inland urban centres. Regional urban centres in northern coastal NSW and Queensland in particular continued to grow rapidly. Population losses tended to be concentrated in inland, smaller, remote and often resource reliant towns. These patterns may be associated with continuing weakness and employment declines in traditional regional industry sectors such as agriculture, or with transitions within resource extractive industries, following the mining infrastructure investment boom of the late-2000s and early-2010s. The patterns of Indigenous population change reflected overall population patter s but diverged also. Indigenous population growth was greatest in some coastal localities, though these were not always the same places where the non-Indigenous population is increasing. Some inland localities without large overall growth saw substantial growth in Indigenous residents. Economically smaller cities are a highly differentiated group, with the processes of growth and decline influenced by individual histories and geographies. Broad patterns can be identified amongst groups of smaller cities. The national economy and policy has had a significant impact on the growth of smaller cities. The liberalisation of the Australian economy post 1984 and the rise of service industries has not benefited smaller cities specialised in manufacturing and agriculture, but has assisted some mining centres. National economic policy change has further reinforced the expansion of the major metropolitan centres. Australia's smaller cities commonly have highly specialised and trade-exposed economies, resulting in periods of ‘boom' and ‘bust' as industries cycle through swings in global markets. There is clear evidence that endogenous growth processes are very weak in many parts of regional Australia, including amongst the economies of smaller cities. Much of the aggregate economic growth across regional Australia trails population growth, that is growing populations lead an expansion of employment. The research found that programs to encourage relocation to smaller cities are likely to gain traction with Australian residents if the appropriate population groups are targetted. State preference analysis found four distinct segments, or classes, across the Australian population, differentiated by their willingness to live in large and mid-sized cities. Critically the four classes provide a guide to the targeting of policy measures: Classes 1 (the Urban Careerists) and 4 (the Small is Best), together comprising 25 per cent of the sample population, displayed distinct preferences for large and mid-sized cities, respectively, and were unlikely to change their preferences. Individuals in Class 1 were young urban professionals who valued living in large cities. Individuals belonging to Class 4 tended to be older individuals employed part-time or retired, valued quality-of-life benefits from living in smaller cities, and were equally reluctant to move to a large city. Classes 2 (Aspirational Changers) and 3 (Lifestyle Maximisers) comprised the remaining 75 per cent and were more open to moving to a mid-sized city. Individuals belonging to Class 2 were more likely to be a mix of young individuals living in single or shared households, and the middle-aged in households with children. They tended to be university educated and employed full-time in high-wage managerial or professional jobs. They prioritised employment and education opportunities and were likely to move to mid-sized cities if they could offer comparable opportunities. Individuals in Class 3 were older, and employed part-time in lower paying jobs or retired. They placed high importance on quality of life, local healthcare, housing and other living costs. They viewed mid-sized cities as excellent places to retire, and would be encouraged to move there if they could get support for post retirement living. A sense of community remains an important feature of life in smaller cities, helping retain population and building a sense of cohesion. This sense of community contributes to the pattern of movement between smaller cities and other regional centres as individuals seek comparable living environments. The natural and other amenity of smaller cities is much valued by residents and it too remains a factor in the retention of residents in smaller cities, as well as the attraction of migrants from the capitals. High quality, affordable housing remains an important attractant for smaller cities but it needs to be balanced out with significant employment opportunities in order to encourage the growth of these places. Residents in smaller cities were wary of growth for its own sa e. While many see advantages, there are concerns these may be exceeded by the disadvantages. Planning policies have had unequal outcomes across the Australian states. In NSW programs were developed that led to success, while the SA experience highlighted the limitations of approaching regional planning as an administrative exercise, distant from other programs of investment and development;and, Evidence-informed approaches that concentrate resources in places with both a record of growth and the potential for further expansion will be more successful. Policy development options This research examined the ways in which the policy landscape in Australia could be adjusted to promote the growth of smaller cities in order to deliver better outcomes for all Australians. Critically, one dimensional or simple policy measures are unlikely to deliver growth to smaller cities, instead a more holistic approach is required that draws together a number of actions. All, however, are eminently achievable, with either a track record of success in Australia or internationally. The research drew on the findings to consider five policy options: Option 1: Maintain existing policy settings and do not introduce new programs or initiatives Option 2: Further develop and activate land use planning to support the development of smaller cities Option 3: Develop a portfolio of place-based policies that seek to concentrate investment in a limited number of smaller cities Option 4: Implement policies that encourage the growth of further education in smaller cities Option 5: Expedite the growth of smaller cities as preferred places of residence for older Australians, including retirees. The research concluded that Option 1 was unlikely to deliver additional growth for Australia's smaller cities becausewhile current policy settings resulted in long term national economic growth, smaller cities largely lagged the very largest cities. Moreover, the population outcomes evident under contemporary policy settings are a product of deeply entrenched patterns and processes, and change in the external environment is essential if the nation is to achieve better outcomes. Option 2 was assessed to have real potential for delivering growth for smaller cities. However, this policy domain remains firmly the remit of the Australian states, which makes the achievement of positive outcomes in all parts of the nation more challenging as each jurisdiction has their own frameworks and settings. In addition, statutory planning systems are based in legislation and are therefore not adjusted easily or quickly. Option 2 also calls for a strong level of co-ordination and integration across the portfolios of governments, with planning, service delivery and infrastructure investment brought together to deliver growth locally. While this has been achieved in NSW, other states have either not prioritised the growth of smaller cities or have failed to develop integrating mechanisms. The further development of the planning system to deliver the growth of smaller cities can be assessed as having considerable potential, but would struggle to deliver uniform outcomes at the national scale. Option 3 draws on both national and international experience and seeks to both empower local decision makers to encourage growth, and provide a select number of smaller cities with a pathway to expedited growth. To a degree, Option 3 builds on established policy frameworks such as the City and Regional Deals, but more fundamentally it represents an approach that tailors growth investment to the opportunities evident in each locality. It is an approach that calls for both investment by the senior tiers of government and buy-in locally, and is likely to require a long-term investment of policy attention and capital. The available international evidence suggests strong prospects for success, with the OECD as strong advocates of place-based polices. Option 4 specifically addresses two of the evident weaknesses in the economic and demographic structures of smaller cities. First, most regional centres ex erience the loss of young people to the metropolitan regions as they seek employment and education opportunities. Second, many of these places have lower incomes and few well paid jobs, and the evidence within this research suggests much of their employment growth has been in low-paying employment. Option 4 seeks to redirect policy attention and resourcing in higher education and research to smaller cities in order to attract and retain young people in these places, and more closely integrate smaller cities into the global knowledge economy. This option would not require additional funding, but would require a redirection of resources. Option 5 seeks to further enhance the attractiveness of smaller cities as places for retirement for older Australians. It acknowledges that these places are already attractive to a significant percentage of older Australians and that this could be further enhanced through additional investment in health care and other services targetted at this age group. Such investment would also generate employment for other age cohorts. This option has a strength in harnessing the growth potential embedded in already established patterns within the economy and the population, and would potentially come at modest cost to Australian governments. It may, however, further entrench the lower income structures evident in a number of smaller cities. Finally, it is important to acknowledge the policy options discussed in this report are not mutually exclusive. Governments could potentially implement a portfolio of actions to maximise the prospects of smaller cities and associated regions. A portfolio approach would create opportunities for participation by all tiers of government and allow for a focus on the development of these places, rather than a simple focus on growth. The study The overarching aims of the Inquiry were addressed through three associated projects. Each of the projects focussed on Australia's non-capital cities including the larger satellites, such as Newcastle, Wollongong, Geelong and the Gold Coast. The Inquiry examined all Australian jurisdictions, effectively establishing a nation-wide evidence base. The analysis focussed on urban centres with a population of 50,000 or more and in states with fewer than three urban centres reaching this threshold, it considered the three largest non-metropolitan centres in that jurisdiction. In addition, for technical reasons, Project B examined all urban centres with a population of 5,000 or more. © Australian Housing and Urban Research Institute Limited 2022.

