The maternal health behaviours of non-Irish nationals during pregnancy and the effect of time living in Ireland.

OBJECTIVES: Maternal health behaviours (MHBs) can influence pregnancy outcomes. Despite efforts internationally to encourage positive MHBs, women often fail to comply with pregnancy guidelines. International studies show differences in MHBs between nationalities and an effect of time spent in the host country. There is limited Irish data in this area, with no previous research relating to the effect of time in Ireland. STUDY DESIGN: This study is a cross-sectional analysis of the Growing Up in Ireland infant cohort, a nationally representative longitudinal study. METHODS: Examination of the MHBs of non-Irish nationals during pregnancy and the effect of time in Ireland on the said behaviours. RESULTS: An association was found between time spent in Ireland and increased alcohol consumption prevalence. Those living in Ireland for ≤5 years were 60.8% less likely to consume alcohol during pregnancy (0.000) and 29.3% less likely to take folic acid before conception (0.021). Those who smoked during pregnancy were 98.6% more likely to consume alcohol (0.000) and those who consumed alcohol were 95.2% more likely to smoke during pregnancy (0.000). CONCLUSIONS: The results demonstrate differences in MHBs and the influence of time living in Ireland. These findings are of relevance for policy and intervention planning to optimise pregnancy outcomes among non-nationals.

Prevalence and factors associated with depression and depression-related healthcare access in mothers of 9-month-old infants in the Republic of Ireland.

AIMS: Untreated maternal depression during the postpartum period can have a profound impact on the short- and long-term psychological and physical well-being of children. There is, therefore, an imperative for increased understanding of the determinants of depression and depression-related healthcare access during this period. METHODS: Respondents were 11 089 mothers of 9-month-old infants recruited to the Growing Up in Ireland study. Of this sample, 10 827 had complete data on all relevant variables. Respondents provided sociodemographic, socioeconomic and household information, and completed the Center for Epidemiologic Studies Depression Scale (CESD). RESULTS: 11.1% of mothers scored above the CESD threshold for depression. 10.0% of depressed mothers and 25.4% of depressed fathers had depressed partners. Among depressed mothers, 73.1% had not attended a healthcare professional for a mental health problem since the birth of the cohort infant. In the adjusted model, the likelihood of depression was highest in mothers who: had lower educational levels (odds ratio (OR) 1.26; 95% confidence intervals (CIs) 1.08, 1.46); were unemployed (OR 1.27; 95% CIs 1.10, 1.47); reported previous mental health problems (OR 6.55; 95% CIs 5.68, 7.56); reported that the cohort child was the result of an unintended pregnancy (OR 1.43; 95% CIs 1.22, 1.68), was preterm (OR 1.35; 95% CIs 1.07, 1.70), or had health/developmental problems (OR 1.20; 95% CIs 1.04, 1.39); had no partner in the household (OR 1.33; 95% CIs 1.04, 1.70) or were living with a depressed partner (OR 2.66; 95% CIs 1.97, 3.60); reported no family living nearby (OR 1.33; 95% CIs 1.16, 1.54); were in the lowest income group (OR 1.60; 95% CIs 1.21, 2.12). The primary determinant of not seeking treatment for depression was being of non-white ethnicity (OR 2.21; 95% CIs 1.18, 4.13). CONCLUSIONS: Results highlight the prevalence of maternal depression in the later postpartum period, particularly for lower socioeconomic groups, those with previous mental health problems, and those with limited social support. The large proportion of unmet need in depressed mothers, particularly among ethnic minority groups, emphasises the need for a greater awareness of postpartum mental health problems and increased efforts by healthcare professionals to ensure that mothers can access the required services.

Recent Trends in Vaginal Birth After Caesarean Section.

