Culturally Relevant Physical Activity in the Behavioral Risk Factor Surveillance System in Hawai'i.

INTRODUCTION: Culturally relevant physical activity is a promising field for chronic disease prevention and management. Native Hawaiians and Other Pacific Islanders have higher rates of physical inactivity than other racial or ethnic groups and increased risk of chronic disease. The study objective was to provide population-level data from Hawai'i on lifetime experiences in the Native Hawaiian Indigenous practices of hula and outrigger canoe paddling across demographic and health factors to identify opportunities for public health intervention, engagement, and surveillance. METHODS: Questions about hula and paddling were added to the Hawai'i 2018 and 2019 Behavioral Risk Factor Surveillance System (N = 13,548). We considered level of engagement by demographic categories and health status indicators, accounting for the complex survey design. RESULTS: Overall, 24.5% of adults engaged in hula and 19.8% in paddling in their lifetime. Prevalence of engagement was higher among Native Hawaiians (48.8% hula, 41.5% paddling) and Other Pacific Islanders (35.3% hula, 31.1% paddling) than among other racial and ethnic groups. In adjusted rate ratios, experience in these activities was strong across age groups, education, sex, and income levels, particularly among Native Hawaiians and Other Pacific Islanders. CONCLUSION: Throughout Hawai'i, hula and outrigger canoe paddling are important and popular cultural practices with high physical activity demands. Participation was notably high for Native Hawaiians and Other Pacific Islanders. Surveillance information around culturally relevant physical activities can benefit public health programming and research from a strength-based community perspective.

Identifying best practices in adoption, implementation and enforcement of flavoured tobacco product restrictions and bans: lessons from experts.

OBJECTIVE: To identify recommended components for adopting, implementing and enforcing bans or restrictions targeting flavoured tobacco products. METHODS: Between April and June 2019, semistructured interviews were conducted with 17 high-level experts across the USA and Canada with expertise in flavoured tobacco product policies. Participants included health department staff, researchers, legal professionals and local government officials. Interviews were recorded, transcribed and analysed for key themes. RESULTS: Major findings were organised into four categories: programme planning and legislative preparations; education and community outreach; implementation and enforcement; and policy impact. Critical pre-implementation elements included using comprehensive policy language, identifying enforcement agents, examining potential economic costs, deploying media campaigns and engaging community partners and retailers. Recommended implementation processes included a 6-month preparation timeline, focus on retailer education and clearly outlined enforcement procedures, particularly for concept flavours. CONCLUSIONS: Flavoured tobacco policies have successfully limited sales, withstood legal challenges and become more comprehensive over time, providing useful lessons to inform ongoing and future legislative and programmatic efforts. Identifying and sharing best practices can improve passage, implementation, efficacy and evaluation of flavoured tobacco policies.

Disaggregating Data to Measure Racial Disparities in COVID-19 Outcomes and Guide Community Response - Hawaii, March 1, 2020-February 28, 2021.

Native Hawaiian and Pacific Islander populations have been disproportionately affected by COVID-19 (1-3). Native Hawaiian, Pacific Islander, and Asian populations vary in language; cultural practices; and social, economic, and environmental experiences,† which can affect health outcomes (4).§ However, data from these populations are often aggregated in analyses. Although data aggregation is often used as an approach to increase sample size and statistical power when analyzing data from smaller population groups, it can limit the understanding of disparities among diverse Native Hawaiian, Pacific Islander, and Asian subpopulations¶ (4-7). To assess disparities in COVID-19 outcomes among Native Hawaiian, Pacific Islander, and Asian populations, a disaggregated, descriptive analysis, informed by recommendations from these communities,** was performed using race data from 21,005 COVID-19 cases and 449 COVID-19-associated deaths reported to the Hawaii State Department of Health (HDOH) during March 1, 2020-February 28, 2021.†† In Hawaii, COVID-19 incidence and mortality rates per 100,000 population were 1,477 and 32, respectively during this period. In analyses with race categories that were not mutually exclusive, including persons of one race alone or in combination with one or more races, Pacific Islander persons, who account for 5% of Hawaii's population, represented 22% of COVID-19 cases and deaths (COVID-19 incidence of 7,070 and mortality rate of 150). Native Hawaiian persons experienced an incidence of 1,181 and a mortality rate of 15. Among subcategories of Asian populations, the highest incidences were experienced by Filipino persons (1,247) and Vietnamese persons (1,200). Disaggregating Native Hawaiian, Pacific Islander, and Asian race data can aid in identifying racial disparities among specific subpopulations and highlights the importance of partnering with communities to develop culturally responsive outreach teams§§ and tailored public health interventions and vaccination campaigns to more effectively address health disparities.