Examining Risk Factors Related to Cardiac Rehabilitation Cessation among Heart Transplant Recipients

Background Cardiac rehabilitation (CR) has shown clinical benefit in heart transplant (HT) recipients. However, variable adherence with CR has been reported. We aimed to describe adherence and factors associated with CR cessation. Methods We performed a retrospective chart review of HT recipients who attended at least one CR session at a tertiary medical center (2013-2021). Complete adherence was defined as participation in all 36 CR sessions. We extracted participant age, sex, race, BMI, diabetes, creatinine clearance, post-operative complications (reoperation, major bleeding, infection, or need for dialysis), hospital length of stay, and METs on baseline exercise tolerance test prior to CR. We computed the proportion of HT recipients who did not complete CR, and then compared their characteristics to those of HT recipients with complete adherence using Kruskal Wallis tests and Fisher's Exact tests for continuous and categorical variables, respectively. Primary reasons for cessation were extracted from the electronic health record. Results There were 55 HT recipients (median age 55.9 years, 67.3% male) who attended CR;25 (45.5%) had complete adherence. Thirty did not complete CR (14 patients attended 1-12 sessions, 12 patients attended 13-24 sessions, and 4 patients attended 25-35 sessions) and participated in a median of 13 sessions (IQR 9-21). Within this group, 46.7% reported medical reasons for cessation, 20.0% for personal reasons, 13.3% for COVID-19 pandemic, 6.7% for insurance expense, 3.3% for relocation, and 3.3% for return to work or school. Patients who did not complete CR experienced more post-operative complications after HT (63.3% vs 32.0%, p = 0.03) but there were no other differences in characteristics between groups. Conclusion Nearly half of HT recipients in our sample had complete adherence to CR. Among those who did not complete CR, medical reasons were most commonly cited. Postoperative complications predicted CR cessation, but there were no other differences between groups, albeit with a relatively small sample size.Copyright © 2023 American College of Cardiology Foundation

