Emeritus Professor Julie Byles

Background: Improving the coordination and integration of health services is recognised nationally and internationally as a key strategy for improving the quality of diabetes care. The Australian Diabetes Alliance Program (DAP) is an integrated care model implemented in the Hunter New England Local Health District (HNELHD), New South Wales (NSW), in which endocrinologists and diabetes educators collaborate with primary care teams via case-conferencing, practice performance review, and education sessions. The objective of this study was to report on general practitioners¿ (GPs) perspectives on DAP and whether the program impacts on their skills, knowledge, and approach in delivering care to adult patients with type 2 diabetes. Methods: Four primary care practices with high rates of monitoring haemoglobin A1c (HbA1c) levels (> 90% of patients annually) and five practices with low rates of monitoring HbA1c levels (< 80% of patients annually) from HNELHD, NSW provided the sampling frame. A total of nine GPs were interviewed. The transcripts from the interviews were reviewed and analysed to identify emergent patterns and themes. Results: Overall, GPs were supportive of DAP. They considered that DAP resulted in significant changes in their knowledge, skills, and approach and improved the quality of diabetes care. Taking a more holistic approach to care, including assessing patients with diabetes for co-morbidities and risk factors that may impact on their future health was also noted. DAP was noted to increase the confidence levels of GPs, which enabled active involvement in the provision of diabetes care rather than referring patients for tertiary specialist care. However, some indicated the program could be time consuming and greater flexibility was needed. Conclusions: GPs reported DAP to benefit their knowledge, skills and approach for managing diabetes. Future research will need to investigate how to improve the intensity and flexibility of the program based on the workload of GPs to ensure long-term acceptability of the program.

Introduction: With no standard frailty tool for clinical care, research and policymaking, identifying frail older people is a challenge. Aims: This study aimed to compare two validated scales, which are the Frail Scale and Hospital Frailty Risk Score (HFRS) for their ability in identifying frailty in older Australian women and predicting hospital use. Methods: This study included older Australian women aged 75¿95¿years, who had unplanned overnight hospital admission as an index admission between 2001 and 2016. Data from the Australian Longitudinal Study on Women's Health (ALSWH) were linked with administrative hospital data to calculate HFRS (using the International Statistical Classification of Diseases, Australia Modification (ICD-10-AM) diagnostic codes) and the Frail Scale (using the ALSWH self-reported survey). Results: The Frail Scale identified a higher proportion of older frail women (30.54%) compared to the HFRS (23.0%). Frail older women, classified by Frail Scale, were at higher risk of long hospital stay (adjusted odds ratio¿=¿1.28, 95% CI¿=¿1.02¿1.60), repeated admission (adjusted hazard ratio [AHR]¿=¿1.30, 95% CI¿=¿1.03¿1.41) and death (AHR¿=¿1.70, 95% CI¿=¿1.45¿2.01). HFRS was associated with longer hospital stay and mortality. Conclusions: The proportion of older women classified as frail by the Frail Scale tool was higher than women classified as frail by HFRS. The Frail Scale and HFRS were not significantly associated with each other. While both tools were associated with the risk of long hospital stay and mortality, only the Frail Scale predicted the risk of repeated admission.

Purpose: Telehealth consultations are likely to continue while living with COVID-19 and the risk of other pandemics. Greater understanding of patient perceptions is important in order to inform future integrated care models involving telehealth. Design/methodology/approach: An interpretative qualitative study. Fifteen, in-depth qualitative interviews were conducted with diverse range of community dwelling patients who attended outpatient clinics at The John Hunter Hospital, Newcastle. Data were analysed using an inductive thematic approach. Findings: Key themes were identified: (1) telehealth is valuable in a pandemic; (2) telehealth accessibility can be challenging; (3) there are variations in care experiences, especially when visual feedback is lacking; (4) telehealth for acute and complex care needs may lead to gaps and (5) considerations towards the future of telehealth, beyond a pandemic. Research limitations/implications: There is a shortfall in evidence of the patient experience of integrated care within a telehealth framework. The results provided practical insights into how telehealth services can play a greater role in integrated care. Practical implications: Apart from the need for affordable access to high-speed data for basic Internet access, the author posit the need for patient and clinician training towards promoting communication that is underpinned by choice, trust and shared decision-making. Originality/value: Telehealth is important towards keeping patients safe during COVID-19. Key findings extend knowledge of the practical implications need to promote integrated telehealth systems. While there is a benefit in extending telehealth to more preventative activities, there is also a need for greater service coordination and sharing of information between treating clinicians. Overall the results highlight telehealth consultations to be an effective means of treating well-known conditions and for follow-up rather than for acute conditions.

Background: Older population with dementia use huge range of medications. In this study, we aimed to determine the prevalence of commonly used medications a year before and after first recorded dementia diagnosis among older Australian women. Methods: The study utilized Australian Longitudinal Study on Women¿s Health (ALSWH) data from 2090 women with known dementia, linked with administrative health datasets. The Pharmaceutical Benefits Scheme (PBS) data provided detailed information about prescribed medications. We applied latent class analysis (LCA) to the post-dementia data to identify patterns of medication use. Logistic regression model was used to explore the impact of potential predictors for medication utilization. Results: Antipsychotic use increased from 5% before dementia to 19% after dementia, while antidementia medication use increased from < 1 to 28%. There was a modest increase in benzodiazepines and antidepressants. Post-dementia, four distinct groups were identified using LCA (names based on probabilities of medications use) as: ¿High Psychotropic¿Low Cardiovascular¿ (16% of the sample); ¿Moderate Psychotropic¿High Cardiovascular¿ (12%); ¿Low Psychotropic¿High Cardiovascular¿ (27%); and ¿Low Psychotropic¿Low Cardiovascular¿ (45%). Living in Residential Aged Care (RAC) and frailty were associated with increased odds of being in the higher psychotropic use groups. Conclusions: Substantial utilization of psychotropic medications by older people with dementia indicates a need for a careful review of the use of these medications. Appropriate alternative approaches to the management of dementia should be practiced with a special focus on RAC residents with frailty.

The aim of this study was to assess the long-term risk for mortality and incident dementia associated with exposure to intimate partner violence (IPV) at any time over the life course. Data were taken from the Australian Longitudinal Study of Women¿s Health, a population-based cohort study initiated in 1996. Analysis is based on 12,085 community-dwelling women aged 70 to 75 years at baseline from all states and territories. Self-reported exposure to violence was separated into historical (any time before baseline), current (past 12 months), or both. Date of death was obtained from the National Death Index, and dementia status was self-reported or obtained from administrative data. We modeled mortality risk using Cox regression, and risk for incident dementia using Fine-Gray proportional hazards modeling with death as a competing risk. Follow up continued to December 2017. At baseline, 728 women (6.0%) reported historical IPV, 121 (1.0%) reported current violence, and 38 reported both (0.3%). Historical IPV increased 20-year mortality risk after controlling for demographic, socioeconomic, and lifestyle variables (hazard ratio 1.10, 95% confidence interval = [1.00, 1.20]). There was no relationship between current violence and mortality (hazard ratio 1.04, 95% confidence interval = [0.85, 1.29]). There was also no association between IPV and risk for incident dementia (hazard ratio 1.02, 95% confidence interval = [0.89, 1.17]). Older women who self-report exposure to IPV over the lifespan die significantly earlier than women who do not. Further research that considers the mediating role of psychological trauma is needed to examine the relationship between IPV and dementia.

Health assessments have potential to improve health of older people. This study compares long-term health care utilisation, physical functioning, and mortality for women aged 75 years or over who have had a health assessment and those who have not. Prospective data on health service use, physical functioning, and deaths among a large cohort of women born 1921¿26 were analysed. Propensity score matching was used to produce comparable groups of women according to whether they had a health assessment or not. The study population included 6128 (67.3%) women who had an assessment, and 2971 (32.7%) women who had no assessment. Propensity matching produced 2101 pairs. Women who had an assessment had more use of other health services, longer survival, and were more likely to survive with high physical functioning compared to women with no assessment. Among women who had good baseline physcial functioning scores, women who had an assessment had significantly lower odds of poor outcomes at 1000 days follow-up compared to women who had no assessment (OR: 0.67, 95%CI: 0.52, 0.85). This large observational study shows the real-world potential for assessments to improve health outcomes for older women. However, they also increased health service use. This increased healthcare is likely to be an important mechanism in improving the women¿s health outcomes.

Objective: To assess the psychological impacts and risk for elder abuse associated with historical intimate partner violence (IPV) in older women. Design: Prospective cohort study Setting: All Australian states and territories. Participants: A total of 12,259 women aged 70¿75 years at baseline participating in the Australian Longitudinal Study of Women's Health. Measurements: Women were asked at baseline whether they had ever been in a violent relationship with a partner, and completed a comprehensive survey about their physical and psychological health every 3 years (15 years follow-up) including the Short Form-36 Mental Health subscale (SF-MH) and Vulnerability to Abuse Screening Scale (VASS). Linear mixed effects modelling with maximum likelihood estimation assessed the impact of IPV over time on the SF-MH and VASS. Risk for incident depression and experiencing physical or sexual violence over follow-up was examined using logistic regression models. Results: The 782 (6.4%) women who reported historical IPV recorded significantly poorer psychological wellbeing at all timepoints compared to those who did not report historical IPV, and were at higher risk for incident depression over follow up (adjusted odds ratio [aOR] = 1.36, 95% confidence interval [CI]:1.11¿1.67). There was no significant relationship between historical IPV and self-reported exposure to physical or sexual violence in late life (aOR = 0.87, 95%CI: 0.53¿1.43), but women who reported historical IPV recorded higher rates of vulnerability to abuse on the VASS. Discussion: Women who have experienced a violent relationship continue to experience negative effects into older age, highlighting the importance of clinical monitoring and ongoing support for survivors as they age.

Objectives: This study aimed to determine the prevalence of continuous polypharmacy and hyperpolypharmacy, determine medications that contribute to continuous polypharmacy, and examine the association between frailty and continuous polypharmacy. Study design: A prospective study using data from the Australian Longitudinal Study on Women's Health. Women aged 77¿82 years in 2003, and 91¿96 years in 2017 were analysed, linking the Pharmaceutical Benefits Scheme data to participants¿ survey data. Main outcome measures: The association between frailty and continuous polypharmacy was determined using generalised estimating equations for log binomial regressions, controlling for confounding variables. Descriptive statistics were used to determine the proportion of women with polypharmacy, and medications that contributed to polypharmacy. Results: The proportion of women with continuous polypharmacy increased over time as they aged. Among participants who were frail (n = 833) in 2017, 35.9 % had continuous polypharmacy and 1.32 % had hyperpolypharmacy. Among those who were non-frail (n = 1966), 28.2 % had continuous polypharmacy, and 1.42 % had hyperpolypharmacy. Analgesics (e.g. paracetamol) and cardiovascular medications (e.g. furosemide and statins) commonly contributed to continuous polypharmacy among frail and non-frail women. Accounting for time and other characteristics, frail women had an 8% increased risk of continuous polypharmacy (RR 1.08; 95 % CI 1.05, 1.11) compared to non-frail women. Conclusions: Combined, polypharmacy and frailty are key clinical and public health challenges. Given that one-third of women had continuous polypharmacy, monitoring and review of medication use among older women are important, and particularly among women who are frail.

