The impact of childhood parental quality on mental health outcomes in older adults.

OBJECTIVE: Parental bonding is cited as a determinant of mental health outcomes in childhood, adolescence and early-mid adulthood. Examination of the long-term impact for older adults is limited. We therefore examine the long-term risk of perceived poor parental bonding on mental health across the lifespan and into early-old age. METHODS: Participants (N = 1255) were aged 60-64 years of age and drawn from the Australian Life Histories and Health study. Quality of parental bonding was assessed with the Parental Bonding Instrument (PBI). Self-reported history of doctors' mental health diagnoses and current treatment for each participant was recorded. Current depression was assessed with the Centre for Epidemiologic Studies Depression-8 (CESD-8). Due to known gender differences in mental health rates across the lifespan, analyses were stratified by sex. RESULTS: A bi-factor analysis of the PBI in a structural equation framework indicated perceived Poor Parental Quality as a risk for both ever and current depression for both sexes. For males, Over-Protective Fathers were a risk for ever and current depression, whilst overall Poor Parental Quality was a risk for reporting current depression treatment. Whilst a number of the risks associated with current depression and treatment were attenuated when controlling for current mood, parental quality remained a significant risk for having reported a lifetime diagnosis for depression and anxiety for men. CONCLUSION: Our results extend the existing literature base and demonstrate that mental health risk attributed to poor perceived parental quality continues across the life-course and into early-old age.

BMI and healthy life expectancy in old and very old women.

There is conflicting evidence for the effect of BMI on mortality at older ages, and little information on its effect on healthy life expectancy (HLE). Longitudinal data were from the 1921-1926 cohort of the Australian Longitudinal Study on Women's Health (n 11 119), over 18 years of follow-up. Self-rated health status was measured at each survey, and BMI was measured at baseline. Multi-state models were fitted to estimate the effect of BMI on total life expectancy (TLE) and HLE. Compared with women of normal weight, overweight women at the age of 75 years had similar TLE but fewer years healthy (-0·79; 95 % CI -1·21, -0·37) and more years unhealthy (0·99; 95 % CI 0·56, 1·42). Obese women at the age of 75 years lived fewer years in total than normal-weight women (-1·09; 95 % CI -1·77, -0·41), and had more unhealthy years (1·46; 95 % CI 0·97, 1·95 years). Underweight women had the lowest TLE and the fewest years of healthy life. Women should aim to enter old age at a normal weight and in good health, as the slight benefit on mortality of being overweight is offset by spending fewer years healthy. All outcomes were better for those who began in good health. The relationship between weight and HLE has important implications for nutrition for older people, particularly maintenance of lean body mass and prevention of obesity. The benefit of weight loss in obese older women remains unclear, but we support the recommendation that weight-loss advice be individualised, as any benefits may not outweigh the risks in healthy obese older adults.

Factors associated with the health care cost in older Australian women with arthritis: an application of the Andersen's Behavioural Model of Health Services Use.

OBJECTIVE: Factors associated with the utilisation of health care have not been rigorously examined in people with arthritis. The objective of this study was to examine the determinants of health care utilisation and costs in older women with arthritis using the Andersen's behavioural model as a framework. STUDY DESIGN: Longitudinal cohort study. METHODS: Participants of Surveys 3 to 5 of the Australian Longitudinal Study on Women's Health who reported arthritis were included in the study. Information about health care utilisation and unit prices were based on linked Medicare Australia data, which included prescription medicines and health services. Total health care costs of participants with arthritis were measured for the years 2002 to 2003, 2005 to 2006, and 2008 to 2009, which corresponded to the survey years. Potential explanatory variables of the health care cost and other characteristics of the participants were collected from the health surveys. Explanatory variables were grouped into predisposing characteristics, enabling factors and need variables conforming to the Andersen's Behavioural Model of Health Services Use. Longitudinal data analysis was conducted using generalized estimating equations. RESULTS: A total of 5834 observations were included for the three periods. Regression analysis results show that higher health care cost in older Australian women with arthritis was significantly associated with residing in an urban area, having supplementary health insurance coverage, more comorbid conditions, using complementary and alternative medicine, and worse physical functioning. It was also found that predisposing characteristics (such as the area of residence) and enabling factors (such as health insurance coverage) accounted for more variance in the health care cost than need variables (such as comorbid conditions). CONCLUSION: These results may indicate an inefficient and unfair allocation of subsidised health care among older Australian women with arthritis, where individuals with less enabling resources and more socio-economic disadvantages have a lower level of health care utilisation. Future research may focus on evaluating the effectiveness of policies designed to reduce excessive out-of-pocket costs and to improve equity in health care access in the older population.

