Health literacy and older adults: Findings from a national population-based survey.

ISSUE ADDRESSED: With an ageing population and growing complexity and fragmentation of health care systems, health literacy is increasingly important in managing health. This study investigated health literacy strengths and challenges reported by older Australians (people aged 65 or over) and identified how socio-demographic and health factors related to their health literacy profiles. METHODS: The sample comprised 1578 individuals responding to the Australian Government's 2018 Health Literacy Survey, conducted between January and August. Regression modelling was used to estimate the association between each of nine domains of the Health Literacy Questionnaire (HLQ) and individual socio-demographic and health characteristics. The model allowed for correlation between HLQ scores that was linked to unobserved characteristics of individuals. RESULTS: Across the health literacy domains, few individuals received mean scores in the lowest score range. Key individual characteristics associated with higher health literacy were increasing age, English proficiency, higher education levels, better self-assessed health and having certain chronic conditions (cancer, hypertension and arthritis). CONCLUSIONS: Our findings suggest that, among those aged 65 or over, being older or living with chronic illnesses were associated with greater confidence in engaging with providers, accessing information and navigating health services compared to individuals aged 65-69 and those older individuals without chronic illness. Lower health literacy was associated with psychological distress and low English proficiency. SO WHAT?: Interventions to improve individual health literacy and organisation health literacy responsiveness to minimise complexity of the Australian health system are required. This may enhance uptake and use of health information and services for the underserviced members of the community.

Large Discrepancies in Dementia Mortality Reported in Vital Statistics: The Need for Improved Data to Inform Policy.

PURPOSE: There is limited understanding of the intercountry comparability of dementia mortality data. This study compares reported dementia mortality in national vital statistics between countries and over time. In countries with low dementia reporting, this study identifies other causes to which dementia may be misclassified. METHODS: Using the World Health Organization (WHO) Mortality Database, we calculated the ratio of reported to expected (Global Burden of Disease estimated) age-standardized dementia death rates in 90 countries from 2000 to 2019. Other causes to which dementia may be misclassified were identified as having relatively high cause fractions compared with other countries. PATIENTS: No patients were involved. RESULTS: There is a large intercountry variation in reported dementia mortality rates. The ratio of reported to expected dementia mortality exceeded 100% in high-income countries but was below 50% in other super regions. In countries with low reported dementia mortality, cardiovascular diseases, ill-defined causes, and pneumonia have relatively high cause fractions and may be misclassified from dementia. DISCUSSION: Large discrepancies in dementia mortality reporting between countries, including often implausibly low reported mortality, makes comparison extremely difficult. Improved guidance for and training of certifiers and the use of multiple cause-of-death data can help strengthen the policy utility of dementia mortality data.

Discrepancies in self-reported and measured anthropometric measurements and indices among older Australians: prevalence and correlates.

BACKGROUND: Anthropometric measurements and indices such as weight, height and Body Mass Index (BMI) are often used to assess overall health and nutritional status. Clinicians and epidemiologists often rely on self-reported weight and height to measure BMI. Differences between self-reported and measured weight and height can lead to differences between self-reported and measured BMI, biasing relative risks of diseases associated with differential BMI. METHODS: Applying regression analysis to a large nationally representative survey data with contemporaneous self-reports and measurements on 3412 individuals aged 65 or over, we provided estimates of the difference between self-reports and measurements of weight, height and BMI for older Australians, analysing demographic, socioeconomic and health correlates of estimated differences. RESULTS: We found both males and females underestimated weight, overestimated height and underestimated BMI and there was some evidence these differences increased with age. There was also evidence that these differences were associated with high levels of education and household composition. CONCLUSION: Although average differences were small, for many individuals the differences may be significant, indicating measurements should be taken in clinically focused research and practice. This is important as systematic underestimation of BMI in older adults can have implications for estimating the size of populations at risk of many health conditions, including diabetes, hypertension and functional limitations.

The role of demographic change in explaining the growth of Australia's older migrant population living with dementia, 2016-2051.