Background and aims: Little is known about how weight trajectories among women during menopausal transition and beyond may be related to risk of type 2 diabetes mellitus (T2DM). The aim of this study was to examine associations between body mass index (BMI) trajectories over 20 years, age of obesity onset, cumulative obese-years and incidence of T2DM among middle-aged women. Methods and results: 12,302 women enrolled in the Australian Longitudinal Study on Women's Health (ALSWH) were surveyed in 1996 (Survey 1, age 45¿50), 1998 and then every three years to 2016. Self-reported weight and height were collected for up to eight time points. Incident diabetes was assessed via validated self-report of physician-diagnosed diabetes. Growth mixture models were used to identify distinct BMI trajectories. A total of 1380 (11.2%) women newly developed T2DM over an average 16 years of follow-up. Seven distinct BMI trajectories were identified with differential risk of developing T2DM. Initial BMI was positively associated with T2DM risk. We also observed that risk of T2DM was positively associated with rapid weight increase, early age of obesity onset and greater obese-years. Conclusion: Slowing down weight increases, delaying the onset of obesity, or reducing cumulative exposure to obesity may substantially lower the risk of developing T2DM.

Background: Comorbidity can complicate cardiovascular diseases (CVDs), increasing the risk of adverse events including hospitalisation and death. This study aimed to assess the Charlson Comorbidity Index (CCI) as a predictor of repeated hospital admission and mortality in older CVD patients. Methods: This study linked data from the Australian longitudinal study on women¿s health (ALSWH) with hospital and National Death Index datasets to identify dates for hospital admission, discharge, and death for women born 1921¿26. CCI was calculated using the International Statistical Classification of Diseases, Australia Modification (ICD-10-AM) diagnostic codes. Results: Women with a higher CCI on index admission had increased risk of repeated hospital admission (AHR = 1.29, 95% CI 1.06, 1.58) and mortality (AHR = 3.05, 95% CI 2.15, 4.31). Older age and hypertension were also significantly associated with a higher risk of repeated hospital admission and mortality. Living in a remote area was associated with a higher risk of mortality. Conclusions: The Charlson Comorbidity Index predicts repeated hospital admission and mortality incidences among older women with CVD. Improving management of comorbidities for older CVD patients should be considered as part of a strategy to mitigate subsequent repeated hospitalisation and delay mortality.

BACKGROUND: Smoking and obesity are 2 modifiable risk factors for disability. We examine the impact of smoking and obesity on disability-free life expectancy (DFLE) at older ages, using 2 levels of disability. METHOD: We used the DYNOPTA dataset, derived by harmonizing and pooling risk factors and disability outcomes from 5 Australian longitudinal aging studies. We defined mobility disability as inability to walk 1 km, and more severe (activities of daily living [ADL]) disability by the inability to dress or bathe. Mortality data for the analytic sample (N = 20 401; 81.2% women) were obtained from Government Records via data linkage. We estimated sex-specific total life expectancy, DFLE, and years spent with disability by Interpolated Markov Chain (IMaCh) software for each combination of smoking (never vs ever), obesity (body mass index =30 vs 18.5 to <30), and education (left school age 14 or younger vs age 15 or older). RESULTS: Compared to those without either risk factor, high educated nonobese smokers at age 65 lived shorter lives (men and women: 2.5 years) and fewer years free of mobility disability (men: 2.1 years; women: 2.0 years), with similar results for ADL disability. Obesity had the largest effect on mobility disability in women; high educated obese nonsmoking women lived 1.3 years less than nonsmoking, not obese women but had 5.1 years fewer free of mobility disability and 3.2 fewer free of ADL disability. Differences between risk factor groups were similar for the low educated. CONCLUSIONS: Our findings suggest eliminating obesity would lead to an absolute reduction of disability, particularly in women.

Objectives: Home Medicines Reviews (HMRs) can optimize medications for frail older adults. This study aimed to determine the use of HMRs according to frailty status and the association between frailty and use of HMRs. Methods: The study included 9139 female participants enrolled in the Australian Longitudinal Study on Women's Health from 2003 (aged 77-82 years) to 2017 (aged 91-96 years). Generalized estimating equations (GEEs) using log-binomial regressions were used to determine associations using repeated measures on individuals over time. Key findings: The majority of participants in the study remained non-frail and did not receive HMRs from 2003 [7116 (77.86%)] to 2017 [1240 (71.31%)]. The use of HMRs was low in both groups with 33 (1.68%; 95% CI, 1.16 to 2.36) frail and 64 (0.89%; 95% CI, 0.69 to 1.14) non-frail participants receiving HMRs in 2003; by 2017, 19 (4.19%; 95% CI, 2.54 to 6.46) frail and 45 (3.50%; 95% CI, 2.57 to 4.66) non-frail participants received HMRs. Frailty was not associated with receiving a HMR (RR 1.06; 95% CI, 0.95 to 1.20), although for every 1-year increase, participants were 10% more likely to receive a HMR (RR 1.10; 95% CI, 1.09 to 1.11). Participants with continuous polypharmacy, =4 chronic diseases, >4 general practitioner visits and Department of Veterans Affairs coverage were more likely to receive a HMR. Conclusions: Despite the proven value of HMRs for frail older people, HMRs were not used for most frail and non-frail community-dwelling women in this study. Reasons for low use of the service should be explored, with interventions to raise awareness of the benefits of the service.

Heavy metal exposures may contribute to diabetes risk but prospective studies are uncommon. We analyzed the Australian Longitudinal Study on Women¿s Health (three cohorts aged 18¿23, 45¿50, or 70¿75 at baseline in 1996, N =¿34,191) merged with emissions data for 10 heavy metals (As, Be, Co, Cr, Cu, Hg, Mn, Ni, Pb, Zn) from the National Pollutant Inventory. Over 20-year follow-up, 2,584 women (7.6%) reported incident diabetes. Cox proportional hazards regression models showed that women aged 45¿50 at baseline had higher diabetes risk in association with exposure to total air emissions, total water emissions, all individual metals air emissions, and six individual water emissions. After correction for false discovery rate, nine of 11 air emissions and five water emissions remained significant. Associations were not observed for land-based emissions, or for younger or older cohorts. Emissions were dominated by mining, electricity generation and other metals-related industrial processes.

As Ghana's older population increases in number and proportion, the social and healthcare needs of older adults and their caregivers become more critical highlighting the relevance of social workers¿ contribution in assisting older adults and their caregivers. The purpose of this study was to explore social workers¿ contributions, discussed against the International Federation of Social Workers (IFSW) Policy on Ageing and Older Person framework. The study employed a descriptive qualitative approach making use of semi-structured interviews to collect information from eight social workers at the Social Welfare Unit in Komfo Anokye Teaching Hospital in Ghana. Themes and codes were developed from the interviews using thematic analysis, employing In-vivo and descriptive coding, and N-Vivo v12 as a management tool. Analysis of interviews revealed three interrelated themes; (a) ¿We provide it accordingly¿: Talking about their contributions as systematic, (b) ¿I think we can do more¿: Talking about their contributions as insufficient, and (c) ¿Our efforts are being hampered¿: Complaints of inadequate resources for working with older adults and their caregivers. The study offers areas of opportunities for social workers per the IFSW policy framework to reflect and examine their current knowledge and skill to address the challenges population ageing presents in Ghana. While social workers contribute towards helping older adults seeking healthcare and their caregivers, their needs cannot be ignored. The findings draw attention to effective policies and programs that can provide social workers with the needed resources to be independent and be able to devise novel approaches unique to older adults and their caregivers.

Background: Estimates of future burden of cancer attributable to current modifiable causal exposures can guide cancer prevention. We quantified future head and neck cancer burden in Australia attributable to individual and joint causal exposures, and assessed whether these burdens differ between population subgroups. Methods: We estimated the strength of the associations between exposures and head and neck cancer using adjusted proportional hazards models from pooled data from seven Australian cohorts (N ¼ 367,058) linked to national cancer and death registries and estimated exposure prevalence from the 2017 to 2018 Australian National Health Survey. We calculated population attributable fractions (PAF) with 95% confidence intervals (CI), accounting for competing risk of death, and compared PAFs for population subgroups. Results: Contemporary levels of current and former smoking contribute 30.6% (95% CI, 22.7%¿37.8%), alcohol consumption exceeding two standard drinks per day 12.9% (95% CI, 7.6%¿17.9%), and these exposures jointly 38.5% (95% CI, 31.1%¿45.0%) to the future head and neck cancer burden. Alcohol-attributable burden is triple and smoking-attributable burden is double for men compared with women. Smoking-attributable burden is also at least double for those consuming more than two alcoholic drinks daily or doing less than 150 minutes of moderate or 75 minutes of vigorous activity weekly, and for those aged under 65 years, unmarried, with low or intermediate educational attainment or lower socioeconomic status, compared with their counterparts. Conclusions: Two-fifths of head and neck cancers in Australia are preventable by investment in tobacco and alcohol control. Impact: Targeting men and other identified high-burden subgroups can help to reduce head and neck cancer burden disparities.

Air pollution may contribute to depression risk, but prospective incidence studies of risks and resiliencies for young women have not been undertaken. We analyzed prospective cohort data from the Australian Longitudinal Study on Women's Health combined with air pollution exposure data from the National Pollutant Inventory. We followed 7804 women without baseline depression who were aged 21-26 years at baseline for up to 14 years. Cox proportional hazards regression models were used to examine associations between greater air pollution exposures and incident depression controlling for covariates. Air pollutants included carbon monoxide, nitrogen oxides, particulate matter (PM2.5 and PM10), and sulfur dioxide, measured in inverse distance weighted exposures in kilograms occurring within 10 km of participants' residences. Results showed that total air pollution exposure decile was significantly associated with incident depression (hazards ratio = 1.039, 95% confidence interval 1.018-1.060). Exposures were also significantly related to depression when total exposure, and each of the five individual air pollutants, was measured in quartile. Multiple other sociodemographic and behavioral variables were independently associated with depression. Women who possessed behavioral resiliencies (nonsmokers and nonobese) or socioeconomic resiliencies (higher education and adequate income) were not at elevated depression risk when exposed to high amounts of air pollution. Multiple depression risks, and the presence of behavioral and socioeconomic resiliencies, suggest multiple leverage points to reduce depression risk among young women with air pollution exposures, including effects to improve air quality and improve human connection to the natural environment, especially for women who experience lifestyle or socioeconomic disadvantages.

Aims/hypothesis: Obesity is a risk factor for type 2 diabetes, yet little is known about how timing and cumulative exposure of obesity are related to disease risk. The aim of this study was to examine the associations between BMI trajectories, age of onset of obesity and obese-years (a product of degree and duration of obesity) over early adulthood and subsequent risk of type 2 diabetes. Methods: Women aged 18¿23¿years at baseline (n = 11,192) enrolled in the Australian Longitudinal Study on Women¿s Health (ALSWH) in 1996 were followed up about every 3¿years via surveys for up to 19¿years. Self-reported weights were collected up to seven times. Incident type 2 diabetes was self-reported. A growth mixture model was used to identify distinct BMI trajectories over the early adult life course. Cox proportional hazards regression models were used to examine the associations between trajectories and risk of diabetes. Results: One hundred and sixty-two (1.5%) women were newly diagnosed with type 2 diabetes during a mean of 16¿years of follow-up. Six distinct BMI trajectories were identified, varying by different initial BMI and different slopes of increase. Initial BMI was positively associated with risk of diabetes. We also observed that age at onset of obesity was negatively associated with risk of diabetes (HR 0.87 [95% CI 0.79, 0.96] per 1¿year increment), and number of obese-years was positively associated with diabetes (p for trend <0.0001). Conclusions/interpretation: Our data revealed the importance of timing of obesity, and cumulative exposure to obesity in the development of type 2 diabetes in young women, suggesting that preventing or delaying the onset of obesity and reducing cumulative exposure to obesity may substantially lower the risk of developing diabetes.