Falls and life-space mobility: longitudinal analysis from The International Mobility in Aging Study.

OBJECTIVES: To investigate a 4-year longitudinal relationship between falls, recurrent falls, and injurious falls, according to different levels of life-space mobility (LSM). METHODS: Longitudinal analysis of an international cohort study. The participants were older adults from the International Mobility in Aging Study (IMIAS) aged between 65 and 74 years at baseline. Three waves of data (2012, 2014, 2016) were used. Fall history during the past year was recorded. Recurrent fallers were identified as those who fell at least twice and injurious fallers as participants who required medical attention. LSM measurements included Total Life-Space (LS-C), Maximal Life-Space (LS-M), Assisted Life-Space (LS-A), Independent Life-Space (LS-I) and Restricted Life-space (LS-ID) scores. Generalized estimation equation (GEE) models were used to determine whether life-space mobility measures and their change over time differed between recurrence of falls and injurious falls. RESULTS: At baseline, the prevalence of falls in the last year was 28%. 11.8% reported recurrent falls and 2.6% had serious injurious falls in the last year preceding the assessments. Recurrent fallers were more likely to be female, with insufficient income and, with comorbidities. GEE models showed that life-space mobility was lower among those with recurrent falls or serious injurious falls compared to those who never fell, but the rate of change did not differ over the 4-year follow-up except for the LS-A and LS-I scores, where some improvements were observed over time. CONCLUSIONS AND IMPLICATIONS: Falls were independently associated with a decrease in LSM over 4 years. Targeting older adults with recurrent and injurious falls with appropriate interventions may improve community mobility and social participation.

Promoting a Culture of Prevention in Albania: the "Si Je?" Program.

Albania is a small country on the Balkan Peninsula that recently implemented an innovative primary healthcare program called "Si Je?" (How are you?) which allowed all Albanians aged 40-65 years to receive a free, yearly basic health examination at their local health center. Access to basic primary care is a critical component of a nationwide culture of prevention particularly for the non-communicable diseases that comprise 89% of total deaths in the country. Yet, as in many middle-income countries, a culture of prevention in Albania is often secondary to ensuring basic health infrastructure and healthcare access for those critically in need. Using the social-ecological model as our conceptual framework, this paper provides new insights into the culture of prevention in Albania by analyzing the need for, and implementation of, the Si Je? program using (1) findings from a critical literature review, (2) quantitative data from the database created from this program, and (3) qualitative data from key informant interviews from 15 health center directors. Positive developments towards a culture of prevention include the fact that the Si Je? program has been expanded to those 35-70 years, strengthened links between community and primary care, and participation among rural communities who traditionally have limited primary care access. Challenges include continued urgent health infrastructure needs, politicization of the Si Je? effort, limited participation by some groups (particularly urban men), and regional variations. Despite challenges, Albania appears to be building new infrastructure for a sustainable culture of prevention, particularly around chronic disease.

Gene-obesogenic environment interactions on body mass indices for older black and white men and women from the Health and Retirement Study.

BACKGROUND: Gene-obesogenic environment interactions influence body mass index (BMI) across the life course; however, limited research examines how these interactions may differ by race and sex. METHODS: Utilizing mixed-effects models, we examined the interaction effects of a polygenic risk score (PGS) generated from BMI-associated single-nucleotide polymorphisms, and environmental factors, including age, physical activity, alcohol intake, and childhood socioeconomic status on measured longitudinal BMI from the Health and Retirement Study (HRS). HRS is a population representative survey of older adults in the United States. This study used a subsample of genotyped Black (N = 1796) and White (N = 4925) men and women (50-70 years) with measured BMI. RESULTS: Higher PGS was associated with higher BMI. The association between PGS and BMI weakened as individuals aged among White men (Pinteraction = 0.0383) and White women (Pinteraction = 0.0514). The mean BMI difference between the 90th and 10th PGS percentile was 4.25 kg/m2 among 50-year-old White men, and 3.11 kg/m2 among the 70 years old's, i.e., a 1.14 kg/m2 (95% CI: -0.27, 2.82) difference. The difference among 50- and 70-year-old White women was 1.34 kg/m2 (95% CI: 0.09, 2.60). In addition, the protection effect of physical activity was stronger among White women with higher PGS (Pinteraction = 0.0546). Vigorous physical activity (compared with never) was associated with 1.66 kg/m2 (95% CI: 1.06, 2.29) lower mean BMI among those in the 90th PGS percentile, compared with 0.83 kg/m2 (95% CI: 0.37, 1.29) lower among those in the 10th PGS percentile. Interactions were also observed between both PGS and alcohol intake among White men (Pinteraction = 0.0034) and women (Pinteraction = 0.0664) and Black women (Pinteraction = 0.0108), and PGS and childhood socioeconomic status among White women (Pinteraction = 0.0007). CONCLUSIONS: Our findings reinforce the importance of physical activity among those with an elevated genetic risk; additionally, other detected interactions may underscore the influence of broader social environments on obesity-promoting genes.