In developed countries, caesarean section (CS) rates continue to escalate and in Ireland nearly one in three women are now delivered by CS. The purpose of this study was to compare the management of women after one previous CS in two large Dublin maternity hospitals with the management in two other well-resourced countries. Data were analysed for Dublin, Massachusetts in the United States, and Hesse in Germany. It was found that since 1990, the CS rate in Dublin has increased by much more than in the other areas. This increase may be explained by the precipitous fall in the vaginal birth after CS rate because the rates in Massachusetts and Hesse in 1990 were initially much lower. Changes in the clinical management of women with one previous CS are a major contributor to the rising CS rates and are likely to be an ongoing driver of CS rates unless clinical practices evolve.

CASP-19 special section: how does chronic disease status affect CASP quality of life at older ages? Examining the WHO ICF disability domains as mediators of this relationship.

OBJECTIVES: The effect of chronic disease status on quality of life (QoL) has been well established. However, less is known about how chronic diseases affect QoL. This article examines impairment in three domains of the WHO International Classification of Functioning, Health and Disability (ICF) - body function, activity and participation, as well as affective well-being, - as potential mediators of the relationship between chronic disease and QoL. METHOD: A cross-sectional sample (n = 4961) of the general Irish community-dwelling population aged 50+ years was obtained from the Irish Longitudinal Study of Ageing (TILDA). The CASP measure of QoL was examined as two dimensions - control/autonomy and self-realisation/pleasure. Structural equation modelling was used to test the direct and indirect effects of chronic disease on QoL, via variables capturing body function, activity, participation and positive affect. RESULTS: A factor analysis showed that indicators of body function and activity loaded onto a single overall physical impairment factor. This physical impairment factor fully mediated the effect of chronic disease on positive affect and QoL. The total effect of chronic disease on control/autonomy (-0.160) was primarily composed of an indirect effect via physical impairment (-0.86), and via physical impairment and positive affect (-0.45). The decomposition of effects on self-realisation/pleasure was similar, although the direct effect of physical impairment was weaker. The model fitted the data well (RMSEA = 0.02, TLI = 0.96, CFI = 0.96). CONCLUSION: Chronic disease affects QoL through increased deficits in physical body function and activity. This overall physical impairment affects QoL both directly and indirectly via reduced positive affect.

Trends in socio-economic inequalities in mortality by sex in Ireland from the 1980s to the 2000s.

BACKGROUND: It has been recognised for some time that mortality rates vary across social class groups, with lower rates in the higher social classes. Internationally, but particularly in Ireland, many studies on the topic of inequalities in mortality have been confined to men, partly because the most frequently used socioeconomic classification, that based on occupation, can less easily be applied to women. Where research does exist, studies indicate that health inequalities are greater for men than for women. Given the issues around classification, there remains however, little knowledge of the socio-economic inequalities in female mortality in Ireland. AIMS: Using annual mortality data from the Irish Central Statistics Office over the period 1984-2008 this paper calculates crude and standardised mortality rates per 100,000 population for men and women in different socio-economic groups (SEG) and examines trends in these over time. This means that for the first time, longitudinal comparisons can be made between men and women across an important period of recent Irish history. RESULTS: There is a significant gradient in mortality rates across SEG for both men and women with the absolute and relative differential between professional and manual occupational groups increasing between the 1980s and 2000s even though the mortality rates were falling over time for all SEG groups for both sexes. CONCLUSIONS: The results confirm international findings that women generally have smaller gradients than men across SEG with the ratio of male/female differentials (i.e. the ratio of the male SEG rate ratio to the female SEG rate ratio) decreasing between the 1980s and 2000s from 1.25 to 1.07.

Social class variation in the predictors of rapid growth in infancy and obesity at age 3 years.