Objective: Older women are more likely than men to enter residential aged care (RAC) and generally stay longer. We aimed to identify and examine their trajectories of care needs over time in RAC across 3 fundamental care needs domains, including activities of daily living (ADL), behavior, and complex health care. Design: Population-based longitudinal cohort study. Setting: RAC facilities in Australia. Participants: A total of 3519 participants from the 1921-1926 birth cohort of the Australian Longitudinal Study on Women's Health (ALSWH), who used permanent RAC between 2008 and 2014. Methods: We used data from the Aged Care Funding Instrument, National Death Index, and linked ALSWH survey. Participants¿ care needs in the 3 domains were followed every 6 months up to 60 months from the date of admission to RAC. Trajectories of care needs over time were identified using group-based multitrajectory modeling. Results: Five distinct trajectory groups were identified, with large variation in the combinations of levels of care needs over time. Approximately 28% of residents belonged to the ¿high dependent¿behavioral and complex need¿ group, which had high care needs in all 3 domains over time, whereas around one-third of residents (31%) were included in 2 trajectory groups (¿less dependent¿low need¿ and ¿less dependent¿increasing need¿), which had low or low to medium care needs over time. More than two-fifths of residents (41%) comprised 2 trajectory groups (¿high dependent¿complex need¿ and ¿high dependent¿behavioral need¿), which had medium to high care needs in 2 domains. Higher age at admission to RAC and multiple morbidities were associated with increased odds of being a member of the high dependent¿complex need group than the less dependent¿increasing need group. Conclusions and Implications: Identification of the differential trajectories of care needs among older women in RAC will help to better understand the circumstances of their changing care needs over time. This will facilitate appropriate care planning and service delivery for RAC residents, who are mostly older women.

Objective: To examine whether patterns of home and community care (HACC) use and person-based characteristics were associated with time to enter permanent residential aged care (RAC). Study design: A prospective cohort study. The sample consisted of 8062 participants of the Australian Longitudinal Study on Women's Health who used HACC services between 2001 and 2014. Main outcome measures: Time from first HACC use to enter permanent RAC. The median follow-up time was 63 months. Factors associated with time to enter RAC were identified using competing risk regression models. Results: Of the 8062 participants, 60% belonged to the ¿basic HACC¿ group, who used few services minimally; 16% belonged to the ¿moderate HACC¿ group, who predominantly used domestic assistance with moderate use of other services; and 24% belonged to the ¿complex HACC¿ group, who used many services frequently. Being a member of the complex HACC group was associated with a lower cumulative incidence of RAC than basic or moderate HACC (chances 15% versus 30% by the median observation period, p < 0.01). Living in a remote/outer region (sub-distributional hazard ratio (sdHR) = 0.83, 95%CI: 0.74 ¿ 0.93) was associated with delayed admission to RAC. Meanwhile, earlier admission was associated with living in an apartment (sdHR = 1.29, 95%CI: 1.20¿1.40) or a retirement village (sdHR = 1.54, 95%CI = 1.38¿1.72), having a physical functioning score <40 (sdHR = 1.16, 95%CI = 1.05¿1.25), and falls with injury (sdHR = 1.15, 95%CI = 1.05¿1.25). Conclusions: Our findings highlight the importance of providing more community care services, age-friendly housing, falls prevention and physical activity programs to reduce inappropriate admission to RAC.

Objective: To assess consumer-level socioeconomic factors associated with waiting times for access to aged care services, specifically community-based care and permanent residential care. Methods: Administrative data on assessment outcomes and admissions to services were linked with survey data at the person-level and were used to implement a competing risks regression model. We estimated the association between health needs, and socioeconomic variables and subsequent waiting periods for individuals with approval for access. Results: The main consumer-level factors driving waiting time were the individual's assessed needs, including health status, whether they lived alone and age. We found no evidence that socioeconomic status was associated with waiting times for community-based care; however, admission to residential care reflected socioeconomic factors including education levels and geographical isolation. Conclusion: This paper provides baseline evidence for factors affecting wait times in aged care, essential for evaluating subsequent policy reforms aimed at reducing wait times and increasing equity of access and consumer choice.

Objective: To explore if better diet quality scores as a measure of adherence to the Australian Dietary Guidelines (ADG) and the Mediterranean diet (MedDiet) are associated with a lower incidence of hypertension and non-fatal CVD.Design: Prospective analysis of the 1946-1951 cohort of the Australian Longitudinal Study on Women's Health (ALSWH). The Australian Recommended Foods Score (ARFS) was calculated as an indicator of adherence to the ADG; the Mediterranean Diet Score (MDS) measured adherence to the MedDiet. Outcomes included hypertension and non-fatal CVD. Generalised estimating equations estimated OR and 95 % CI across quartiles of diet quality scores.Setting: Australia, 2001-2016.Participants: 1946-1951 cohort of the ALSWH (n 5324), without CVD, hypertension and diabetes at baseline (2001), with complete FFQ data.Results: There were 1342 new cases of hypertension and 629 new cases of non-fatal CVD over 15 years of follow-up. Multivariate analysis indicated that women reporting better adherence to the ARFS (=38/74) had 15 % (95 % CI 1, 28 %; P = 0·05) lower odds of hypertension and 46 % (95 % CI 6, 66 %; P = 0·1) lower odds of non-fatal CVD. Women reporting better adherence to the MDS (=8/17) had 27 % (95 % CI 15, 47 %; P = 0·0006) lower odds of hypertension and 30 % (95 % CI 2, 50 %; P = 0·03) lower odds of non-fatal CVD.Conclusions: Better adherence to diet quality scores is associated with lower risk of hypertension and non-fatal CVD. These results support the need for updated evidenced based on the ADG as well as public health nutrition policies in Australia.

Substantial changes in the prevalence of the principal kidney and bladder cancer risk factors, smoking (both cancers) and body fatness (kidney cancer), have occurred but the contemporary cancer burden attributable to these factors has not been evaluated. We quantified the kidney and bladder cancer burden attributable to individual and joint exposures and assessed whether these burdens differ between population subgroups. We linked pooled data from seven Australian cohorts (N = 367,058) to national cancer and death registries and estimated the strength of the associations between exposures and cancer using adjusted proportional hazards models. We estimated exposure prevalence from representative contemporaneous health surveys. We combined these estimates to calculate population attributable fractions (PAFs) with 95% confidence intervals (CIs), accounting for competing risk of death, and compared PAFs for population subgroups. During the first 10-year follow-up, 550 kidney and 530 bladder cancers were diagnosed and over 21,000 people died from any cause. Current levels of overweight and obesity explain 28.8% (CI = 17.3¿38.7%), current or past smoking 15.5% (CI = 6.0¿24.1%) and these exposures jointly 39.6% (CI = 27.5¿49.7%) of the kidney cancer burden. Current or past smoking explains 44.4% (CI = 35.4¿52.1%) of the bladder cancer burden, with 24.4% attributable to current smoking. Ever smoking explains more than half (53.4%) of the bladder cancer burden in men, and the burden potentially preventable by quitting smoking is highest in men (30.4%), those aged <65 years (28.0%) and those consuming >2 standard alcoholic drinks/day (41.2%). In conclusion, large fractions of kidney and bladder cancers in Australia are preventable by behavior change.

Objectives: To identify patterns of health, socioeconomic, behavioral, and psychosocial indicators that may be associated with low birth weight delivery or preterm birth. Study design: Data were analyzed from the Australian Longitudinal Study on Women's Health. A total of 9075 live singleton births among 3801 women were linked to state perinatal records with birth outcome data. Survey data were used to identify 11 indicators for latent class analysis. Latent classes were tested for association to birth outcomes. These indicators also were used along with covariates in main effect multiple logistic regression analyses of birth outcomes. Results: Latent class analysis revealed 5 classes, including those characterized by low education, recent drug use, stress/anxiety/depression, smoking/drinking/low education/multi-risk, and a low risk referent group. The stress/anxiety/depression class was associated with preterm delivery (OR 1.87, 95% CI 1.20-2.92), and the smoking/drinking/low education/multirisk class was associated with low birth weight (OR 1.54, 95% CI 1.02-2.30). Traditional logistic regression analyses for main effects identified some measures not captured by the latent classes, and the latent classes identified variable combinations not captured by the main effect analysis. Conclusions: Unique latent classes were associated with preterm delivery vs low birth weight. Both latent class analysis and main effects analyses may be combined to improve understanding of birth outcome risks. Clinical and programmatic interventions to reduce risks of low birth weight and preterm delivery may benefit from risk profiles that women experience.

Purpose: To determine the prevalence and incidence of atrial fibrillation (AF) among older Australian women from 2000 to 2015, determine factors associated with AF, and to calculate risk of stroke at the time of AF diagnosis. Methods: This is a retrospective analysis of 6671 women of the 1921¿1926 birth cohort of the Australian Longitudinal Study on Women's Health, linked to data from hospital admissions to identify AF and National Death Index to determine date of death. Yearly prevalence and incidence proportions of AF, and stroke risk using CHA2DS2-VA scheme, were calculated. Factors associated with AF were assessed using logistic regression. Results: From 2000 to 2015, a total of 1827 women with AF were identified. AF prevalence increased every year as women aged from 2.71% (95% CI 1.62%¿3.80%) in 2000 among women aged 74¿79 years to 24.83% (95% CI = 23.23%¿26.44%) in 2015 among women aged 89¿94 years. The incidence proportion remained constant (between 3% and 5%) throughout the study period. Sedentary lifestyle (OR = 1.24, 95% CI = 1.04¿1.49), hypertension (OR = 1.24, 95% CI = 1.09¿1.42), arthritis (OR = 1.24, 95% CI = 1.09¿1.41), heart attack (OR = 1.62, 95% CI = 1.18¿2.24), and angina (OR = 1.39, 95% CI = 1.14¿1.70) were independently associated with AF. Mean CHA2DS2-VA score for women with AF was 3.43 (SD ± 1.23). Conclusions: The prevalence of AF reported in Australian women is among the highest compared to previous estimations from other countries and regions. According to the findings, about one in four women over the age of 90 years had AF. These women were also at high risk of stroke. This has significant public health implications especially with changing demographics of increase in the aging population. Further research is required on understanding how women with AF are treated in Australia and their health outcomes.

Objective: To cross-sectionally examine heavy episodic drinking (HED) and pre-loading with alcohol among young Australian women in relation to the alcohol-induced adverse outcomes of memory loss, vomiting and injury. Methods: A total of 7,800 participants, aged 20¿25 years, from the 1989¿95 cohort of the Australian Longitudinal Study on Women's Health answered all questions on alcohol use, reported drinking alcohol in the previous year and were not pregnant at the third survey in 2015. Log-binomial models were used to estimate prevalence ratios for adverse outcomes associated with increased frequency of HED and pre-loading. Results: The majority of participants reported HED (83.4%) and/or pre-loading (65.6%), which had a moderate correlation (r=0.646). Just over half (55.2%) of participants experienced at least one adverse event, with vomiting being most common. As the frequency of HED or pre-loading increased, so did the risk of an adverse outcome. Conclusions: Both HED and pre-loading pose a risk to young Australian women, and that risk rises with increased frequency. Implications for public health: Although HED has been a target of public health policy and interventions, pre-loading has received limited attention. In addition to addressing HED, there is a need to consider the risk posed by pre-loading, a related, yet unique risky drinking behaviour.