OBJECTIVE: To examine the demographic drivers contributing to the future growth in the population of older migrants in Australia living with dementia. METHODS: Using birthplace-specific cohort-component projection models, we projected the number of older migrants living with dementia. ABS data on births, deaths, migration and birthplace were used, alongside Australian Institute of Health and Welfare (AIHW) estimates of dementia prevalence with birthplace dementia weights calculated from administrative data. RESULTS: The number of older migrants living with dementia is projected to increase from about 134,423 in 2016 to 378,724 by 2051. Increases in populations with dementia varied considerably, from a slight decrease for those born in Southern & Eastern Europe to over 600% increases amongst the South-East Asia, Southern & Central Asia, and Sub-Saharan Africa-born populations. CONCLUSIONS: Cohort flow is the primary driver increasing the number of older migrants living with dementia. This growth is largely inevitable because the cohorts are already living in Australia as part of the migrant population, but currently at ages below 60 years. IMPLICATIONS FOR PUBLIC HEALTH: High relative growth and shifting birthplace composition in the number of migrants living with dementia poses implications for culturally appropriate care, health care access and workforce needs to support migrant families, carers and their communities.

Local area population projections dataset for Australia.

A new dataset of population projections for local areas of Australia is described. The areas comprise SA3 areas of the Australian Statistical Geography Standard, which mostly range in population between 30,000 and 130,000. The projections are launched from the 2020 Estimated Resident Populations published by the Australian Bureau of Statistics and extend out to 2035. They are available by sex and five year age group up to 80-84 with 85+ as the final age group and in five year projection intervals. The projections were prepared using the synthetic migration cohort-component model, a new model for population projections which requires much less input data than conventional projection models, and therefore involves much lower costs and production time. Despite this, a recent evaluation demonstrated respectable forecast accuracy, and greater accuracy than equivalent simple projection models producing populations by age and sex. The age-sex projections are constrained to independent age-sex national projections and local area projections of total populations. The dataset consists of local area projections for the whole of the country which is consistent in methods, input data, and projection outputs due to the use of one model. This is rare in Australia because local area projections are most commonly prepared by individual State/Territory Governments using different methods, data sources, projection assumptions (which can be influenced by State/Territory population policies), and time periods. These nationally consistent projection data should be useful for a wide range of local area planning, policy, and research purposes, such as childcare demand, school enrolments, power and water usage, aged care provision, store and business site selection, living arrangements and household projections, labour force projections, and transport modelling.

Demographic drivers of the growth of the number of Aboriginal and Torres Strait Islander people living with dementia, 2016-2051.

OBJECTIVE: To examine the demographic drivers that contribute to the future growth in the population of Aboriginal and Torres Strait Islander peoples living with dementia in Australia. METHODS: Design: Multistate, Indigenous status, cohort component, population projection model. SETTING: National-level, Aboriginal and Torres Strait Islander population. DATA: Data prepared by the Australian Bureau of Statistics on births, deaths, migration and identification change. Australian Institute of Health and Welfare estimates of dementia prevalence alongside estimates from several studies. MAJOR OUTCOME MEASURES: Number of older people living with dementia alongside a decomposition of demographic drivers of growth. RESULTS: By 2051, the relative growth in the number of Aboriginal and Torres Strait Islander peoples aged 50+ with dementia ranges from 4½ to 5½ times (under three prevalence scenarios) its 2016 estimate. Cohort flow (the gradual movement of younger cohorts into the 50+ age group, and the depletion of older cohorts from death, over time) is a key driver of the growth in the number of older people living with dementia. CONCLUSIONS: High growth in the number of people living with dementia poses implications for culturally appropriate care, health-care access and support for Aboriginal and Torres Strait Islander families, carers and their communities.

The Impact of Demographic and Economic Change on the Australian Generational Economy: Financial Sustainability, Intergenerational Inequality, and Material Living Standards.