The Healthy Hawai'i Initiative: insights from two decades of building a culture of health in a multicultural state.

BACKGROUND: The Healthy Hawai'i Initiative was created in 2000 with tobacco settlement funds as a theory-based statewide effort to promote health-supporting environments through systems and policy change. Still active today, it is imbedded explicitly in a multi-sectoral, social ecological approach, effectively striving to build a culture of health before this was the name for such an ambitious effort. METHODS: From interviews with key informants, we analyze two decades of the Healthy Hawai'i Initiative (HHI) in the context of the Robert Wood Johnson Foundation (RWJF) Culture of Health Action Framework (CHAF). We list HHI accomplishments and examine how the Initiative achieved notable policy and environmental changes supportive of population health. RESULTS: The Healthy Hawai'i Initiative started with an elaborate concept-mapping process that resulted in a common vision about making "the healthy choice the easiest choice." Early on, the Initiative recognized that making health a shared value beyond the initial stakeholders required coalition and capacity building across a broad range of governmental and nonprofit actors. HHI coalitions were designed to promote grassroots mobilization and to link community leaders across sectors, and at their height, included over 500 members across all main islands of the state. Coalitions were particularly important for mobilizing rural communities. Additionally, the Initiative emphasized accessibility to public health data, published research, and evaluation reports, which strengthened the engagement to meet the shared vision and goals between diverse sector partners and HHI. Over the past two decades, HHI has capitalized on relationship building, data sharing, and storytelling to encourage a shared value of health among lawmakers, efforts which are believed to have led to the development of health policy champions. All of these factors combined, which centered on developing health as a shared value, have been fundamental to the success of the other three action areas of the CHAF over time. CONCLUSIONS: This evidence can provide critical insights for other communities at earlier stages of implementing broad, diverse, multifaceted system change and fills a key evidence gap around building a culture of health from a mature program in a notably multicultural state.

Prevalence of Selected Chronic Conditions Among Children, Adolescents, and Young Adults in Acute Care Settings in Hawai'i.

INTRODUCTION: Chronic disease prevalence among young people is understudied generally and specifically for Native Hawaiian, Filipino, and Pacific Islander youth who are at high risk for these conditions. We determined the statewide prevalence of chronic diseases in acute care for those aged 5 to 29 years, including Native Hawaiians, Filipinos, and Pacific Islanders. METHODS: We used Hawai'i statewide inpatient and emergency department (ED) data across all payers from 2015-2016 to determine the presence of at least 1 of 5 chronic conditions (ie, asthma, hypertension, chronic kidney disease, diabetes, stroke) from 13,514 inpatient stays by 9,467 unique individuals and 228,548 ED visits by 127,854 individuals. RESULTS: Twenty-eight percent of youth who were hospitalized and 12% with an ED visit had at least 1 chronic condition. Medicaid covered more than half of these visits. When comparing patients with and without a chronic condition, race/ethnicity, age group, and payer varied significantly in both inpatient and ED settings. Patients with a chronic condition were disproportionately Native Hawaiian, Filipino, and Pacific Islander; 32.3% of those with an inpatient chronic condition and 34.9% of those with an ED chronic condition were Native Hawaiian. Prevalence of chronic conditions among racial/ethnic groups varied significantly by age. CONCLUSION: Chronic diseases, including those more often seen in adulthood, are prevalent in young people in acute care settings in Hawai'i, with notable disparities. These findings can help justify, guide, and support programs that are needed to address these changing epidemiological trends, which may be of particular interest for Medicaid.