Objective: To identify factors associated with incidence of medication reviews (MRs), particularly in women with dementia and in residential aged care (RAC). Methods: Data from 10¿359 women in the 1921-1926 cohort of the Australian Longitudinal Study on Women's Health were linked to Medicare Benefits Schedule data to identify MRs for each year from 2003 to 2015. Results: Incidence of MR increased from 2003 to 2013 (age 87-92¿years) when 37.1% of women with dementia had a MR compared to 19.8% of women without dementia. Adjusting for time and other factors, the odds of having a MR were higher for women with dementia (AOR¿=¿1.18, 95% CI: 1.06-1.32) and women in RAC (AOR¿=¿3.61, 95% CI: 3.28-3.98). Conclusions: Although higher in women with dementia and those in RAC, utilisation of MR was modest. System-level interventions may be required to ensure the use and benefits of MRs.

Objective: Prospective studies on obesity incidence specifically among young adults have not been reported. This study examined risks of obesity incidence over 19 years among young women without obesity at baseline. Methods: Women aged 18 to 23 years at baseline (N = 8,177) were followed up every 2 to 3 years to ages 37 to 42 using the Australian Longitudinal Study on Women¿s Health. A latent class analysis identified obesity-risk classes based on time-dependent measures of income, education, physical activity, sleep quality, dietary behavior, depression, stressful events, and social functioning. Cox proportional hazards regression models examined associations between incident obesity and latent classes, controlling for covariates. Results: Four latent classes were identified, including a lower-risk referent class and classes characterized by poor exercise and diet, stress and low income, and multiple intermediate-level risks. Compared with the referent, all three risk classes had significantly higher obesity risk, with the highest risk in the stress and low-income group (hazard ratio = 2.22; 95% CI: 1.92-2.56). Individual risks associated with obesity included lower education, stressful life events, and lower vigorous physical activity. Conclusions: Young women without baseline obesity were at risk of developing obesity when they experienced co-occurring behavioral, socioeconomic, and psychosocial risks. Both latent classes and individual risk indicators offer insights into prevention strategies.

Estimates of the future breast cancer burden preventable through modifications to current behaviours are lacking. We assessed the effect of individual and joint behaviour modifications on breast cancer burden for premenopausal and postmenopausal Australian women, and whether effects differed between population subgroups. We linked pooled data from six Australian cohort studies (n = 214,536) to national cancer and death registries, and estimated the strength of the associations between behaviours causally related to cancer incidence and death using adjusted proportional hazards models. We estimated exposure prevalence from representative health surveys. We combined these estimates to calculate Population Attributable Fractions (PAFs) with 95% confidence intervals (CIs), and compared PAFs for population subgroups. During the first 10 years follow-up, there were 640 incident breast cancers for premenopausal women, 2,632 for postmenopausal women, and 8,761 deaths from any cause. Of future breast cancers for premenopausal women, any regular alcohol consumption explains 12.6% (CI = 4.3¿20.2%), current use of oral contraceptives for =5 years 7.1% (CI = 0.3¿13.5%), and these factors combined 18.8% (CI = 9.1¿27.4%). Of future breast cancers for postmenopausal women, overweight or obesity (BMI =25 kg/m2) explains 12.8% (CI = 7.8¿17.5%), current use of menopausal hormone therapy (MHT) 6.9% (CI = 4.8¿8.9%), any regular alcohol consumption 6.6% (CI = 1.5¿11.4%), and these factors combined 24.2% (CI = 17.6¿30.3%). The MHT-related postmenopausal breast cancer burden varied by body fatness, alcohol consumption and socio-economic status, the body fatness-related postmenopausal breast cancer burden by alcohol consumption and educational attainment, and the alcohol-related postmenopausal breast cancer burden by breast feeding history. Our results provide evidence to support targeted and population-level cancer control activities.

Background: Hysterectomy is a common surgical procedure, predominantly performed when women are between 30 and 50 years old. One in 3 women in Australia has had a hysterectomy by the time they are 60 years old, and 30% have both ovaries removed at the time of surgery. Given this high prevalence, it is important to understand the long-term effects of hysterectomy. In particular, women who have a hysterectomy/oophorectomy at younger ages are likely to be premenopausal or perimenopausal and may experience greater changes in hormone levels and a shortened reproductive lifespan than women who have a hysterectomy when they are older and postmenopausal. Use of menopausal hormone therapy after surgery may compensate for these hormonal changes. To inform clinical decisions about postsurgery management of women who have a hysterectomy prior to menopause (ie, average age at menopause 50 years), it is useful to compare women with a hysterectomy to women with no hysterectomy and to stratify the hysterectomy status by whether or not women have had a bilateral oophorectomy, or used menopausal hormone therapy. Objective: We sought to investigate whether women who had a hysterectomy with ovarian conservation or a hysterectomy and bilateral oophorectomy before the age of 50 years were at a higher risk of premature all-cause mortality compared to women who did not have this surgery before the age of 50 years. We also sought to explore whether use of menopausal hormone therapy modified these associations. Study Design: Women from the midcohort (born 1946 through 1951) of the Australian Longitudinal Study on Women's Health were included in our study sample (n = 13,541). Women who reported a hysterectomy (with and without both ovaries removed) before the age of 50 years were considered exposure at risk and compared with women who did not report these surgeries before age 50 years. To explore effect modification by use of menopausal hormone therapy we further stratified hysterectomy status by menopausal hormone therapy use. Risk of all-cause mortality was assessed using inverse-probability weighted Cox regression models. Results: During a median follow-up of 21.5 years, there were 901 (6.7%) deaths in our study sample. Overall, there was no difference in all-cause mortality between women who reported a hysterectomy with ovarian conservation (hazard ratio, 0.86; 95% confidence interval, 0.72¿1.02) or women who reported a hysterectomy and bilateral oophorectomy (hazard ratio, 1.02; 95% confidence interval, 0.78¿1.34) and women with no hysterectomy. When stratified by menopausal hormone therapy use, women with hysterectomy and ovarian conservation before the age of 50 years were not at higher risk of all-cause mortality compared to no hysterectomy, regardless of menopausal hormone therapy use status. In contrast, among nonusers of menopausal hormone therapy only, women who reported a hysterectomy-bilateral oophorectomy before the age of 50 years were at a higher risk of death compared to women with no hysterectomy (hazard ratio, 1.81; 95% confidence interval, 1.01¿3.25). Conclusion: Hysterectomy with ovarian conservation before the age of 50 years did not increase risk of all-cause mortality. Among nonmenopausal hormone therapy users only, hysterectomy and bilateral oophorectomy before the age of 50 years was associated with a higher risk of death.

Background: Women live longer than men and have an increased need for long-term care. The objective of this study was to identify patterns of aged care use among older Australian women and to examine how these patterns were associated with their demographic and health-related characteristics. Methods: The sample consisted of 8768 women from the 1921¿1926 birth cohort of the Australian Longitudinal Study on Women's Health (ALSWH), who had survived to age 75-80 years. ALSWH survey and linked administrative aged care and death datasets from 2001 to 2011 were utilized. Patterns of aged care use were identified using a repeated measure latent class analysis. Results: We identified four patterns of aged care use over time, differentiated by timing of service onset, types of service use and time of death. Approximately 41% of the sample were non-users or using basic home and community care (HACC), while 24% were at high risk of using moderate to high-level HACC/community aged care package (CACP). Only 11% had a greater risk of using residential aged care (RAC) over time. Being widowed, residing in remote/regional areas, having difficulty in managing income, having a chronic condition, reporting poor/fair self-rated health, and lower SF-36 quality of life scores were associated with an increased odds of being a member of the following classes: 1) moderate to high-level HACC/CACP, 2) increasing RAC, and 3) early mortality, compared with the non-user class. Conclusions: Distinct patterns of aged care use were identified. These results will facilitate future capacity planning for aged care systems in Australia.

Aims: To assess the impact of diabetes on the survival of older women, adjusted for other all-cause mortality predictors. Methods: Data were used from the 1921¿26 cohort of the Australian Longitudinal Study on Women's Health, when the women were aged 76¿81 years at baseline, with linkage to the National Death Index. Survival curves were plotted to compare the survival of women with no diabetes, incident diabetes and prevalent diabetes over 15 years. Cox proportional hazards models were used to examine the association between diabetes and all-cause mortality risks. Results: A total of 972 (11.7%) of 8296 eligible women reported either incident, 522 (6.3%) or prevalent, 450 (5.4%) diabetes. The median survival times were 10.1, 11.4 and 12.7 years among women with prevalent, incident and no diabetes, respectively. The risks of death were 30% [HR: 1.30 (95% CI: 1.16¿1.45)] and 73% [HR: 1.73 (CI: 1.57¿1.92)] higher for women with incident and prevalent diabetes compared to women without diabetes. These associations were sustained after controlling for demographics, body mass index, smoking status, comorbidities and health care use. Conclusions: This study revealed that diabetes is associated with reduced survival probabilities for older women with minimal moderation after adjustment for other predictors. Our findings suggest that diabetes management guidelines for older women need to integrate factors such as comorbidities, smoking and being underweight to reduce the risk of mortality.

The perinatal period is a critical time for mental health and is also associated with high health care expenditure. Our previous work has identified a history of poor mental health as the strongest predictor of poor perinatal mental health. This study aims to examine the impact of a history of poor mental health on health care costs during the perinatal period. Data from the 1973¿1978 cohort of the Australian Longitudinal Study on Women¿s Health (ALSWH) were linked with a number of administrative datasets including the NSW Admitted Patient Data Collection and Perinatal Data Collection, the Medicare Benefits Scheme and the Pharmaceuticals Benefits Scheme between 2002 and 2011. Even when taking birth type and private health insurance status into account, a history of poor mental health resulted in an average increase of over 11% per birth across the perinatal period. These findings indicate that an investment in prevention and early treatment of poor mental health prior to child bearing may result in a cost saving in the perinatal period and a reduction of the incidence of women experiencing poor perinatal mental health.

Objectives: Explore characteristics of hospital use for adults aged 85 and over in their last year of life and examine factors associated with cumulative overnight length of stay (LOS). Data source/study setting: NSW 45 and Up Study linked with hospital data. Study design: Longitudinal cohort study. Methods: Quantile regression models were performed for men and women (N = 3145)to examine heterogeneity in predictors of overnight hospital admissions. Coefficients were estimated at the 25th, 50th, 75th and 90th percentiles of the LOS distribution. Principal findings: 86% had at least one hospitalisation in their last year of life, with 60% dying in hospital. For men, first admission for organ failure was associated with a 26 day increase at the 90th LOS percentile, and a 0.22 day increase at the 10th percentile compared to men with cancer. Women admitted with influenza had decreased LOS of 20.5 days at the 75th percentile and 6 to 8 fewer days at the lower percentiles compared to those women with cancer. Conclusions: Poor health behaviours were a major driver of highest LOS among older men, pointing to opportunities to achieve health care savings through prevention. For older women, influenza was associated with shorter LOS, which could be an indicator of the high and rapid mortality rates at older ages, and may be easily prevented. Other factors associated with LOS among women, included where they lived before they were admitted, and discharge destination.