The generational economy-which is that aspect of the economy that pertains to the economic activities of, and the economic relationships between, different ages and generations-can be evaluated on the basis of a number of different criteria. The most critical of these include the financial sustainability of the generational economy, the intergenerational inequality that the generational economy creates, and the material living standards associated with the generational economy. How the generational economy performs in terms of these three criteria is, moreover, shaped by underlying processes of demographic and economic change. This paper examines how the Australian generational economy can be expected to perform in coming decades in terms of financial sustainability, intergenerational inequality, and material living standards. How the performance of the Australian generational economy is shaped by variations in fertility, mortality, overseas migration, and labour-income growth is also assessed. The results reported in the paper indicate that, because of population aging, consumption can only grow at a substantially lower rate than labour income if financial sustainability is to be maintained. These results also suggest that increasing overseas migration is a distinctly useful policy tool for meeting the challenges posed by population aging, since increasing overseas migration both increases material living standards and decreases intergenerational inequality.

Identifying patterns of potentially preventable hospitalisations in people living with dementia.

BACKGROUND: Older Australians make up 46% of all potentially preventable hospitalisations (PPHs) and people living with dementia are at significantly greater risk. While policy reforms aim to reduce PPHs, there is currently little evidence available on what drives this, especially for people living with dementia. This study examines patterns of PPHs in people living with dementia to inform service delivery and the development of evidence-based interventions. METHODS: We used the Victorian Admitted Episodes Dataset from Victoria, Australia, to extract data for people aged 50 and over with a diagnosis of dementia between 2015 and 2016. Potentially avoidable admissions, known as ambulatory care sensitive conditions (ACSCs), were identified. The chi-square test was used to detect differences between admissions for ACSCs and non-ACSCs by demographic, geographical, and administrative factors. Predictors of ACSCs admissions were analysed using univariate and multiple logistic regression. RESULTS: Of the 8156 hospital records, there were 3884 (48%) ACSCs admissions, of which admissions for urinary tract infections accounted for 31%, followed by diabetes complications (21%). Mean bed-days were 8.26 for non-ACSCs compared with 9.74 for ACSCs (p ≤ 0.001). There were no differences between admissions for ACSCs and non-ACSCs by sex, marital status, region (rural vs metro), and admission source (private accommodation vs residential facility). Culture and language predicted ASCS admission rates in the univariate regression analyses, with ACSC admission rates increasing by 20 and 29% if English was not the preferred language or if an interpreter was required, respectively. Results from the multiple regression analysis confirmed that language was a significant predictor of ACSC admission rates. CONCLUSIONS: Improved primary health care may help to reduce the most common causes of PPHs for people living with dementia, particularly for those from culturally and linguistically diverse backgrounds.

Including ethnic minorities in dementia research: Recommendations from a scoping review.

Introduction: Ethnicity influences dementia etiology, prognosis, and treatment, while culture shapes help-seeking and care. Despite increasing population diversity in high-income settlement countries, ethnic minorities remain underrepresented in dementia research. We investigated approaches to enhance the recruitment, and consistent collection and analysis of variables relevant to, ethnic minorities in dementia studies to make recommendations for consistent practice in dementia research. Methods: We did a scoping review, searching Embase, PsycINFO, Medline, CENTRAL, and CINAHL between January 1, 2010 and January 7, 2020. Dementia clinical and cohort studies that actively recruited ethnic minorities in high-income countries were included. A steering group of experts developed criteria through which high-quality studies were identified. Results: Sixty-six articles were retrieved (51 observational; 15 experimental). Use of interpreters and translators (n = 17) was the most common method to facilitate participant recruitment. Race and ethnicity (n = 59) were the most common variables collected, followed by information on native language (n = 14), country of birth (n = 9), and length of time in country of settlement (n = 8). Thirty-three studies translated or used a culturally validated instrument. Twenty-three articles conducted subgroup analyses based on ethnicity. Six high-quality studies facilitated inclusion through community engagement, collected information on multiple aspects of ethnic diversity, and adjusted/substratified to analyze the impact of ethnicity on dementia. Discussion: We make recommendations for consistent recruitment, collection, and reporting of variables relating to ethnic and cultural diversity in dementia research.