The utility of estimating population-level trajectories of terminal wellbeing decline within a growth mixture modelling framework.

PURPOSE: Mortality-related decline has been identified across multiple domains of human functioning, including mental health and wellbeing. The current study utilised a growth mixture modelling framework to establish whether a single population-level trajectory best describes mortality-related changes in both wellbeing and mental health, or whether subpopulations report quite different mortality-related changes. METHODS: Participants were older-aged (M = 69.59 years; SD = 8.08 years) deceased females (N = 1,862) from the dynamic analyses to optimise ageing (DYNOPTA) project. Growth mixture models analysed participants' responses on measures of mental health and wellbeing for up to 16 years from death. RESULTS: Multi-level models confirmed overall terminal decline and terminal drop in both mental health and wellbeing. However, modelling data from the same participants within a latent class growth mixture framework indicated that most participants reported stability in mental health (90.3 %) and wellbeing (89.0 %) in the years preceding death. CONCLUSIONS: Whilst confirming other population-level analyses which support terminal decline and drop hypotheses in both mental health and wellbeing, we subsequently identified that most of this effect is driven by a small, but significant minority of the population. Instead, most individuals report stable levels of mental health and wellbeing in the years preceding death.

Impact of persistent constipation on health-related quality of life and mortality in older community-dwelling women.

OBJECTIVES: Very little is known about whether the reported health-related impact of constipation is worse in people who experience constipation over a long period of time vs. those with more transient symptoms. We aimed to determine the impact of persistent vs. transient constipation on health-related quality of life (QOL), depression, and mortality. METHODS: We analyzed data from 5,107 women (aged 70-75 years in 1996) who answered "Have you had constipation in the past 12 months?" in all five surveys sent out every 3 years of the Australian Longitudinal Study on Women's Health. RESULTS: Of the 5,107 women, 20.9, 54.1, and 24.7% reported having persistent constipation on at least 4 out of 5 surveys, transient constipation reported on 1-3 surveys, or none reported over the 15-year time frame, respectively. Women who reported persistent constipation had significantly lower scores for all domains of QOL on the SF-36 except role-emotional, and had higher levels of self-reported depression, even after adjusting for number of chronic illnesses and fluid intake. Mortality rates were increased when comparing women with no reported constipation with persistently reported constipation (8.2% vs. 11%, odds ratio = 1.32, 95% confidence interval 1.0, 1.74, P = 0.05) controlling for specific chronic illnesses. CONCLUSIONS: Persistent constipation among older women is associated with poor health outcomes.

Vegetable-rich food pattern is related to obesity in China.

OBJECTIVE: To investigate the association between a vegetable-rich food pattern and obesity among Chinese adults. DESIGN: A food pattern rich in vegetables is associated with lower risk of obesity and non-communicable chronic disease in Western countries. A similar food pattern is found in the Chinese population but the cooking method is different. A cross-sectional household survey of 2849 men and women aged 20 years and over was undertaken in 2002 in Jiangsu Province (response rate, 89.0%). Food intake was assessed by food frequency questionnaire. Factor analysis was used to identify food patterns. Nutrient intake was measured by food weighing plus consecutive individual 3-day food records. Height, weight and waist circumference were measured. RESULTS: The prevalence of general obesity (BMI > or =28 kg m(-2)) was 8.0% in men and 12.7% in women, central obesity was 19.5% (> or =90 cm) and 38.2% (> or =80 cm), respectively. A four-factor solution explained 28.5% of the total variance in food frequency intake. The vegetable-rich food pattern (whole grains, fruits and vegetables) was positively associated with vegetable oil and energy intake. Prevalence of obesity/central obesity increased across the quartiles of vegetable-rich food pattern. After adjusting for sociodemographic factors and four distinct food patterns, the vegetable-rich pattern was independently associated with obesity. Compared with the lowest quartile of vegetable-rich pattern, the highest quartile had higher risk of general obesity (men, prevalence ratio (PR): 1.82, 95% confidence interval (CI): 1.05-3.14; women, PR: 2.25, 95% CI: 1.45-3.49). CONCLUSION: The vegetable-rich food pattern was associated with higher risk of obesity/central obesity in Chinese adults in both genders. This association can be linked to the high intake of energy due to generous use of oil for stir-frying the vegetables.