This study investigates the long-term impact of English adult migration to Australia by comparing health and wellbeing outcomes in later life of English migrants to their counterparts who remained in England (non-migrants) and to native-born Australians. It traces the influence of selection, adaptation and advantage as three mechanisms that can influence migrant health in later life. The analysis utilises data for a cohort aged 60¿64 years from the Australian Life Histories and Health (LHH) survey (n = 1088), a sub-study of the Australian 45 and Up Study, in combination with a matched cohort from the English Longitudinal Study of Ageing (ELSA) (n = 1139). Social rather than health characteristics were found to play a role in the selection of English migrants. English migrants reported higher subjective quality of life than English non-migrants, and better physical health than the Australian-born, but their mental health outcomes did not significantly differ from the other cohorts. The comparatively better later-life outcomes for the English migrants can partly be linked to advantage, as they hold higher prestige jobs than the Australian-born at lower levels of education.

Objectives: We examined the development of disease and disability in a large cohort of older women, the extent to which these conditions exempt them from being classified as successful agers and different trajectories of disease, disability and longevity across women's later life. Methods: We used survey data from 12,432 participants of the 1921-26 birth cohort of the Australian Longitudinal Study of Women's Health from 1996 (age 70-75) to 2016 (age 90-95). Repeated measures latent class analysis (RMLCA) identified trajectories of the development of disease with or without disability and according to longevity. Bivariate analyses and multivariable multinomial logistic regression models were used to examine the association between participants' baseline characteristics and membership of the latent classes. Results: Over one-third of women could be considered to be successful agers when in their early 70s, few women could still be classified in this category throughout their later life or by the end of the study when they were in their 90s (~1%). RMLCA identified six trajectory groups including managed agers long survivors (9.0%) with disease but little disability, usual agers long survivors (14.9%) with disease and disability, usual agers (26.6%) and early mortality (25.7%). A small group of women having no major disease or disability well into their 80s were identified as successful agers (5.5%). A final group, missing surveys (18.3%), had a high rate of non-death attrition. Groups were differentiated by a number of social and health factors including marital status, education, smoking, body mass index, exercise and social support. Conclusions: The study shows different trajectories of disease and disability in a cohort of ageing women, over time and through to very old ages. While some women continue into very old age with no disease or disability, many more women live long with disease but little disability, remaining independent beyond their capacity to be classified as successful agers.

Objective: Evidence on the endometrial and ovarian cancer burden preventable through modifications to current causal behavioural and hormonal exposures is limited. Whether the burden differs by population subgroup is unknown. Methods: We linked pooled data from six Australian cohort studies to national cancer and death registries, and quantified exposure-cancer associations using adjusted proportional hazards models. We estimated exposure prevalence from representative health surveys. We then calculated Population Attributable Fractions (PAFs) with 95% confidence intervals (CIs), accounting for competing risk of death, and compared PAFs for population subgroups. Results: During a median 4.9 years follow-up, 510 incident endometrial and 303 ovarian cancers were diagnosed. Overweight and obesity explained 41.9% (95% CI 32.3¿50.1) of the endometrial cancer burden and obesity alone 34.5% (95% CI 27.5¿40.9). This translates to 12,800 and 10,500 endometrial cancers in Australia in the next 10 years, respectively. The body fatness-related endometrial cancer burden was highest (49¿87%) among women with diabetes, living remotely, of older age, lower socio-economic status or educational attainment and born in Australia. Never use of oral contraceptives (OCs) explained 8.1% (95% CI 1.8¿14.1) or 2500 endometrial cancers. A higher BMI and current long-term MHT use increased, and long-term OC use decreased, the risk of ovarian cancer, but the burden attributable to overweight, obesity or exogenous hormonal factors was not statistically significant. Conclusions: Excess body fatness, a trait that is of high and increasing prevalence globally, is responsible for a large proportion of the endometrial cancer burden, indicating the need for effective strategies to reduce adiposity.

Objective: To assess which older Australian women had Medicare subsidized health assessments between 1999 and 2013. Methods: This study used prospective, longitudinal survey data from the 1921 to 1926 birth cohort of Australian Longitudinal Study on Women¿s Health (ALSWH) linked with Medicare Australia data on health services use. Over 11,000 Australian women were included in the study. Latent class analysis was used to identify assessment patterns over time, accounting for death, and based on three categories (¿no assessment¿; ¿assessment; ¿deceased¿) for each year between 1999 and 2013. Further analysis explored the impact of health and sociodemographic characteristics on class membership. Results: Of the women included in the latent class analysis, 37% never had any assessment and the remainder had had at least one assessment. After a steady uptake from 1999 to 2003, there was decline in uptake from 2003 onwards. A six-class model with sufficient homogeneity and reliable estimation was selected to represent assessment patterns and mortality risk, labelled as: ¿high mortality¿ rate with little chance for assessment (12.4%), ¿intermediate mortality, low assessment¿ (14.1%), ¿later mortality/low assessment¿ (13.1%), ¿later mortality, high assessment¿ (7.0%), ¿low mortality, low assessment¿ (31.8%), ¿low mortality, high assessment¿ (21.6%). Older women with certain conditions (such as diabetes, depression, heart disease) were more likely to be in the low assessment groups, and women with difficulty managing on income were more likely to be in low assessment groups. Conclusion: Distinct assessment and mortality patterns were seen, with many women not having assessment, in particular those who had certain health conditions, were taking 3+ medications, had difficulty in managing on income, needed help or were in respite care, and had caring responsibilities. The findings point to a need to promote these assessments among older women, and to reduce financial barriers, even within the context of a heavily subsidized health care system.

The aims of this study were to investigate patterns of home and community care (HACC) use and to identify factors influencing first HACC use among older Australian women. Our analysis included 11,133 participants from the Australian Longitudinal Study of Women¿s Health (1921¿1926 birth cohort) linked with HACC use and mortality data from 2001 to 2011. Patterns of HACC use were analysed using a k-median cluster approach. A multivariable competing risk analysis was used to estimate the risk of first HACC use. Approximately 54% of clients used a minimum volume and number of HACC services; 25% belonged to three complex care use clusters (referring to higher volume and number of services), while the remainder were intermediate users. The¿initiation of HACC use was significantly associated with (1) living in remote/inner/regional areas, (2) being widowed or divorced, (3) having difficulty in managing income, (4) not receiving Veterans¿ Affairs benefits, (5) having chronic conditions, (6) reporting lower scores on the SF-36 health-related quality of life, and (7) poor/fair self-rated health. Our findings highlight the importance of providing a range of services to meet the diverse care needs of older women, especially in the community setting.

Background/aim: Increased age and cognitive decline have been linked to difficulties with activities of daily living (ADL) and instrumental activities of daily living (IADL). Cognitive decline can often be signalled by complaints about one's cognition, such as memory. With older Australians living longer, there is an increasing proportion of the population at risk of declined performance in daily tasks. The aim of this study was to identify if subjective memory complaints in later life among older women predict changes in independence in performing ADL and IADL. Methods: Data were from 3721 women born 1921¿1926, who completed Surveys 4¿6 of the Australian Longitudinal Study on Women's Health. Memory complaints and difficulties on ADL were measured at each survey, using the Memory Complaint Questionnaire and 16 questions regarding specific ADL. Latent growth modelling examined correlations between initial scores on each measure, changes in measures, and the association between memory complaints and changes in ADL and IADL. Results: There was a significant association between baseline scores for subjective memory difficulty and baseline ADL and IADL scores. Initial memory difficulty was also associated with increase in ADL and IADL difficulty. Conclusions: Subjective memory complaints may be a risk factor for decline in performance on ADL. Attention to these concerns may be important in identifying functional decline in older age.

This article presents a broad narrative review of the epidemiological evidence on how and why the mental health of older adults varies by gender. We draw upon international research literatures spanning gerontology and population mental health, as well as major reports from global health agencies. Compared with older men, older women are more likely to experience common mental disorders such as depression and anxiety, although the gender gap is smaller than it is at younger ages. In contrast, the mortality-related impacts of poor mental health, including suicide, are more severe for older men. These gendered patterns vary by country and other social contexts. Factors proposed to account for these findings include cultural and social norms, differentiation of gender roles, disadvantage and (dis)empowerment across the life course, and the coping styles of older men. However, little research has explicitly tested these explanations. Research to date has overwhelmingly focused on identifying differences in the mental health of older men and women. Notably, most studies have been restricted to binary comparisons, lacking the data to disentangle sex and gender dynamics, and few studies have examined the mental health of minority gendered adults in later life. Finally, there remains a need for high-quality population-based research into the mental health of those aged over 80 that includes coverage of people living in residential aged care settings.

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.

Aim: To determine differences in food and nutrient intakes between Australian- and Asian-born women living in Australia. Methods: Data were obtained from the Australian Longitudinal Study on Women's Health, including 6461 women born in Australia or Asia who completed food frequency questionnaires in 2001 and 2013. Diet was assessed using the Dietary Questionnaire for Epidemiological Studies version 2. Longitudinal generalised estimating-equation modelling was performed to determine the effect of country of birth and survey year on fruit and vegetable intake. Results: Asian-born women ate more cereals, soybeans and fish but less vegetables, legumes, dairy, meat and meat products than Australian-born women both in 2001 and in 2013. Asian-born women ate less cereals, rice and noodles, meat and its products (P < 0.05) in 2013 than in 2001. The earlier people came to Australia, the less their rice and noodle intake per day. However, the reverse was demonstrated regarding vegetable intake. Asian-born women had a lower daily intake of fat, calcium, zinc, thiamin, riboflavin, folate and retinol compared with those born in Australia. Conclusions: Asian-born women living in Australia show different food and nutrient intakes from Australian-born women, although their diets tend to deviate from typical Asian characteristics and approach a Western diet.

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.

Background and Objectives: With rapid population ageing and an increasing rate of hypertension in China, this study aims to examine the association between dietary patterns, dietary lead and hypertension among older Chinese population. Methods and Study Design: We analysed the 2009 China Health and Nutrition Survey data (2,634 individuals with dietary and hypertension measurement data, aged =60 years). Dietary data were obtained using 24 hour-recall over three consecutive days. Dietary lead intake is based on a published systematic review of food lead concentration and dietary lead exposure in China. Factor analysis was used to identify dietary patterns. Poisson regression and multinomial logistic regression models were used to explore the association between dietary patterns and hypertension. Results: The prevalence of hypertension was 47.0% in men and 48.9% in women. Traditional dietary pattern (high intake of rice, pork and vegetables) was significantly inversely associated with known hypertension. In the fully adjusted model, compared with the lowest quartile of traditional dietary pattern, the highest quartile had a lower risk of known hypertension, with Relative Risk Ratio=0.69 (95% CI: 0.50; 0.95). However, associations between modern dietary pattern and hypertension differed by urbanization; an inverse, positive and null association was seen in low, medium and high urbanization. Additionally, dietary lead showed a significant positive association with hypertension and known hypertension. Conclusions: Policies that facilitate and promote healthy diets, and the availability of healthy foods particularly at the regional and local levels, are important for the prevention of hypertension.

Scant research exists on the patterns of changes in older women¿s housing, and whether and when women transition into residential aged care (RAC). This study aimed to identify groups of women with different housing patterns (latent classes) over time, with a secondary aim to describe socio-demographic and health characteristics of women in each class. We analysed linked data for 9575 women born 1921¿1926 from the Australian Longitudinal Study of Women¿s Health (ALSWH), Australian National Death Index, and Residential Aged Care (RAC) administrative records for the years 1999 through to 2011. Seven distinct housing patterns (classes) were identified over time. Four classes showed a stable pattern: living in a house for most surveys (47.0%), living in a house but with earlier death (13.7%), living in an apartment (12.8%), living in a retirement village (5.8%). One class showed a pattern of downsizing: moving from a house to retirement village (6.6%). Two patterns showed transition: from an apartment or retirement village, to RAC and death (7.8%), and from house to RAC (6.4%). This study provides new evidence about socio-demographic and health influences on housing patterns and entry into residential care in later life. These findings can inform policy and aged care planning for women in later life, by identifying patterns of transition into residential aged care, or alternatively, remaining in the community.