Is the Rise in Reported Dementia Mortality Real? Analysis of Multiple-Cause-of-Death Data for Australia and the United States.

Official statistics in Australia and the United States show large recent increases in dementia mortality rates. In this study, we assessed whether these trends are biased by an increasing tendency of medical certifiers (predominantly physicians) to report on the death certificate that dementia was a direct cause of death. Regression models of multiple-cause-of-death data in Australia (2006-2016) and the United States (2006-2017) were constructed to adjust dementia mortality rates for changes in death certification practices. Compared with official statistics, the recent increase in adjusted age-standardized dementia death rates was less than half as large in Australia and about two-thirds as large in the United States. Further adjustment for changes in reporting of dementia anywhere on the death certificate implied even lower increases in dementia mortality. Declines in reporting of cardiovascular diseases as comorbid conditions also contributed to rises in dementia mortality rates. The increasing likelihood of dementia's being reported as directly leading to death largely explains recent increases in dementia mortality rates in both countries. However, studies have found that reported dementia on death certificates remains low compared with clinical evaluations of its prevalence. Improved guidance and training for certifiers in reporting of dementia on death certificates will help standardize mortality statistics within and between countries.

Methods for Small Area Population Forecasts: State-of-the-Art and Research Needs.

Small area population forecasts are widely used by government and business for a variety of planning, research and policy purposes, and often influence major investment decisions. Yet, the toolbox of small area population forecasting methods and techniques is modest relative to that for national and large subnational regional forecasting. In this paper, we assess the current state of small area population forecasting, and suggest areas for further research. The paper provides a review of the literature on small area population forecasting methods published over the period 2001-2020. The key themes covered by the review are extrapolative and comparative methods, simplified cohort-component methods, model averaging and combining, incorporating socioeconomic variables and spatial relationships, 'downscaling' and disaggregation approaches, linking population with housing, estimating and projecting small area component input data, microsimulation, machine learning, and forecast uncertainty. Several avenues for further research are then suggested, including more work on model averaging and combining, developing new forecasting methods for situations which current models cannot handle, quantifying uncertainty, exploring methodologies such as machine learning and spatial statistics, creating user-friendly tools for practitioners, and understanding more about how forecasts are used. Supplementary Information: The online version contains supplementary material available at 10.1007/s11113-021-09671-6.

English Language Proficiency Among Older Migrants in Australia, 2016-2046.

Australia's population is growing, ageing and exhibiting increasing heterogeneity with respect to birthplace and ethnic composition. Yet, little is understood about the levels of English language proficiency among the next generation of older migrants in Australia. Utilising a modified cohort-component model incorporating detailed language proficiency transition probabilities, we project birthplace populations by levels of English language proficiency to mid-century. Our results show that although Asian-born migrants tend to have lower levels of English proficiency, the majority of older migrants with poor proficiency are currently from a predominantly European background. In the future, we project a strong shift in the population of poor English speakers toward an Asian-born dominance as some European-born migrant groups dwindle in size and cohort flow increases population growth among older Asian migrants. Specifically, most of the population growth among older migrants with poor English proficiency occurs among Chinese and Mainland Southeast Asian migrants. However, we demonstrate that population growth among the total migrant population with poor proficiency is considerably lower than populations with good proficiency or from English-speaking households. Over the projection horizon, the total older migrant population with poor English proficiency increases by under 80,000 compared with an increase of 726,000 with good levels of proficiency and 518,000 in English-speaking households. However, we caution against conflating improved English language proficiency with a policy shift away from ethno-specific aged care services as culture, which is more than language, strongly influences perceptions of quality of aged care.

Will the COVID-19 pandemic affect population ageing in Australia?