Hysterectomy and incidence of depressive symptoms in midlife women: the Australian Longitudinal Study on Women's Health.

AIMS: There is limited longitudinal research that has looked at the longer term incidence of depressive symptoms, comparing women with a hysterectomy to women without a hysterectomy. We aimed to investigate the association between hysterectomy status and the 12-year incidence of depressive symptoms in a mid-aged cohort of Australian women, and whether these relationships were modified by use of exogenous hormones. METHODS: We used generalised estimating equation models for binary outcome data to assess the associations of the incidence of depressive symptoms (measured by the 10-item Centre for Epidemiologic Studies Depression Scale) across five surveys over a 12-year period, in women with a hysterectomy with ovarian conservation, or a hysterectomy with bilateral oophorectomy compared with women without a hysterectomy. We further stratified women with hysterectomy by their current use of menopausal hormone therapy (MHT). Women who reported prior treatment for depression were excluded from the analysis. RESULTS: Compared with women without a hysterectomy (n = 4002), both women with a hysterectomy with ovarian conservation (n = 884) and women with a hysterectomy and bilateral oophorectomy (n = 450) had a higher risk of depressive symptoms (relative risk (RR) 1.20; 95% confidence interval (CI) 1.06-1.36 and RR 1.44; 95% CI 1.22-1.68, respectively). There were differences in the strength of the risk for women with a hysterectomy with ovarian conservation, compared with those without, when we stratified by current MHT use. Compared with women without a hysterectomy who did not use MHT, women with a hysterectomy with ovarian conservation who were also MHT users had a higher risk of depressive symptoms (RR 1.57; 95% CI 1.31-1.88) than women with a hysterectomy with ovarian conservation but did not use MHT (RR 1.17; 95% CI 1.02-1.35). For women with a hysterectomy and bilateral oophorectomy, MHT use did not attenuate the risk. We could not rule out, however, that the higher risk seen among MHT users may be due to confounding by indication, i.e. MHT was prescribed to treat depressive symptoms, but their depressive symptoms persisted. CONCLUSIONS: Women with a hysterectomy (with and without bilateral oophorectomy) have a higher risk of new incidence of depressive symptoms in the longer term that was not explained by lifestyle or socio-economic factors.

Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa.

BACKGROUND: The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries. METHODS: Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa. RESULTS: This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa. CONCLUSIONS: Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

Ontario Child Health Study. I. Methodology.

We developed the methodology for a community survey to determine the prevalence of emotional and behavioral disorders among children 4 to 16 years of age in Ontario, Canada. Our discussion includes the objectives of the survey, the measurement of disorder, sampling methods and survey design, and a description of the data collected and instrumentation. Among 2052 households with eligible children, 1869 (91%) participated in the survey. The results can be used to help plan the future allocation of mental health resources in Ontario.

Ontario Child Health Study. II. Six-month prevalence of disorder and rates of service utilization.