Self-Measured Blood Pressure Monitoring: Program Planning, Implementation, and Lessons Learned From 5 Federally Qualified Health Centers in Hawai'i.

Self-measured blood pressure monitoring programs (BPMPs) are effective at controlling hypertension. We examined implementation of self-measured BPMPs at 5 Hawai'i-based Federally Qualified Health Centers (FQHCs). In a process evaluation of these programs, we found that FQHCs developed protocols for self-measured BPMP recruitment and enrollment and provided additional supports to account for their patients' psychosocial needs to achieve blood pressure control, such as lifestyle change education and opportunities through referrals either to on-site or other programs (eg, on-site gym, tobacco cessation program). Common barriers across sites included insufficient material support for blood pressure monitors and data collection; funding, which affects program sustainability; and the lack of an "off-the-shelf" self-measured BPMP intervention. Policy makers and funding organizations should address these issues related to self-measured BPMPs to ensure implementation success.

Assessing the relationship between multimorbidity and depression in older men and women: the International Mobility in Aging Study (IMIAS).

Objectives: Our study aims to assess whether multimorbidity is an independent risk factor for the development of depression in older adults living in Canada, Brazil, Colombia, and Albania and examines differences in incidence of depression regarding social and psychosocial characteristics.Methods: The longitudinal International Mobility Aging Study (IMIAS) collected information from adults between 65-74 years old. Depression was defined by a 16 or higher score assessed by the Centre for Epidemiological Studies Depression (CES-D) Scale. Multimorbidity was defined as having two or more chronic conditions, which were self-reported by participants using a list of eight physical chronic conditions. Poisson regression was performed to estimate the relative risk of depression in older adults with multimorbidity compared to those living with 0-1 chronic conditions, adjusting for sex, age, education, number of doctor visits, degree of assistance needed, social support, and smoking status. The analysis was stratified by study region (Canada; Latin America; Albania).Results: Crude and adjusted models showed no statistically significant associations between multimorbidity and the incidence of depression in any of the study regions, confirmed by sensitivity analyses. However, the incidence of depression varied across study region, confirmed by the intra-class correlation coefficient which indicated that 13% of variations in depression incidence were due to geographic differences.Conclusion: Multimorbidity does not appear to increase the risk of developing depression in older adults between 65-74. Higher rates of depression in Latin America and Albania (compared to Canada) may be attributed to lifecourse exposures to social and economic adversity in these regions.

Perspectives and Experiences of Obstetricians Who Provide Labor and Delivery Care for Micronesian Women in Hawai'i: What Is Driving Cesarean Delivery Rates?

Access to cesarean delivery is vital for quality obstetrical care, but the procedure can increase maternal mortality, morbidity, and complications in subsequent deliveries. The objective of this study was to describe obstetrician-gynecologists' (OB-GYNs) perspectives on labor and delivery care for Micronesian women in Hawai'i and possible factors contributing to higher cesarean delivery rates among that racial/ethnic group. The Framework Method guided the analysis of 13 semi-structured interviews with OB-GYNs. Study results indicated that OB-GYNs were more likely to attribute racial/ethnic differences in mode of delivery to challenges resulting from nonmedical factors, particularly communication and negative attitudes toward Micronesian patients, than to medical risk factors. In this study, we explored aspects of care that cannot be captured in medical charts or clinical data, but may impact health outcomes for this population. The findings could help improve care for Micronesian women, with lessons applicable to other racial/ethnic minority groups.

Meeting Physical Activity Guidelines by Walking in Older Adults From Three Middle-Income Countries: A Cross-Sectional Analysis From the International Mobility in Aging Study.

Physical activity (PA) among older adults is understudied in middle-income countries. The authors examined the associations of factors across levels of the social ecological model (individual, interpersonal, organizational, and community) with older adults meeting guidelines of 150 min of moderate- to vigorous-intensity PA per week through walking in three middle-income countries: Albania (n = 387), Colombia (n = 404), and Brazil (n = 402). Using 2012 International Mobility in Aging Study data, multivariate logistic regression models identified the following significant associations with meeting PA guidelines through walking (a) individual level: depression (odds ratio [OR] = 0.62, 95% confidence interval, CI [0.45, 0.86]), being female (OR = 0.74, 95% CI [0.56, 0.998]), and high relative education (OR = 1.79, 95% CI [1.33, 2.41]) and (b) interpersonal level: high life partner (OR = 1.38, 95% CI [1.04, 1.83]) and friend social ties (OR = 1.39, 95% CI [1.05, 1.83]). While individual and interpersonal variables were associated with meeting PA guidelines, community-level social and environmental variables were not.