OBJECTIVE: To examine the extent to which early child nutrition, maternal antenatal lifestyle behaviours and child diet and lifestyle explain social class inequalities in the risk of rapid weight gain between birth and 3 years and obesity at age 3 years. DESIGN: A longitudinal and prospective birth cohort study. SUBJECTS: Nationally representative sample of 11,134 children and their parents followed from 9 months of age until 3 years. Child weight and maternal height and weight were measured at 9 months and 3 years and child birth weight was extracted from hospital records. Other predictors of child growth and obesity were collected by maternal report at 9 months and 3 years. RESULTS: Although born lighter on average, children of unskilled manual parents were 274 g heavier than children of professional parents by 3 years of age. The fully adjusted model of rapid growth from birth to 3 years of age and obesity at 3 years of age accounted for all social class differentials. Breastfeeding and age at the introduction of solids were associated with the largest average reduction (41%) in the odds ratio (OR) of rapid growth in the first 9 months of life for each class relative to the professional class. In the period from 9 months to 3 years of age, the class differential in rapid growth was reduced most by measures of the child's diet and lifestyle. However, the impact of the groups of predictors varied by social class. For early life growth, among the non-manual classes the proportionate reductions are largest when adjusted for early infant nutrition, whereas maternal prenatal smoking is more important for the manual social classes. CONCLUSION: Preventative interventions to reduce levels of childhood obesity should be multi-dimensional but different dimensions should be given more or less significance depending on socio-economic group.

International variation in caesarean section rates and maternal obesity.

This study examined variations in caesarean section (CS) rates associated with a woman's birthplace and differences in maternal adiposity. Women were enrolled in the 1st trimester. Maternal adiposity was assessed by body mass index (BMI) and bioelectrical impedance analysis (BIA). Irish women were compared with women born in the 14 countries who joined the European Union (EU) before 2004 (EU 14), and with those born in 12 countries who joined following enlargement (EU 12). Of the 2,811 women enrolled, 2,235 women were born in Ireland, 100 in EU 14 countries and 476 in EU 12 countries. Based on a BMI > 29.9 kg/m(2), maternal obesity was higher in Irish (19.8%; n = 443) and EU 14 women (19.0%; n = 19) compared with EU 12 women (9.5%; n = 45), p < 0.001. BIA of maternal body composition confirmed increased adiposity in both the Irish and EU 14 women. Variations in emergency CS rates in primigravidas based on the woman's birthplace were associated with maternal adiposity and induction of labour, both modifiable risk factors for CS. We recommend, therefore, that induction of labour in obese primigravidas should be undertaken only in carefully considered clinical circumstances. Our findings also suggest economic development in Europe may drive an increase in the CS rates mediated through increased levels of maternal obesity and, therefore, public health interventions should focus on optimising a woman's prepregnancy weight.

Evaluation of index and profile measures of health status in a randomized controlled trial. Comparison of the Medical Outcomes Study 36-Item Short Form Health Survey, EuroQol, and disease specific measures.

OBJECTIVES: The authors compare two generic measures of health status with disease-specific measures in a randomized controlled trial of transurethral resection of the prostate with laser vaporization prostatectomy for benign prostatic hypertrophy. METHODS: Patients entered into the trial completed the following questionnaires prior to treatment and at follow-up at 3 months and 1 year. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) is a generic measure that produces an eight-dimension profile as well as two summary measures of health status (the physical component score and the mental component score). The EuroQol provides two single index measures of health status; one intended to convey the utility (or lack of) that an individual derives from his or her own health state compared with alternative states and a second simple visual analog scale "thermometer" of health status. The American Urological Association symptom score and the Bothersome index are disease-specific indices of health status for use specifically with benign prostatic hypertrophy patients. RESULTS: The EuroQol indicates no statistically significant improvements with time for either arm of the trial. The SF-36 physical and general health perceptions domains indicates statistically significant improvements for the transurethral resection of the prostate arm alone at 3 months and 1 year, as do the physical summary score at the 3-month follow-up visit. The effect sizes of these improvements, however, are small, using standard criteria. In contrast, statistically significant differences are found with time for both transurethral resection of the prostate and laser prostatectomy on both disease-specific measures, which also indicate statistically significant superior outcome for the transurethral resection of the prostate arm compared with the laser arm. CONCLUSIONS: The results indicate that the disease-specific measures are more sensitive to change than the generic measures of outcome. Possible explanations for this are discussed.

A shorter form health survey: can the SF-12 replicate results from the SF-36 in longitudinal studies?