The COVID-19 pandemic has caused extensive disruption to economies and societies across the world. In terms of demographic processes, mortality has risen in many countries, international migration and mobility has been widely curtailed, and rising unemployment and job insecurity is expected to lower fertility rates in the near future. This paper attempts to examine the possible effects of COVID-19 on Australia's demography over the next two decades, focusing in particular on population ageing. Several population projections were prepared for the period 2019-41. We formulated three scenarios in which the pandemic has a short-lived impact of 2-3 years, a moderate impact lasting about 5 years, or a severe impact lasting up to a decade. We also created two hypothetical scenarios, one of which illustrates Australia's demographic future in the absence of a pandemic for comparative purposes, and another which demonstrates the demographic consequences if Australia had experienced excess mortality equivalent to that recorded in the first half of 2020 in England & Wales. Our projections show that the pandemic will probably have little impact on numerical population ageing but a moderate effect on structural ageing. Had Australia experienced the high mortality observed in England & Wales there would have been 19,400 excess deaths. We caution that considerable uncertainty surrounds the future trajectory of COVID-19 and therefore the demographic responses to it. The pandemic will need to be monitored closely and projection scenarios updated accordingly.

Carers of older Australians: unmet support needs and carer well-being.

Primary carers play an important role in supporting the Australian Government's policy of 'ageing in place' or encouraging people to receive care in their own homes or communities rather than in institutions. Supporting carers in their role is therefore an important aspect of the policy's success. Despite numerous programs in place, this study finds that among carers of older Australians, a relatively high proportion (39%) cite unmet needs in their carer role, including a need for financial support, physical assistance, emotional support, improvement in carer health and more respite care. Concerningly, unmet support needs were shown to be strongly associated with markers of poor carer well-being, including an almost 2-fold increase in odds of poor carer satisfaction (odds ratio (OR) 1.77, 95% confidence interval (CI) 1.24-2.51), a 4- to 5-fold increase in the odds of changes to physical and emotional well-being (OR 5.29, 95% CI 3.83-7.31), deterioration in financial situation (OR 4.60, 95% CI 3.26-6.48) and strained carer-recipient relationship (OR 3.79, 95% CI 2.39-6.01).

Barriers to health care reported by carers of older Australians: new evidence from the 2018 Survey of Disability, Ageing and Carers.

Carers play an important role in assisting older care recipients with their daily lives and attending to their health care. Yet research has largely overlooked the barriers to health care that carers of older Australians themselves experience. This study finds that, among those attempting to access care, approximately 31.2% of carers of older Australians reported a barrier to health care, with one-third of this group reporting barriers at many points in the healthcare system. Barriers to care were considerable for those attempting to access dental, GP and medical specialist services (27.8%, 18.3% and 15.2% respectively), but lower for accessing hospital services (8.6%). People living with a disability or those in high carer distress had a minimum threefold increase in the odds of experiencing a barrier to care, with odds ratios (95% confidence intervals) of 3.35 (2.10-5.36) and 3.37 (2.33-4.88) respectively. Carers of older Australians noted cost as an important barrier to care, but between 20% and 40% cited being too busy or not having enough time to access dental, GP and medical specialist services (21%, 39% and 26% respectively). Addressing the barriers to health care reported by carers is critical not only to their own health and well-being, but also to that of care recipients.

Culturally competent communication in Indigenous disability assessment: a qualitative study.