Symptoms of urinary incontinence and pelvic organ prolapse and physical performance in middle-aged women from Northeast Brazil: a cross-sectional study.

BACKGROUND: Reproductive history and urogynecological disorders have been associated with limitations in physical function. However, little is known about the relationship between symptoms of urinary incontinence and pelvic organ prolapse, and physical performance. Therefore, the purpose of this study was to examine whether symptoms of urinary incontinence and pelvic organ prolapse are independently associated factors with indicators of lower physical performance in middle-aged women from Northeast Brazil. METHODS: This is a cross-sectional study of 381 women between 40 to 65 years old living in Parnamirim, Northeast Brazil. Physical performance was assessed by gait speed, chair stand and standing balance tests. Urinary incontinence and pelvic organ prolapse were self-reported. Multiple linear regression analyses were performed to model the effect of self-reported urinary incontinence and pelvic organ prolapse on each physical performance measure, adjusted for covariates (age, family income, education, body mass index, parity). RESULTS: In the analysis adjusted for confounders, women reporting urinary incontinence spent, on average, half a second longer to perform the chair stand test (ß = 0.505 95% CI: 0.034: 0.976). Those reporting pelvic organ prolapse shortened the balance time with eyes open by 2.5 s on average (ß = - 2.556; CI: - 4.769: - 0.343). CONCLUSIONS: Symptoms of pelvic organ prolapse and urinary incontinence are associated to worse physical performance in middle-aged women. These seemingly small changes in physical performance levels are of clinical importance, since these conditions may influence women's physical ability, with implications for other tasks important to daily functioning and should be addressed by health policies targeting women's health and functionality.

Predictors of uterine rupture in a large sample of women in Senegal and Mali: cross-sectional analysis of QUARITE trial data.

BACKGROUND: The purpose of this study was to investigate predictors of uterine rupture in a large sample of sub-Saharan African women. Uterine rupture is rare in high-income countries, but it is more common in low-income settings where health systems are often under-resourced. However, understanding of risk factors contributing to uterine rupture in such settings is limited due to small sample sizes and research rarely considers system and individual-level factors concomitantly. METHODS: Cross-sectional data analysis from the pre-intervention period (Oct. 1, 2007- Oct. 1, 2008) of the QUARITE trial, a large-scale maternal mortality study. This research examines uterine rupture among 84,924 women who delivered in one of 46 referral hospitals in Mali and Senegal. A mixed-effects logistic regression model identified individual and geographical risk factors associated with uterine rupture, accounting for clustering by hospital. RESULTS: Five hundred sixty-nine incidences of uterine rupture (0.67% of sample) were recorded. Predictors of uterine rupture: grand multiparity defined as > 5 live births (aOR = 7.57, 95%CI; 5.19-11.03), prior cesarean (aOR = 2.02, 95%CI; 1.61-2.54), resides outside hospital region (aOR = 1.90, 95%CI: 1.28-2.81), no prenatal care visits (aOR = 1.80, 95%CI; 1.44-2.25), and birth weight of > 3600 g (aOR = 1.61, 95%CI; 1.30-1.98). Women who were referred and who had an obstructed labor had much higher odds of uterine rupture compared to those who experienced neither (aOR: 46.25, 95%CI; 32.90-65.02). CONCLUSIONS: The results of this large study confirm that the referral system, particularly for women with obstructed labor and increasing parity, is a main determinant of uterine rupture in this context. Improving labor and delivery management at each level of the health system and communication between health care facilities should be a priority to reduce uterine rupture.

Social and community factors associated with hypertension awareness and control among older adults in Tirana, Albania.