We studied the six-month prevalence of four child psychiatric disorders (conduct disorder, hyperactivity, emotional disorder, and somatization) and patterns of service utilization for mental health and social services, ambulatory medical care and special education by different regions of Ontario, urban-rural residence, and age and sex groupings. Among children 4 to 16 years of age, the overall six-month prevalence rate of one or more of these disorders was 18.1%. The prevalences of hyperactivity and one or more disorders were significantly higher in urban areas than rural areas. The utilization data indicated that children with these psychiatric disorders, compared with children without these disorders, were almost four times more likely to have received mental health or social services in the six months preceding this study. However, five of six of these children had not received these specialized services in the previous six-month period. Over 50% of the children in the province had received ambulatory medical care in the last six months. Over 15% of the children in the province had received special education services at some time thus far in their school careers. Implications of these findings, especially for the provision of child mental health services, are discussed.

Trends in health service use for women in Australia with diabetes.

OBJECTIVE: To describe the health, health service use and use of recommended guidelines for care for women in Australia with diabetes. METHODS: Analysis of survey data 1996-99 from the Australian Longitudinal Study on Women's Health, linked with Medicare data for 1997-2001. Participants were 12,338 mid-age women aged 45-50 years in 1996 (1.9% with diabetes) and 10,421 older women aged 70-75 years at Survey 1 in 1996 (8.1% with diabetes). The outcome measures were number of general practice and specialist visits and use of glycosylated haemoglobin (HbAlc), lipids and microalbuminuria tests. RESULTS: Women with diabetes at Survey 1, and those diagnosed by Survey 2, were more likely to have hypertension, heart disease and eyesight problems, have high rates of polypharmacy (four or more medications: mid age 32%, older 64%) and more consultations with general practitioners and specialists than women without diabetes. During 1997-2001, there was a trend for a greater percentage of women with diabetes to have an HbA1c test at least annually (mid age 44%-52%, older age 46%-58%). Rates of testing microalbuminuria and lipids also increased but were far from conforming to guidelines. Having more frequent consultations with a general practitioner was significantly associated with having all three recommended tests. CONCLUSIONS: There is an increasing use of services by women with diabetes, in part due to an increase in compliance with guidelines for the management of diabetes. IMPLICATIONS: Linked health and administrative data provide a means to monitor health service utilisation, adherence to principles for best practice care and issues of equity in care.

Assessing socioeconomic inequalities of hypertension among women in Indonesia's major cities.

Although hypertension has been recognized as one of the major public health problems, few studies address economic inequality of hypertension among urban women in developing countries. To assess this issue, we analysed data for 1400 women from four of Indonesia's major cities: Jakarta, Surabaya, Medan and Bandung. Women were aged ⩾15 years (mean age 35.4 years), and were participants in the 2007/2008 Indonesia Family Life Survey. The prevalence of hypertension measured by digital sphygmomanometer among this population was 31%. Using a multivariable logistic regression model, socioeconomic disadvantage (based on household assets and characteristics) as well as age, body mass index and economic conditions were significantly associated with hypertension (P<0.05). Applying the Fairlie decomposition model, results showed that 14% of the inequality between less and more economically advantaged groups could be accounted for by the distribution of socioeconomic characteristics. Education was the strongest contributor to inequality, with lower education levels increasing the predicted probability of hypertension among less economically advantaged groups. This work highlights the importance of socioeconomic inequality in the development of hypertension, and particularly the effects of education level.

Asthma presentations to emergency departments in western Sydney during the January 1994 Bushfires.

BACKGROUND: From 5 to 12 January 1994, the state of New South Wales suffered from the worst bushfires seen this century. High levels of particulate air pollution were recorded in western Sydney from 7 to 14 January 1994, with nephelometry readings reaching 10.24 beta scat (10(-4)/m) and particulate matter < 10 mu readings peaking at 250.00 micrograms/m3. The aim of this study was to determine whether there was an increase in the proportion of asthma presentations to emergency departments (ED) in western Sydney as a result of the bushfire-generated particulate air pollution. METHOD: We retrospectively analysed the emergency room attendance books for asthma presentations from seven public hospitals serving the Western Sydney and Wentworth Health Areas over two 6-7 week periods, 17 December 1992 to 31 January 1993, and 17 December 1993 to 31 January 1994. Air pollution and meteorological data were obtained from local monitoring stations. RESULTS: The difference in the proportion of all ED presentations that were due to asthma during the week of the bushfire-generated air pollution, compared with the same week 12 months before, after adjusting for baseline changes over the 12-month period, was 0.0067 (95% CI: -0.0007, 0.0141). The maximum daily nephelometry reading was not a significant predictor of the daily number of asthma presentations to ED in any of the Poisson regression models. CONCLUSIONS: The bushfire-generated particulate air pollution in January 1994 did not result in an increase in asthma presentations to ED in western Sydney.