Drawing on free-text survey comments from the Australian Longitudinal Study of Women¿s Health (ALSWH), this article explores themes of transition and change in the lives of 150 women baby boomers (born between 1946 and 1951) in relation to Beck¿s theories of the risk society, reflexive modernisation and individualisation. Few studies have explicitly explored ageing through Beck¿s theoretical lenses. However, Beck¿s emphasis on interactional processes of social, individual and structural change has much to offer for sociological studies of ageing. A key premise is that of complex adaptation and change as people age, with focus on the socio-political contexts in which the post-Second World War baby boomer generation will live out their later years.

Background: Knowledge of preventable disease and differences in disease burden can inform public health action to improve health and health equity. We quantified the future lung cancer burden preventable by behavioural modifications across Australia. Methods: We pooled seven Australian cohort studies (n = 367 058) and linked them to national registries to identify lung cancers and deaths. We estimated population attributable fractions and their 95% confidence intervals (CIs) for modifiable risk factors, using risk estimates from the cohort data and risk factor exposure distribution from contemporary national health surveys. Results: During the first 10-year follow-up, there were 2025 incident lung cancers and 20 349 deaths. Stopping current smoking could prevent 53.7% (95% CI, 50.0-57.2%) of lung cancers over 40 years and 18.3% (11.0-25.1%) in 10 years. The smoking-Attributable burden is highest in males, those who smoke <20 cigarettes per day, are <75 years of age, unmarried, of lower educational attainment, live in remote areas or are healthy weight. Increasing physical activity and fruit consumption, if causal, could prevent 15.6% (6.9-23.4%) and 7.5% (1.3-13.3%) of the lung cancer burden, respectively. Jointly, the three behaviour modifications could prevent up to 63.0% (58.0-67.5%) of lung cancers in 40 years, and 31.2% (20.9-40.1%) or 43 300 cancers in 10 years. The preventable burden is highest among those with multiple risk factors. Conclusions: Smoking remains responsible for the highest burden of lung cancer in Australia. The uneven burden distribution distinguishes subgroups that could benefit the most from activities to control the world's deadliest cancer.

Objective: To provide a direct estimate of the risk of admission to permanent residential aged care among older women while accounting for death, according to housing type and other variables. Methods: A competing risk analysis from 8,867 Australian women born 1921¿26, using linked data from the Australian Longitudinal Study on Women's Health (ALSWH), Residential Aged Care (RAC), and the Australian National Death Index. Results: After accounting for deaths, around 35% of women will be admitted to RAC between ages 73 and 90. The conditional cumulative incidence of admission to RAC was 26.9% if living in a house, compared to 36.0% from an apartment, 43.6% within a retirement village, and 37.1% if living in a mobile home. Each one-year increase in age was associated with a relative 17% increased risk of RAC. Conclusions: Around one-third of women will enter RAC between age 73 and 90. Living in a house had the lowest risk of entering residential aged care over time. Implications for public health: These findings have important implications for planning for aged care services, including the role of housing in delaying admission to residential aged care, and the need for residential care by a high proportion of women towards the end of life.

This study examined factors associated with use of government subsidised mental health services by 229,628 men and women from the Sax Institute¿s 45 and Up Study. Logistical regression models assessed use of mental health services by gender and according to level of psychological distress. Approximately equal proportion of men and women had high psychological distress scores (approximately 7%) but only 7% of these men and 11% of these women used services. Use was associated with predisposing (younger age and higher education), enabling (private health insurance) and need factors (higher psychological distress scores). Associations were similar for men and women except urban area of residence, separated/divorced marital status, and smoking were associated with service use for women but not men. Results suggest some inequity in the use of services by those with higher levels of need and further efforts may be required to reach people with higher need but lower service use.

Objective: To explore qualitative insights into the pain experience of older women with quantitatively derived pain profiles. Methods: The sequential mixed methods design involved applying quantitative pain profiles, derived from an earlier latent class analysis, to qualitative comments by a sample of older Australian women with arthritis. Data from a substudy of the Australian Longitudinal Study on Women's Health, mid-aged cohort, born 1946¿1951, were used. Inductive content analysis was conducted to explore qualitative insights into the experience of pain. Results: The average age of women was 64.6 years (±1.4). Within each derived pain profile, themes generated from the qualitative comments of women were concordant with the profile descriptors: ¿I manage my pain¿ for the uni-dimensional, mild pain profile (comments from 56 women); ¿I live with pain every day¿ and ¿I rely on medication regularly¿ for the moderate multidimensional pain profile (comments from 39 women); and ¿multiple pains¿, ¿I suffer with pain¿ and ¿I am unable and adjust¿ for the severe multidimensional pain profile (comments from 31 women). Conclusion: Women with different pain profiles used different language and strategies in managing their pain experience, information which can guide clinicians to provide more tailored support for self-management and care of arthritis pain.

This study aims to delineate the sociodemographic differences in disability prevalence across the population aged 60 years and over in Bangladesh, and to investigate the association of factors with reporting disability in later life. A microdata sample for those aged 60 years or over from the Census of Bangladesh 2011 was used where disability was assessed with a self-reported single response question. Logistic regression models were performed separately for men and women. Results reveal that the disability prevalence rate increased sharply with age, and it was higher among older women (5.2 per cent) compared to men (4.8 per cent). Physical and vision disabilities were the two categories with the highest prevalence of reported disabilities, with a higher prevalence of physical disability among men and vision disability among women. Being older, female, currently not in marital partnership, and having a lower educational attainment, not being employed, living alone, and residing in the rural areas were significantly associated with reporting disability in later life. The higher prevalence of disability among older women, those who are illiterate, and those residing in rural areas highlights the need for policies prioritising these groups. Special attention should also be given to those who are currently not in marital partnership, particularly women who are living alone.

Objective The aim of the present study was to examine non-communicable disease (NCD) policy formation and implementation in Indonesia. Methods Interviews were conducted with 13 Indonesian health policy workers. The processes and issues relating to NCD policy formation were mapped, exploring the interactions between policy makers, technical/implementation bodies, alliances across various levels and the mobilisation of non-policy actors. Results Problems in NCD policy formation include insufficient political interest in NCD control, disconnected policies and difficulty in multisectoral coordination. These problems are well illustrated in relation to tobacco control, but also apply to other control efforts. Nevertheless, participants were optimistic that there are plentiful opportunities for improving NCD control policies given growing global attention to NCD, increases in the national health budget and the growing body of Indonesia-relevant NCD-related research. Conclusion Indonesia's success in the creation and implementation of NCD policy will be dependent on high-level governmental leadership, including support from the President, the Health Minister and coordinating ministries. What is known about the topic? The burden of NCD in Indonesia has increased gradually. Nationally, NCD-related mortality accounted for 65% of deaths in 2010. Indonesia is also a country with the highest burden of tobacco smoking in the world. However, the government has not instituted sufficient policy action to tackle NCDs, including tobacco control. What does this paper add? This paper deepens our understanding of current NCD control policy formation in Indonesia, including the possible underlying reason why Indonesia has weak tobacco control policies. It describes the gaps in the current policies, the actors involved in policy formation, the challenges in policy formation and implementation and potential opportunities for improving NCD control. What are the implications for practitioners? An effective NCD control program requires strong collaboration, including between government and health professionals. Health professionals can actively engage in policy formation, for example through knowledge production.

Aim: China faces a ¿time-bomb¿ of the aging population. Successful aging has long been a goal in the field of gerontology. The present study aimed to evaluate successful aging among Chinese older adults. Methods: Data on a total of 7102 people in the China Health and Retirement Study aged =60 years were analyzed in the present study. Successful aging is defined by the model of Rowe and Kahn including the following five indicators: ¿no major diseases,¿ ¿no disability,¿ ¿high cognitive functioning,¿ ¿high physical functioning¿ and ¿active engagement with life.¿ Using logistic regression analysis, crude and adjusted odds ratios with 95% confidence intervals were calculated to evaluate the relationship between sociodemographic parameters and successful aging. Results: The prevalence of successful aging was 13.2% among Chinese older people. The percentage of older people with the five indicators, ¿no major diseases,¿ ¿no disability,¿ ¿high cognitive functioning,¿ ¿high physical functioning,¿ and ¿active engagement with life¿ was 41.7%, 92.1%, 54.2%, 70.2% and 46.0%, respectively. Multiple logistic regression showed people who had received education of high/vocational school or above had significantly greater odds of successful aging compared with those with less than primary school education (P < 0.05). The effect of education to college level or above on cognitive functioning was 2.51-fold higher in women than men (P = 0.006). Older people from a non-agricultural Hukou had 1.85-fold higher odds of successful aging than those from an agricultural Hukou. Older people living in the central, northeast or western regions had lower odds of successful aging relative to those living in the east coast region (0.72, 0.72 and 0.56, respectively). Conclusions: The prevalence of successful aging is low among Chinese older people, and is affected by sociodemographic factors, such as education, Hukou and regions. Geriatr Gerontol Int 2017; 17: 1183¿1190.

Background & aims Epidemiological data of dietary patterns and anaemia among older Chinese remains extremely scarce. We examined the association between dietary patterns and anaemia in older Chinese, and to assess whether biomarkers of serum magnesium, C-reactive protein (CRP) and serum ferritin can mediate these associations. Methods We analysed the 2009 China Health and Nutrition Survey data (2401 individuals aged =60 years for whom both dietary and biomarker data are available). Dietary data was obtained using 24¿h-recall over three consecutive days. Fasting blood samples and anthropometry measurement were also collected. Factor analysis was used to identify dietary patterns. Factor scores representing dietary patterns were used in Poisson regression models to explore the association between each dietary pattern and anaemia. Results Of the 2401 participants, 18.9% had anaemia, 1.9% had anaemia related to inflammation (AI), and 1.3% had iron-deficiency anaemia (IDA). A traditional dietary pattern (high intake of rice, pork and vegetables) was positively associated with anaemia; a modern dietary pattern (high intake of fruit and fast food) was inversely associated with anaemia. Progressively lower magnesium and BMI levels were associated with increasing traditional dietary quartiles; while a progressively higher magnesium and BMI levels were associated with increasing modern dietary quartiles (p¿<¿0.001). There were no significant differences (p¿>¿0.05) in CRP and serum ferritin across quartiles for either dietary pattern. In the fully adjusted model, the prevalence ratio (PR) of anaemia, comparing the fourth quartile to the first quartile, was 1.75 (95% CI: 1.33; 2.29) for a traditional dietary pattern, and 0.89 (95% CI: 0.68; 1.16) for a modern dietary pattern. The association between dietary patterns and anaemia is mediated by serum magnesium. Conclusion Traditional dietary pattern is associated with a higher prevalence of anaemia among older Chinese. Future studies need to examine whether correcting micronutrient deficiency (e.g. magnesium) by promoting overall healthy diet, rather than iron supplementation, is a suitable strategy for anaemia prevention in older Chinese people.