Background: Determinants of hypertension diagnosis and/or awareness and control among older adults are understudied in Albania, a former communist country in South Eastern Europe, which is experiencing rapid demographic, socioeconomic and epidemiological transition. This paper examines the association of individual, interpersonal, organizational and community factors with hypertension awareness and control among older adults in Tirana, the Albanian capital. Methods: Using 2012 International Mobility in Aging Study data on older adults from Albania's capital city (n = 393) and the socioecological model as a conceptual framework, multinomial regression models identified factors associated with controlled, uncontrolled and undiagnosed hypertension. Results: For hypertension, 17.3% participants had none, 23.4% were controlled, 48.4% were uncontrolled and 10.9% were undiagnosed/unaware. Compared to those with controlled hypertension, in multivariable models, a high level of friend support was negatively associated with uncontrolled (OR: 0.4; 95% CI: 0.2-0.9) and undiagnosed (OR: 0.2; 95% CI: 0.1-0.6) hypertension. A high level of perceived neighbourhood safety was negatively associated with uncontrolled (OR: 0.6; 95% CI: 0.3-1.0) and undiagnosed (OR: 0.4; 95% CI: 0.2-1.0) hypertension. Compared to those with no hypertension, children's social support was positively associated with uncontrolled (OR: 2.2; 95% CI: 1.1-4.3) and undiagnosed (OR: 3.6; 95% CI: 1.3-9.6) hypertension. Conclusion: This study provides new insights about distinct risk factors for inadequate hypertension management in Albania. It highlights the importance of community-level factors (safety) and interpersonal factors (family and friend ties) to hypertension diagnosis/awareness and control, which may provide novel intervention opportunities for hypertension programs.

Age at First Birth, Parity and History of Hysterectomy Are Associated to Frailty Status: Cross-Sectional Analysis from the International Mobility in Aging Study -Imias.

Frailty at older ages is an adverse health condition that is more prevalent in women than men and the excess prevalence in women cannot be adequately explained by common risk factors. Reproductive history events may be among contributing factors. This study aims to examine associations between age at first childbirth, lifetime parity, and history of hysterectomy with frailty status in community dwelling older women. This is a cross-sectional study of 1047 women participating in the International Mobility in Aging Study at baseline (2012, aged between 65 and 74 years old). Fried's phenotype of frailty was used to identify frail, pre-frail and non-frail groups. Measured reproductive history variables include age at first birth (before 20 years old; 20 years old or older), lifetime parity (0; 1-2 children; 3-4 children; 5 children or more) and hysterectomy (yes/no). We constructed multinomial regression models adjusted for possible confounders to examine the relationships of interest; non frail women were the reference category. Early maternal age (before 20 years-old) was associated with increased risk of frailty (OR 2.15, 95%CI: 1.24-3.72). Compared to women who delivered five or more children, those who had 1-2 children showed significantly lower odds of pre-frail status (OR 0.54, 95%CI 0.36-0.82) and frailty (OR 0.43 95%CI 0.22-0.86). Hysterectomy was independently associated with frailty (OR 1.74 95%CI 1.04-2.89) Age at first birth, parity and hysterectomy are associated to a greater likelihood of frailty in later life. This study reinforces the importance of considering the reproductive characteristics of women as indicators of health status.

Age at first birth and risk of later-life cardiovascular disease: a systematic review of the literature, its limitation, and recommendations for future research.

BACKGROUND: Cardiovascular disease (CVD) is the principal contributor to the burden of disease and mortality worldwide. Previous studies observed associations between early age at first birth (AFB) and all-cause mortality. AFB may be associated with CVD both through physiological and sociobiological pathways. In this paper, we review the literature on AFB and CVD events and mortality. Additionally, we provide an overview of limitations of the current research and recommendations for future research. METHODS: PubMed and Web of Science databases were searched for observational studies published between 1980-June 2016, investigating associations between AFB and CVD events and mortality. Data were extracted using a pre-defined list. RESULTS: A total of 20 publications, reporting on 33 associations, were included in the review. Ten studies observed a positive association between early AFB and CVD while two studies observed a positive association between later AFB and CVD. Substantial methodological limitations were observed related to: operationalization of exposure categories, choice of reference category, sample size, follow-up time and possibly over adjustment. CONCLUSIONS: Early AFB is possibly related to CVD. More work, in particular from large cohort studies starting before reproductive age is reached, is needed to better investigate this relationship, and to ascertain causal pathways that may explain observed associations.

Early maternal age and multiparity are associated to poor physical performance in middle-aged women from Northeast Brazil: a cross-sectional community based study.