Delay in consulting a medical practitioner about rectal bleeding.

STUDY OBJECTIVE: The aims were to estimate the incidence of rectal bleeding in the community, and to determine the proportion of individuals who delay or fail to seek medical advice after a first episode of rectal bleeding. DESIGN: The data were collected as part of a large scale general population survey of the health practices and attitudes of individuals in a randomly selected sample of 2121 households. SETTING: The survey was conducted in the Newcastle and Lake Macquarie areas of New South Wales, Australia, during 1987-88. PARTICIPANTS: Information about rectal bleeding was collected from 1213 individuals aged 40 years and over. MEASUREMENTS AND MAIN RESULTS: Of the 1213 people aged 40 years and over, 239 (20%) reported noticing rectal bleeding at some time in their life. However, since an estimated 4.5% had noticed rectal bleeding for the first time in the past year the true lifetime incidence of rectal bleeding is likely to be much higher. Of the 77 individuals who had noticed a first occurrence of rectal bleeding more than three months but less than five years prior to the interview, 23 (30%) had either not sought medical advice or had only done so after a period of delay. The most commonly reported reason for delay or failure to consult was thinking that the bleeding was not serious and would clear up by itself. CONCLUSIONS: The data suggest that prompt investigation of rectal bleeding is not occurring in a relatively large proportion of cases. However, in the absence of firm evidence that early detection improves prognosis, and considering the costs of screening, it would be premature to initiate programmes which encourage people to seek care promptly for this symptom.

Determinants of general practitioner use among women in Australia.

This study investigates the use of general practitioner services by women in Australia. Although there is a universal health insurance system (Medicare) in Australia, there are variations in access to services and out of pocket costs for services. Survey data from 2350 mid-age (45-50 years) and 2102 older (70-75 years) women participating in the Australian Longitudinal Study on Women's Health were linked with Medicare data to provide a range of individual and contextual variables hypothesised to explain general practitioner use. Structural equation modelling showed that physical health was the most powerful explanatory factor of general practitioner use. However, after adjusting for self-reported health, out of pocket cost per consultation was inversely associated with use of services. The out of pocket cost was generally lower for women with low socioeconomic status but cost was also directly related to geographical remoteness. Women living in more remote areas had higher out of pocket costs and poorer access to services. Women who reported better access to care were more likely to be satisfied with their most recent general practice consultation and less likely to be sceptical of the value of medical care. These results show the need for health policies that improve the equitable use of general practitioner services in Australia.

A collaborative approach to cervical cancer screening.

OBJECTIVE: The main objective of this project was to evaluate a collaborative nurse and general practitioner approach to improve screening for cervical cancer. DESIGN: Multiple group time series design. SETTING: Six postal areas in the Hunter Valley of New South Wales, Australia, chosen as intervention sites because of very low Pap test rates compared with the rest of NSW (fewer than 50% of women screened). Six regions of similar size and with similar baseline screening levels were selected as comparison sites. SUBJECTS: All women selected in the resident postal areas. INTERVENTIONS: Women's health nurses worked in collaboration with general practitioners within the communities selected from within the Hunter area to promote and provide screening for cervical cancer. MAIN OUTCOME MEASURES: Qualitative information on initial expectations and impressions of the collaborative processes were collected at the start of the project period. Process data on client characteristics and Pap test results were obtained from minimum data collections; client satisfaction was assessed from client surveys. Outcome data on the increase in the number of women in each community who were screened for cervical cancer were obtained from Health Insurance Commission claims for screening Pap tests (and from nurses' records where Pap tests were examined under block funding arrangements). RESULTS: This project showed that nurses and general practitioners can collaborate to provide appropriate and highly acceptable cervical cancer screening services for women. Many of the women screened by the nurses were in the high risk age range for cervical cancer (40 years and older) and had only basic education levels, thus representing women who are most likely to have poor screening rates. Further, 33.1% of the women screened had not had a Pap test in the past four years or had never been screened. The number of women having a Pap test during the first six months of the project, compared with the number expected from preintervention patterns, was significantly greater in four intervention areas (P < 0.01). No corresponding increase was seen in comparison areas with similar screening rates at baseline. CONCLUSIONS: There is great potential for nurses to work in collaboration with general practitioners to improve the availability and coverage of community cervical cancer screening programmes.