Objective: This study identified associations between chronic diseases (diabetes, asthma, depression, and arthritis) and workforce participation patterns with a gendered perspective. Method: We used data from 1,261 middle-aged participants of the Australian Life Histories and Health (LHH) Survey, aged 60 to 64 years in 2011. Latent class analysis identified dominant workforce patterns and associations between chronic diseases and these patterns were explored by multinomial regression models. Results: Diabetes, asthma, depression, and arthritis were less prevalent in men and women in class "mostly full-time work," compared with other workforce patterns. The odds of "mostly full-time work" were lower for men reporting depression or arthritis, whereas among women, depression was associated with "increasing part-time work" after adjusting early and adult life factors. Discussion: The results strengthen the importance of gender focused policies aimed to promote and preserve health of young and middle-aged workers, and creating supportive environment for those with chronic health issues over the life course.

Purpose: To examine the longitudinal association between diet quality and depression using prospective data from the Australian Longitudinal Study on Women¿s Health. Methods: Women born in 1946¿1951 (n¿=¿7877) were followed over 9¿years starting from 2001. Dietary intake was assessed using the Dietary Questionnaire for Epidemiological Studies (version 2) in 2001 and a shortened form in 2007 and 2010. Diet quality was summarised using the Australian Recommended Food Score. Depression was measured using the 10-item Centre for Epidemiologic Depression Scale and self-reported physician diagnosis. Pooled logistic regression models including time-varying covariates were used to examine associations between diet quality tertiles and depression. Women were also categorised based on changes in diet quality during 2001¿2007. Analyses were adjusted for potential confounders. Results: The highest tertile of diet quality was associated marginally with lower odds of depression (OR 0.94; 95¿% CI 0.83, 1.00; P¿=¿0.049) although no significant linear trend was observed across tertiles (OR 1.00; 95¿% CI 0.94, 1.10; P¿=¿0.48). Women who maintained a moderate or high score over 6¿years had a 6¿14¿% reduced odds of depression compared with women who maintained a low score (moderate vs low score¿OR 0.94; 95¿% CI 0.80, 0.99; P¿=¿0.045; high vs low score¿OR 0.86; 95¿% CI 0.77, 0.96; P¿=¿0.01). Similar results were observed in analyses excluding women with prior history of depression. Conclusion: Long-term maintenance of good diet quality may be associated with reduced odds of depression. Randomised controlled trials are needed to eliminate the possibility of residual confounding.

Objectives The aims of this study were to (1) report the prevalence and explore the influence of spinal pain on quality of life and (2) assess the relationship between spinal pain and the type and number of comorbidities. Methods This cross-sectional study comprised 579 community-dwelling, older Australian women. Women had ¿spinal pain¿ if they marked ¿yes¿ to neck pain, upper back pain, mid-back pain, and/or lower back pain. Descriptive statistics and binary logistic regression were performed to report the prevalence and explore the relationship between spinal pain and the type and number of comorbidities. Results A majority of women (55.8%) who returned surveys had spinal pain. Women with spinal pain had significantly lower physical and mental quality of life scores than women without spinal pain (Medical Outcomes Study: 36 Item Short Form Survey [SF-36] physical component summary: 40.1 ± 11.1 vs 49.0 ± 9.0, and SF-36 mental component summary: 50.0 ± 10.5 vs 53.9 ± 8.2, respectively). Having spinal pain was significantly associated with overweight and obesity (odds ratio 1.98 [95% confidence interval 1.3-2.96] and 2.12 [1.37-3.28]), diabetes (1.93 [1.01-3.67]), pulmonary comorbidity (1.66 [1.04-2.65]), and cardiovascular comorbidity (1.57 [1.07-2.28]). More than half of the women with spinal pain reported 2 or more comorbidities, with comorbidities significantly more common among women with spinal pain than among women without spinal pain. The odds of having spinal pain increased with an increasing number of comorbidities (2 comorbidities: 2.44 [1.47-4.04], 3 comorbidities: 3.07 [1.66-5.67], 4 comorbidities: 5.05 [1.64-15.54]). Conclusions Spinal pain is common in community-dwelling, older Australian women and is associated with greater disability and poorer quality of life. Diabetes, cardiovascular disease, pulmonary disease, and obesity appear to have a relationship with spinal pain. There was an incremental increase in the risk of spinal pain associated with increasing comorbidity count.

In this paper, we examine patterns of self-reported diagnosis of noncommunicable diseases (NCDs) and prevalences of algorithm/measured test-based, undiagnosed, and untreated NCDs in China, Ghana, India, Mexico, Russia, and South Africa. Nationally representative samples of older adults aged =50 years were analyzed from wave 1 of the World Health Organization's Study on Global Ageing and Adult Health (2007-2010; n = 34,149). Analyses focused on 6 conditions: Angina, arthritis, asthma, chronic lung disease, depression, and hypertension. Outcomes for these NCDs were: 1) self-reported disease, 2) algorithm/measured test-based disease, 3) undiagnosed disease, and 4) untreated disease. Algorithm/measured test-based prevalence of NCDs was much higher than self-reported prevalence in all 6 countries, indicating underestimation of NCD prevalence in low- and middle-income countries. Undiagnosed prevalence of NCDs was highest for hypertension, ranging from 19.7% (95% confidence interval (CI): 18.1, 21.3) in India to 49.6% (95% CI: 46.2, 53.0) in South Africa. The proportion untreated among all diseases was highest for depression, ranging from 69.5% (95% CI: 57.1, 81.9) in South Africa to 93.2% (95% CI: 90.1, 95.7) in India. Higher levels of education and wealth significantly reduced the odds of an undiagnosed condition and untreated morbidity. A high prevalence of undiagnosed NCDs and an even higher proportion of untreated NCDs highlights the inadequacies in diagnosis and management of NCDs in local health-care systems.

We examined women's access to health insurance in Indonesia. We analyzed IFLS-4 data of 1,400 adult women residing in four major cities. Among this population, the health insurance coverage was 24%. Women who were older, involved in paid work, and with higher education had greater access to health insurance (p¿<.05). We also found there were disparities in the probability of having health insurance across community levels (Median Odds Ratios¿=¿3.40). Given the importance of health insurance for women's health, strategies should be developed to expand health insurance coverage among women in Indonesia, including the disparities across community levels. Such problems might also be encountered in other developing countries with low health insurance coverage.

Background: By 2050, adults aged 80 years and over will represent around 20% of the global population. Little is known about how adults surviving into very old age use hospital services over time. Objective: The objective of the study was to examine patterns of hospital usage over a 10-year period for women who were aged 84 to 89 in 2010 and examine factors associated with increased use. Methods: Survey data from 1936 women from the 1921 to 1926 cohort of the Australian Longitudinal Study on Women's Health were matched with the state-based Admitted Patients Data Collection. Hospital use profiles were determined using repeated measures latent class analysis. Results: Four latent class trajectories were identified. One-quarter of the sample were at low risk of hospitalization, while 20.6% demonstrated increased risk of hospitalization and a further 38.1% had moderate hospitalization risk over time. Only 16.8% of the sample was classified as having high hospitalization risk. Correlates of hospital use for very old women differed according to hospital use class and were contingent on the timing of exposure (ie, short-term or long-term). Conclusions: Despite the perception that older adults place a significant burden on health care systems, the majority of women demonstrated relatively low hospital use over an extended period, even in the presence of chronic health conditions. High hospitalization risk was found to be concentrated among a small minority of these long-term survivors. The findings suggest the importance of service planning and treatment regimes that take account of the diverse trajectories of hospital use into and through advanced old age.

Big cities can offer great opportunities for women to have a better life. At the same time, however, the physical and social environment in cities can negatively affect their health. We conducted focus groups with 24 women (aged 18¿72 years) living in Jakarta, Indonesia from October to November 2014. Our aim was to elicit women¿s experiences of living in Jakarta, including their health and accessing health care. The most frequent health problems reported by women in this study were hypertension and arthritis. Women often gave priority to their family, particularly their children, over themselves and their own health. Discussants also thought that the city¿s physical and social conditions could affect their health, and that women were more prone to feel stress than men. The results of this study highlight the importance of addressing social determinants of health across the life course, including gender, to improve women¿s health status. Moreover, multi-sectoral collaboration at the municipal and national level is needed for urban planning to create better living conditions for women in the cities.

Purpose: Decline in physical function is common in older age, with important consequences for health-related quality of life, health care utilisation, and mortality. This study aimed to identify patterns of change in physical functioning (PF) for women in later life. Methods: PF was measured longitudinally using the ten-item subscale of the Medical Outcomes Study 36-item Short Form Health Survey, for 10 515 participants of the Australian Longitudinal Study on Women¿s Health, who completed at least two surveys between 1999 (aged 73¿78¿years) and 2011 (aged 85¿90¿years). Conditional and unconditional latent profile analysis was conducted separately for deceased and surviving subgroups of women to uncover latent patterns of change in PF scores over time. Results: Four patterns of change were identified for women who were still alive in 2011 (N¿=¿5928), and four similar classes for deceased women (N¿=¿4587): (1) ¿poor PF¿ representing women with low PF scores, (2) ¿moderate PF¿, (3) ¿high PF¿, and (4) ¿very high PF¿, where scores remained very high. All patterns exhibited a decrease in PF over time. Factors which predict low PF included sedentary levels of exercise, obese and overweight BMI, difficulty managing on income, and lower education. Conclusions: The results provided evidence for a gradual decrease in PF for all women with age; however, there was no evidence for an increased rate of decline prior to death.

OBJECTIVE: To explore impact of incident osteoarthritis (OA) on health services use by Australian women born 1946-51.

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.

Background and Purpose-As populations age, an increasing number of older women are living with stroke. This study looks at long-term outcomes for women with stroke, comparing mortality rates for women with poor physical function (PF) and those with higher levels of function. The purpose is to understand not only how long women might live after a stroke, but also how long they live with physical disability. Methods-The study uses 15 years of data on women from the Australian Longitudinal Study on Women's Health 1921 to 1926 cohort. The risk of stroke and the risk of stroke and poor PF were estimated using Cox proportional hazard model. Among women who reported a stroke during the study period, mortality risk was compared according to their physical functioning level after that stroke. Results-Almost half of the women who had a stroke and poor PF survived past 10 years. The 10-year mortality rate was 37% for women with stroke and adequate PF and 51% for women with stroke and poor PF at the time of the stroke (hazard rate ratio, 1.52; 95% CI, 1.18-1.95; P=0.0015 adjusting for demographic and health covariates). Conclusions-This study provides evidence of the long-term outcomes of stroke among older women, with women living for many years with poor PF. This outcome has important implications for the women's quality of life during their later years and in understanding the burden of disability associated with stroke.

There are increasing concerns regarding high hospital use among older adults and the capacity to manage the economic impact of the ageing population trend on healthcare systems. First hospitalisation in old age may act as a catalyst for ongoing intensification of health problems and acute care use. This study examined factors associated with first incident hospitalisation in women aged over 70, accounting for the health inequalities associated with geographic location. Survey data from 3780 women from the 1921 to 1926 cohort of the Australian Longitudinal Study on Women's Health were matched with the Admitted Patients Data Collection and National Death Index. Days to first event (hospitalisation or death) were modelled using competing risks methods. A total of 3065 (80.3%) women had at least one hospital admission. More than half of the top 15 reasons for first hospitalisation were related to cardiovascular disease, with atrial fibrillation the most common. Proportional subdistribution hazards models showed that first hospital admission was driven by enabling and need factors including asthma/bronchitis diagnosis (HR = 1.16; p = 0.047), private health insurance (HR = 1.16; p = 0.004) more than two prescribed medications in previous month (HR = 1.31; p = 0.001), more than four general practitioner visits in previous year (HR = 1.50; p = 0.034), lower physical functioning (HR = 0.99; p < 0.001) and living in an inner regional area (HR = 1.17; p = 0.003). First overnight hospitalisation was primarily related with potentially preventable and treatable chronic diseases. Primary and secondary strategies aimed at chronic disease generally, and better chronic disease management particularly for cardiovascular and respiratory diseases, may play a vital role in disease prevention or delay in readmissions among this population.