Cuban Public Healthcare, Economic Scarcity, and COVID-19 Management

This essay employs the author's 1992 through 2010 in-country field research with Cuban citizens, particularly Afro-Cubans/Blacks/Afrodescendientes, and extensive documentary review to examine Cuba's national Public Healthcare Delivery System. The examination begins with a contextual summary of the island's three military struggles for national independence and sovereignty. Removal of most US business’ influences from the island after the revolution brought US-led economic trade embargoes and sanctions that produced sixty years of resource scarcity. This is the contemporary context of Cuba's healthcare system's ability to cope, innovate, and garner international data reports on its healthcare performance. Such reports reveal that on most indicators, the island regularly surpasses many highly developed nations and many others not under economic sanctions. The essay's final discussion is of the island's management of the COVID-19 crisis and its internal development of some five vaccines against the disease. © 2002 Taylor and Francis.

RISK FACTORS FOR INCOMPLETE TELEHEALTH APPOINTMENTS AMONG PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Introduction: The start of the COVID-19 pandemic in March 2020 led to an increased rate of telehealth visits. Older adults, however, may be more vulnerable to missing appointments given cognitive, physical, and technological gaps. We looked to determine the completion rate of telehealth appointments for older adults with inflammatory bowel disease (IBD), as well as predictors of incomplete appointments. Methods: We conducted a retrospective analysis of all patients with IBD who had at least one telehealth visit at the NYU IBD Center between 3/1/2020-8/31/2021. Only the status of the first telehealth appointment was considered, with an incomplete visit defined as left before being seen, a cancellation or noshow. Medical records were parsed for relevant co-variables, and logistic regression was used to estimate the adjusted association between demographic factors and telehealth appointment completion rates. Results: From 3/1/2020 to 8/31/2021 there were 2,508 patients with inflammatory bowel disease (IBD) who had at least one telehealth appointment, with 1088 (43%) having Crohn's disease (CD), 1037 (41%) having ulcerative colitis (UC), and 383 (15%) with indeterminate colitis (Table 1). Of the 2,508 initial telehealth visits, 519 (21%) were not completed, including 435 (20%) among patients under the age of 60-years as compared to 84 (23%) among patients over the age of 60-years. On multivariable analysis, patients with CD had higher odds of an incomplete appointment as compared to patients with UC (adjOR 1.37, 95%CI 1.10-1.69). Additionally, females had significantly higher odds of an incomplete appointment vs. males (adjOR 1.26, 95%CI 1.04-1.54), and patients who had a non-1st degree relative listed as an emergency contact also had significantly higher odds of an incomplete appointment vs. those with a spouse listed (adjOR 1.69, 95%CI 1.16-2.44;Table 2). Age over 60-years, partnership status, and comorbidities were not associated with appointment completion rates. Among the 361 patients over the age of 60-years who had a telehealth appointment, sex, emergency contact information, IBD subtype, and partnership status were not found to be associated with odds of completing a telehealth appointment. Conclusions: In our study, older patients with IBD were not at higher risk for missed telehealth appointments as compared to younger patients. On multivariable analysis, patients with CD as compared to patients with UC, females as compared to males, and patients who had a non-1st degree relative listed as an emergency contact as compared to those who had a spouse listed were more likely to miss telehealth appointments. Future studies should explore the role of these factors, including the role of social support, in order to design interventions aimed at limiting missed telehealth appointments. (Table Presented) (Table Presented)

Impact of COVID-19 on Physical Activity, Diet, and Stroke Awareness in Homeless Individuals of Chicago

Objective: This research aims to characterize stroke awareness in homeless individuals of Chicago while providing guidance on stroke recognition and response. Additionally, we aim to assess the effects that the COVID-19 pandemic and social isolation have on stroke risk factors. Background: Strokes occur every 40 seconds in the United States and are one of the leading causes of preventable death and debilitation for both men and women. Higher stroke mortality rates occur in neighborhoods with larger proportions of Black residents and lower median incomes. Some physicians are concerned that risk factors for stroke such as physical inactivity and poor diet have worsened in the setting of the COVID-19 pandemic and have led to an even higher risk stratification in these populations. Design/Methods: A 53-item stroke survey along with health and wellness questionnaires were administered to 40 residents at A Safe Haven, a social enterprise serving the homeless. Participants were recruited at random from a booth on-site. Results: The majority of participants were Black (n=36/40) with most being between the ages 30-44. Participants identified as male (n=18) or female (n=22). Those surveyed endorsed decreased physical activity levels (m=2.2/5) and increased screen time (m=4.0/5) since the beginning of the pandemic. Subjectively worse dietary changes were reported in 78% of participants since the pandemic began. Stroke symptom and risk factor awareness was poor in 29%, fair in 40%, and good in 31% of participants. Among those surveyed, 45% agreed they would not be able to recognize a stroke and 55% agreed they would not know what to do if they witnessed a stroke. Conclusions: These data suggest that poor stroke awareness, decreased physical activity levels, and worsening dietary habits have become more prevalent among homeless populations in Chicago during the ongoing pandemic. Our goals of promoting healthy lifestyles and raising stroke awareness are particularly important during this time.