A survey of screening compliance among first degree relatives of people with colon cancer in New South Wales.

OBJECTIVE: To survey screening practices, knowledge, and attitudes towards screening among first degree relatives of people with colon cancer. SETTING: A random sample of people with colon cancer listed on the New South Wales (NSW) Cancer Registry were mailed a questionnaire to be passed on to an appropriate first degree relative. METHODS: Two hundred and twenty five first degree relatives completed a self administered questionnaire. RESULTS: Although there were high levels of awareness about colorectal cancer, and attitudes towards colorectal cancer were generally positive, screening rates were low, and only three relatives had been screened in accordance with current Australian recommendations. Factors associated with previous participation in any type of screening test (usually once) included receiving a medical recommendation to screen, having more than one relative with colorectal cancer, being a sibling of the relative with colon cancer, the relative with cancer being female, and perceiving screening as messy, but not painful. CONCLUSIONS: Strategies to enhance screening awareness and participation among relatives need to be considered. This study provides some insight into factors to be considered in developing awareness programmes. Further research is required to explore these factors, and to identify ways to overcome barriers.

What are women told about Pap smears that lack endocervical cells?

BACKGROUND: Debate exists about the definition of what constitutes an adequate Pap smear and about the recommended rescreening interval for Pap smears lacking an endocervical component. This study aimed at determining whether women are currently informed about the endocervical status of their Pap smears and what rescreening recommendations are made to women whose smears lack endocervical cells. METHOD: Consecutive Pap smears lacking an endocervical component were identified from pathology records. After obtaining consent from the referring doctor, 165 women were interviewed by telephone. RESULTS: Only 110 (67%) of 165 women received active notification of their Pap test result and only six (4%) were aware that their smear lacked endocervical cells. Thirteen (8%) had been advised to have a repeat smear within three months. Nearly half the women reported that they would like more information about their result. CONCLUSIONS: It seems that current Pap smear notification patterns for women in New South Wales could be improved. One third are not actively informed at all about their results, and few are given detailed information about their Pap test results. Methods of enhancing the level of information women are given about their medical and screening tests need to be improved.

Effectiveness of three community based strategies to promote screening for cervical cancer.

OBJECTIVE: Evaluation of three potential methods for increasing Pap smear use: television media, television media combined with letter based recruitment, and television media combined with general practitioner based (GP based) recruitment. SETTING: A trial of each intervention was carried out in three postal regions in New South Wales, Australia-a rural locality (containing about 1000 women), a country town (about 3000 women), and a major rural centre (about 10,000 women). Three control regions were selected to be demographically similar to the corresponding intervention regions. METHODS: Outcome data on regional Pap smear rates were obtained from government health insurance claims for cervical screening, and from pathology service records. Expected Pap smear rates for the three months after the intervention were predicted from 45 pre-intervention months and were compared with observed rates for this period. RESULTS: Television media alone was associated with a significant increase in attendances for screening in one of the three regions where a trial was carried out: 13.3% in the rural centre. The media/letter based campaign was associated with a significant increase in attendances in two out of three regions: 52.7% in the rural locality, 43.2% in the rural centre. The media/GP based campaign was associated with significant increases in attendances in all three regions: 50.2% in the rural locality, 80.8% in the country town, 15.7% in the rural centre. All three interventions were associated with significant increases in the number of women attending for cervical screening above those observed in the control regions. Furthermore, these increases were not restricted to women at low risk. They were also found for older women (aged 50-69 years) and women who had not had a Pap smear within the past three years.