BACKGROUND: The SF-36 is a generic health status measure which has gained popularity as a measure of outcome in a wide variety of patient groups and social surveys. However, there is a need for even shorter measures, which reduce respondent burden. The developers of the SF-36 have consequently suggested that a 12-item sub-set of the items may accurately reproduce the two summary component scores which can be derived from the SF-36 [the Physical Component Summary Score (PCS) and Mental Health Component Summary Score (MCS)]. In this paper, we adopt scoring algorithms for the UK SF-36 and SF-12 summary scores to evaluate the picture of change gained in various treatment groups. METHODS: The SF-36 was administered in three treatment groups (ACE inhibitors for congestive heart failure, continuous positive airways therapy for sleep apnoea, and open vs laparoscopic surgery for inguinal hernia). RESULTS: PCS and MCS scores calculated from the SF-36 or a sub-set of 12 items (the 'SF-12') were virtually identical, and indicated the same magnitude of ill-health and degree of change over time. CONCLUSION: The results suggest that where two summary scores of health status are adequate than the SF-12 may be the instrument of choice.

Evaluation of treatment for congestive heart failure in patients aged 60 years and older using generic measures of health status (SF-36 and COOP charts).

OBJECTIVES: to assess the functioning and well-being of older patients presenting with congestive heart failure (CHF) using established generic health status measures-the short form 36 health survey (SF-36) and Dartmouth COOP charts. METHODS: patients aged 60 or older with CHF were asked if they would take part. They were requested to complete interviewer-administered questionnaires before angiotensin converting enzyme (ACE) inhibitor treatment and at follow-up 4 weeks later. The interviewer administered the SF-36, COOP charts, the oxygen cost diagram and also asked patients to assess their health state overall and, after treatment, to assess changes, if any, in overall health. RESULTS: multi-dimensional health status measures indicate that patient's functioning and well-being is substantially compromised by CHF, especially in areas relating to physical functioning, and that treatment with ACE inhibitors has only limited effect in improving health-related quality of life. However, on simple single-item global assessments of health, patients report that their overall health-related quality of life is good and many report improvements in overall health status at follow-up. CONCLUSIONS: ACE inhibitor treatment, whilst lengthening life, has a relatively limited impact on its quality. While multidimensional health status measures indicate CHF to be associated with poor health as measured by the SF-36 and COOP charts. However, when patients are asked simple single-item questions relating to their overall health state and the extent of change experienced after treatment, they report relatively good health and positive improvements as a consequence of therapy. Since elderly patients' expectations of improvement may be modest and their expectations of physical ability relatively limited, relatively small improvements, which may not appear large when reported in effect size statistics, may be important. Standardized questionnaires, and standardized statistical methods of assessing change, may not be appropriate for this patient group. A fuller understanding of their expectations and assessment of treatment outcomes is necessary.

Development and testing of the UK SF-12 (short form health survey).

OBJECTIVES: The 36 item short form health survey (SF-36) has proved to be of use in a variety of settings where a short generic health measure of patient-assessed outcome is required. This measure can provide an eight dimension profile of health status, and two summary scores assessing physical function and mental well-being. The developers of the SF-36 in America have developed algorithms to yield the two summary component scores in a questionnaire containing only one-third of the original 36 items, the SF-12. This paper documents the construction of the UK SF-12 summary measures from a large-scale dataset from the UK in which the SF-36, together with other questions on health and lifestyles, was sent to randomly selected members of the population. Using these data we attempt here to replicate the findings of the SF-36 developers in the UK setting, and then to assess the use of SF-12 summary scores in a variety of clinical conditions. METHODS: Factor analytical methods were used to derive the weights used to construct the physical and mental component scales from the SF-36. Regression methods were used to weight the 12 items recommended by the developers to construct the SF-12 physical and mental component scores. This analysis was undertaken on a large community sample (n = 9332), and then the results of the SF-36 and SF-12 were compared across diverse patient groups (Parkinson's disease, congestive heart failure, sleep apnoea, benign prostatic hypertrophy). RESULTS: Factor analysis of the SF-36 produced a two factor solution. The factor loadings were used to weight the physical component summary score (PCS-36) and mental component summary score (MCS-36). Results gained from the use of these measures were compared with results gained from the PCS-12 and MCS-12, and were found to be highly correlated (PCS: rho = 0.94, p < 0.001; MCS: rho = 0.96, p < 0.001), and produce remarkably similar results, both in the community sample and across a variety of patient groups. CONCLUSIONS: The SF-12 is able to produce the two summary scales originally developed from the SF-36 with considerable accuracy and yet with far less respondent burden. Consequently, the SF-12 may be an instrument of choice where a short generic measure providing summary information on physical and mental health status is required.