BACKGROUND: Indigenous people tend to exhibit a higher burden of disability than their non-Indigenous counterparts, and are often underserved by disability services. Engaging appropriately with Indigenous communities, families and individuals in the initial stages of disability assessment and planning is crucial in order to build trust and understanding of disability service models and ensure that Indigenous people receive support that is tailored to their needs and cultural realities. This article aims to identify key elements of culturally competent communication in Indigenous disability assessment and planning, and provide recommendations for strengthening capacity in this area. METHODS: This qualitative research was designed to involve Aboriginal and Torres Strait Islander people at all stages and to reflect the views of Aboriginal and Torres Strait Islander researchers, people and families affected by disability and the community-controlled health sector. Semi-structured individual interviews were undertaken with staff implementing the National Disability Insurance Scheme (NDIS) (n = 4), NDIS participants (n = 24), disability support providers and organisational partners (n = 19) and Community Connectors (n = 8) in Queensland and the Northern Territory of Australia. Key themes derived from thematic analysis included appropriate and adequate engagement of individuals with disability and their families, the role of trusted relationships, and culturally safe and appropriate communication during planning meetings. RESULTS: Overall, the research findings highlight that a low level of cultural competence in the initial stages of the disability assessment and planning process exacerbated participant confusion and distrust towards assessment staff and the NDIS. Given difficulties in communication, participant understanding of the NDIS was generally limited. The necessity of culturally safe and appropriate use of interpreters was stressed, as was the role of trusted individuals, including existing service providers, Community Connectors and family members in providing a solid base for participant understanding of the NDIS. CONCLUSIONS: Cultural competence in disability assessment and planning can be strengthened through multi-level engagement with the Aboriginal community-controlled sector and community leaders. Implementing mechanisms to enable the involvement of families, trusted service providers and Community Connectors can support a more meaningful understanding of individuals' needs within their cultural context and in relation to their cultural roles.

Projections of Older European Migrant Populations in Australia, 2016-56.

Many of the European migrant populations which settled in Australia in the three decades after World War Two are now much older, and their aged care and health care needs are changing. While there is a considerable literature on individual aspects of ageing in many migrant groups (particularly as it pertains to culturally appropriate aged care), little research attention has been given to population aspects of ageing and its implications. The aim of this paper is to address this lacuna by presenting projections of Australia's Europe-born older migrant population from 2016 to 2056. The population projections were created by a cohort-component model modified to accommodate multiple birthplace populations. Findings show the older Europe-born population is projected to experience a slight increase over the next few years, reach a peak of just under one million in the early 2030s, and then undergo a gradual decline thereafter. The Europe-born share of Australia's 65+ population will fall, from 25.5% in 2016 to 10% by 2056. Populations born in Western and Southern Europe are likely to decline throughout the projection horizon while, the Northern Europe-born and Ireland-born older populations are projected to grow continually. The populations born in the UK and South Eastern Europe initially grow before decline sets in. To a large extent the future population size of these older migrant groups will be the result of cohort flow. We discuss the implications of the coming demographic changes for government policy and culturally appropriate service provision.

Discrimination reported by older adults living with mental health conditions: types, contexts and association with healthcare barriers.

OBJECTIVE: Australian policy-making needs better information on the prevalence, context and types of discrimination reported by people living with mental health conditions and the association of exposure to discrimination with experiencing a barrier to accessing healthcare. METHODS: Secondary data analysis using the national representative General Social Survey 2014 to examine discrimination and healthcare barriers. Multivariable logistic regression was used to examine the association between discrimination and barriers to healthcare. RESULTS: Around 10% of older adults without mental health conditions reported an instance of discrimination in the last 12 months, compared to 22-25% of those with mental health conditions. Approximately 20% with mental health conditions attributed discrimination to their health conditions, along with other characteristics including age. Discrimination was reported in settings important to human capital (e.g., healthcare, workplace), but also in general social and public contexts. Everyday discrimination (OR = 2.11 p < 0.001), discrimination in healthcare (OR = 2.92 p < 0.001), and discrimination attributed to the person's health condition (OR = 1.99 p < 0.05) increased the odds of experiencing a barrier to care two-to-three-fold. For each type of discrimination reported (e.g., racism, ageism etc.), the odds of experiencing a barrier to care increased 1.3 times (OR = 1.29 p < 0.01). CONCLUSION: This new population-level evidence shows older adults with mental health conditions are experiencing discrimination at more than twofold compared to those without mental health conditions. Discrimination was associated with preventing or delaying healthcare access. These findings indicate that future strategies to promote mental healthcare in underserved groups of older people will need to be multidimensional and consideration given to address discrimination.