BACKGROUND: Adolescent childbirth and elevated parity are relatively common in middle and low-income countries and they may be related to the higher prevalence and earlier onset of physical decline documented in these settings, especially in women. The aim of this paper is to investigate whether reproductive history is associated with physical function in middle-aged women from Northeast Brazil. METHODS: The relationship between poor physical performance (grip strength, gait speed and chair stand), early maternal age at first birth (<18 years old), and multiparity (≥ 3 children) was evaluated in a community sample of 473 women living in Parnamirim (Northeast Brazil). Linear regression models were used to examine the relationship of interest; in addition, mediation analyses were employed to assess indirect effects of obesity and family income. RESULTS: Women who gave birth at less than 18 years of age took approximately 0.50 s longer to complete the chair stand test compared to women who gave birth at 18 years or older. Moreover, women who gave birth to < 3 children completed the chair stand test 0.42 s faster compared to those who had ≥ 3 children. The relation between reproductive history and physical performance was mediated by BMI. Reproductive history was not associated with performance in gait speed. CONCLUSIONS: This study provides evidence that adolescent childbirth and multiparity are related to worse physical performance in middle-aged women from a low income setting. Reproductive history may partially account for earlier physical decline and greater disability in women from lower income settings.

Early maternal age at first birth is associated with chronic diseases and poor physical performance in older age: cross-sectional analysis from the International Mobility in Aging Study.

BACKGROUND: Early maternal age at first birth and elevated parity may have long-term consequences for the health of women as they age. Both are known risk factors for obstetrical complications with lifelong associated morbidities. They may also be related to diabetes and cardiovascular disease development. METHODS: We examine the relationship between early maternal age at first birth, defined as ≤18 years of age, multiparity (>2 births), and poor physical performance (Short Physical Performance Battery≤8) in community samples of women between 65 and 74 years of age from Canada, Albania, Colombia, and Brazil (N=1040). Data were collected in 2012 to provide a baseline assessment for a longitudinal cohort called the International Mobility in Aging Study. We used logistic regression and general linear models to analyse the data. RESULTS: Early maternal age at first birth is significantly associated with diabetes, chronic lung disease, high blood pressure, and poor physical performance in women at older ages. Parity was not independently associated with chronic conditions and physical performance in older age. After adjustment for study site, age, education, childhood economic adversity and lifetime births, women who gave birth at a young age had 1.75 (95% CI: 1.17-2.64) the odds of poor SPPB compared to women who gave birth>18 years of age. Adjustment for chronic diseases attenuated the association between early first birth and physical performance. Results were weaker in Colombia and Brazil, than Canada and Albania. CONCLUSIONS: This study provides evidence that adolescent childbirth may increase the risk of developing chronic diseases and physical limitations in older age. Results likely reflect both the biological and social consequences of early childbearing and if the observed relationship is causal, it reinforces the importance of providing contraception and sex education to young women, as the consequences of early pregnancy may be life-long.

Training and nutritional components of PMTCT programmes associated with improved intrapartum quality of care in Mali and Senegal.

OBJECTIVE: Scale-up of prevention of mother-to-child transmission (PMTCT) of HIV programmes in sub-Saharan Africa has stimulated interest to assess whether these programmes can indirectly affect other health priorities. This study assesses whether PMTCT programmes, or components of these programmes, are associated with better obstetrical quality of care and how PMTCT may reinforce existing maternal health programmes. DESIGN: Cross-sectional analysis of data from a cluster-randomized trial called QUARITE. SETTING: Mali and Senegal, West Africa. PARTICIPANTS: Thirty-one referral hospitals and 612 obstetrical patients. INTERVENTION: The exposure of interest was PMTCT measured with a scale containing 10 components describing different prongs of a hospital PMTCT programme. Other variables of interest included: presence of a quality of care improvement programme, hospital resources and patient demographic characteristics. MAIN OUTCOME MEASURE: Obstetrical quality of care measured through a validated chart abstraction tool. RESULTS: Of 45 points, the mean hospital PMTCT score was 26.1 (SD: 6.7). Total PMTCT score was not significantly associated with quality of care, but programme component scores were. After adjustment for known predictors of quality of care, staff training in PMTCT (P = 0.03) and complementary nutritional services (P = 0.03) were significantly associated with better quality obstetrical care. A point increase in scores for either of these components was associated with 40% greater odds of good obstetrical care. CONCLUSIONS: PMTCT training and nutritional components are significantly associated with better quality intrapartum care. Health professionals' training in maternal healthcare and PMTCT could be combined to improve the quality of obstetric care in the region.