Emotional health problems are the most important cause of disability in adults of working age: a study in the four counties of the old Oxford region.

OBJECTIVE: To assess the contribution of emotional health problems to the burden of disability affecting people of working age. DESIGN: Analysis of data collected in a postal questionnaire survey of a random sample of people aged 18-64 years. SETTING: The four counties of the old Oxford region in 1991. SUBJECTS: 9332 people who responded to a questionnaire survey mailed to 14,000 people randomly selected from the Family Health Service Authority registers of the four counties of Berkshire, Buckinghamshire, Oxfordshire, and Northamptonshire. OUTCOMES MEASURES: Interference with work or other regular daily activity as reported in questions 4 and 5 of the health status measure SF-36. RESULTS: In this population the prevalence of disability attributable to emotional health problems was greater than that attributable to all physical health problems combined. People reporting that their work or other regular daily activity was affected by their emotional health were much less likely to report a long-standing illness, consultation with a GP or consultation with a hospital doctor than people reporting a physical health problem. CONCLUSIONS: Emotional health problems are a more important cause of disability in adults of working age than all physical health problems put together. Their importance is underestimated in health needs assessment exercises, which are based on NHS consultation rates or reporting of chronic illness. Research into the causes, prevention, and management of emotional health problems should be a national priority for the health service.

Evidence for the sensitivity of the SF-36 health status measure to inequalities in health: results from the Oxford healthy lifestyles survey.

OBJECTIVES: The short form 36 (SF-36) health questionnaire may not be appropriate for population surveys assessing health gain because of the low responsiveness (sensitivity to change) of domains on the measure. An hypothesised health gain of respondents in social class V to that of those in social class I indicated only marginal improvement in self reported health. Subgroup analysis, however, showed that the SF-36 would indicate dramatic changes if the health of social class V could be improved to that of social class I. DESIGN: Postal survey using a questionnaire booklet containing the SF-36 and a number of other items concerned with lifestyles and illness. A letter outlining the purpose of the study was included. SETTING: The sample was drawn from family health services authority (FHSA) computerised registers for Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire. SAMPLE: The questionnaire was sent to 13,042 randomly selected subjects between the ages of 17-65. Altogether 9332 (72%) responded. OUTCOME MEASURES: Scores for the eight dimensions of the SF-36. STATISTICS: The sensitivity of the SF-36 was tested by hypothesising that the scores of those in the bottom quartile of the SF-36 scores in class V could be improved to the level of the scores from the bottom quartile of SF-36 scores in class I using the effect size statistic. RESULTS: SF-36 scores for the population at the 25th, 50th, and 75th centiles were provided. Those who reported worse health on each dimension of the SF-36 (ie in the lowest 25% of scores) differ dramatically between social class I and V. Large effect sizes were gained on all but one dimension of the SF-36 when the health of those in the bottom quartile of the SF-36 scores in class V were hypothesised to have improved to the level of the scores from the bottom quartile of SF-36 scores in class I. CONCLUSIONS: Analysis of SF-36 data at a population level is inappropriate; subgroup analysis is more appropriate. The data suggest that if it were possible to improve the functioning and wellbeing of those in worst health in class V to those reporting the worst health in class I the improvement would be dramatic. Furthermore, differences between the classes detected by the SF-36 are substantial and more dramatic than might previously have been imagined.