Objective. To estimate the prevalence and examine the associations of neuropathic-like pain in a community-based sample of older Australian women with arthritis. Design. Population based cross-sectional survey. Setting. Participants were recruited from the 1946- 1951 cohort of the Australian Longitudinal Study of Women¿s Health. Subjects. Women with self-reported arthritis (n = 147). Methods. Primary outcome measure was self- reported neuropathic-like pain, defined as scores =12 via the painDETECT screening tool. Descriptive statistics summarized health and socio-demographic characteristics, and comparisons made using student¿s t-test or Wilcoxon Rank Sum test, and Chisquare tests. Independent health and demographic variables were examined by univariable logistic regression, and significant variables included in multiple variable logistic regression modelling. Results. Thirty-nine women (26.5%) were screened as having neuropathic-like pain. Women with neuropathic-like pain were more likely to have poorer health, worse pain, higher pain catastrophizing, more fatigue, and more depression than women with nociceptive pain. Neuropathic-like pain was significantly associated with higher scores on the SF-MPQ sensory scale and pain catastrophizing scale, and with more medication use. Conclusions. Neuropathic-like pain in women with arthritis was common and is associated with greater disability and poorer quality of life.

Background: Arthritis is a gendered disease where women have a higher prevalence and more disability than men with arthritis of the same age. Health survey data is a major source of information for monitoring of the burden of arthritis. The validity of self-reported arthritis and the determinants of its accuracy among women have not been thoroughly studied. The objectives of this study were to: 1) examine the agreement between self-report diagnosed arthritis and musculoskeletal signs and symptoms in community-living older women; 2) estimate the sensitivity, specificity, and predictive values of self-reported arthritis; and 3) assess the factors associated with the disagreement. Methods: A cross-sectional survey of women was undertaken in 2012-13. The health survey asked women about diagnosed arthritis and musculoskeletal signs and symptoms. Agreement between self-reported arthritis and musculoskeletal signs symptoms was measured by Cohen's kappa. Sensitivity, specificity, and predictive values of self-reported arthritis were estimated using musculoskeletal signs and symptoms as the reference standard. Factors associated with disagreement between self-reported arthritis and the reference standard were examined using multiple logistic regression. Results: There were 223 participants self-reported arthritis and 347 did not. A greater number of participants who self-reported arthritis were obese compared to those who did not report arthritis. Those who reported arthritis had worse health, physical functioning, and arthritis symptom measures. Among the 570 participants, 198 had musculoskeletal signs and symptoms suggesting arthritis (the reference standard). Agreement between self-reported arthritis and the reference standard was moderate (kappa = 0.41). Sensitivity, specificity, and positive and negative predictive values of self-reported arthritis in older women were 66.7, 75.5, 59.2, and 81.0% respectively. Regression analysis results indicated that false-positive is associated with better health measured by the Short Form 36 physical summary score, the Health Assessment Questionnaire disability index, or the Western Ontario and McMaster University Osteoarthritis Index total score; whereas false-negative is negatively associated with these variables. Conclusion: While some women who reported diagnosed arthritis did not have recent musculoskeletal signs or symptoms, others with the signs and symptoms did not report diagnosed arthritis. Researchers should use caution when employing self-reported arthritis as the case-definition in epidemiological studies.

Objective To ascertain whether the hospital costs for mid-aged Australian women who self-reported diabetes mellitus (DM) and who had one or more hospital admission during an eight and a half year period were higher than the hospital costs for other similarly aged non-DM women. Methods The sample comprised 2,392 mid-aged women, resident in New South Wales (NSW) Australia and participating in the Australian Longitudinal Study on Women's Health (ALSWH), who had any NSW hospital admissions during the eight and a half year period 1 July 2000 to 31 December 2008. Analyses were conducted on linked data from ALSWH surveys and the NSW Admitted Patient Data Collection (APDC). Hospital costs were compared for the DM and non-DM cohorts of women. A generalized linear model measured the association between hospital costs and self-reported DM. Results Eight and a half year hospital costs were 41% higher for women who self-reported DM in the ALSWH surveys (p < 0.0001). On average, women who self-reported DM had significantly (p < 0.0001) more hospital admissions (5.3) than women with no reported DM (3.4). The average hospital stay per admission was not significantly different between the two groups of women. Conclusions Self-reported DM status in mid-aged Australian women is a predictor of higher hospital costs. This simple measure can be a useful indicator for public policy makers planning early-stage interventions that target people in the population at risk of DM.

Objectives There is limited research on hot flushes and night sweats in women with a hysterectomy with ovarian conservation. We aimed to describe the patterns of these symptoms in a cohort of Australian women and to investigate the relationship between distinct symptom patterns and hysterectomy status. Study design and outcome measures Repeated-measures latent class analysis (LCA) was used to identify hot flushes and night sweats symptom patterns across seven surveys (over 17 years) in the mid-cohort of the Australian Longitudinal Study on Women's Health. Multinomial logistic regression was used to assess the associations of the symptom patterns in women with a hysterectomy with ovarian conservation (n = 1129) versus women without a hysterectomy (n = 4977). Results A higher proportion of women with a hysterectomy than of those without experienced a constant pattern of hot flushes (15% versus 30%) and night sweats (9% versus 19%). Women with a hysterectomy had higher odds of constant hot flushes versus minimal hot flushes (OR = 1.97, 95% CI: 1.64, 2.35) and constant versus minimal night sweats (OR = 2.09, 95% CI: 1.70, 2.55). Smoking, a 'lower level of education to non-professional occupation' pathway and body mass index (BMI) patterns of 'always obese' and 'increasingly obese' were also associated with a higher risk of constant symptoms. Conclusions Women who have a hysterectomy (with ovarian conservation) have a higher risk of hot flushes and night sweats that persist over an extended period.

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.

There are a number of complex and seemingly ignored issues around prescribing safely and effectively for older people, particularly for very old women. These issues include polypharmacy, possible compliance issues and communication barriers between patient, specialists and general practitioners (GPs). There are specific pharmacokinetic (PK) and pharmacodynamic (PD) parameters that change in older age generally, and in women more specifically, which if ignored are likely to cause symptoms and to impair quality of life when drug dosage is unchanged. These changed PK and PD parameters are not all-or-nothing processes, but a continuum across age, sex and comorbidity. Very old people also have less ¿reserve¿ when drugs are used in ¿standard' doses, are more likely to have multiple concurrent therapies, and the risk of adverse effects of drugs in this group is very high. Doctors need to consider these issues when providing therapy for this group, or when trying to unravel the complex prescribing cascade here. This review outlines general principles to consider when prescribing for older people, focusing on age- and sex-related changes in both PK and PD processes.

There is increasing evidence for the role of nutrition in the prevention of depression. This study aims to describe changes in diet quality over 12 years among participants in the Australian Longitudinal Study on Women's Health in relation to changes in depressive symptoms. Women born between 1946 and 1951 were followed-up for 12 years (2001-2013). Dietary intake was assessed using the Dietary Questionnaire for Epidemiological Studies (version 2) in 2001, 2007 and every 2-3 years after that until 2013. Diet quality was summarised using the Australian Recommended Food Score (ARFS). Depressive symptoms were measured using the ten-item Centre for Epidemiologic Depression Scale at every 2-3-year intervals during 2001-2013. Linear mixed models were used to examine trends in diet quality and its sub-components. The same model including time-varying covariates was used to examine associations between diet quality and depressive symptoms adjusting for confounders. Sensitivity analyses were carried out using the Mediterranean dietary pattern (MDP) index to assess diet quality. Minimal changes in overall diet quality and its sub-components over 12 years were observed. There was a significant association between baseline diet quality and depression (ß=-0 24, P=0 001), but this was lost when time-varying covariates were added (ß=-0 04, P=0 10). Sensitivity analyses showed similar performance for both ARFS and MDP in predicting depressive symptoms. In conclusion, initial associations seen when using baseline measures of diet quality and depressive symptoms disappear when using methods that handle time-varying covariates, suggesting that previous studies indicating a relationship between diet and depression may have been affected by residual confounding.

Objectives: To identify latent subgroups of women in late life who are alike in terms of their mental health trajectories. Method: Longitudinal data are for 9683 participants in the 1921¿1926 cohort of the Australian Longitudinal Study on Women's Health, who completed at least two surveys between 1999 (aged 73¿78 years) and 2008 (aged 82¿87 years). Mental health was measured using the five-item mental health inventory (MHI-5). Latent profile analysis uncovered patterns of change in MHI-5 scores. Results: Three patterns of change were identified for women who were still alive in 2008 (n = 7061), and three similar patterns for deceased women (n = 2622): (1) ¿poor mental health¿ representing women with low MHI-5 scores, (2) ¿good mental health¿ and (3) ¿excellent¿ mental health, where scores remained very high. Deceased women had lower mental health scores for each class. Remote areas of residence, higher education, single marital status, higher Body Mass Index (BMI) and falls were the covariates associated with mental health in the survivor group. For the deceased group, education, BMI and falls were significant. Arthritis, stroke, heart disease, bronchitis/emphysema, diabetes and osteoporosis were associated with worse mental health for both groups, while asthma increased these odds significantly for the survivor group only. Hypertension and cancer were not significant predictors of poor mental health. Conclusion: The results show associations between chronic disease and level of mental health in older age, but no evidence of a large decline in mental health in the period prior to death.

© 2016 AJA Inc. Aim: To explore the implementation of poslansia, a community-based integrated health service implemented across Indonesia to improve the health status of older people through health promotion and disease prevention. Methods: Data analysis of 307 poslansia surveyed in the 4th wave of Indonesia Family Life Survey (IFLS-4). We examined the services provided in the programme, resources and perceived problems. Results: The services provided by poslansia focused mostly on risk factor screening and treatment for minor illness, and less on health promotion activities. Lack of support from community health centres, no permanent place for holding poslansia and lack of participant interest in joining the programme were associated with fewer services provided in the programme (P < 0.05). Conclusion: The findings indicate existing support from the community, community health centres and related institutions for poslansia is not adequate for optimal service function. Health awareness among the older population should also be increased for programme sustainability.

Dietary intake during pregnancy influences maternal health. Poor dietary practices during pregnancy have been linked to maternal complications. The objective was to determine the effect of dietary intervention before or during pregnancy on pregnancy outcomes. A systematic review was conducted without date restrictions. Randomised controlled trials (RCTs) evaluating whole diet or dietary components and pregnancy outcomes were included. Two authors independently identified papers for inclusion and assessed methodological quality. Meta-analysis was conducted separately for each outcome using random effects models. Results were reported by type of dietary intervention: (1) counselling; (2) food and fortified food products; or (3) combination (counselling+food); and collectively for all dietary interventions. Results were further grouped by trimester when the intervention commenced, nutrient of interest, country income and body mass index. Of 2326 screened abstracts, a total of 28 RCTs were included in this review. Dietary counselling during pregnancy was effective in reducing systolic [standardised mean difference (SMD) -0.26, 95% confidence interval (CI) -0.45 to -0.07; P<0.001] and diastolic blood pressure (SMD -0.57, 95% CI -0.75 to -0.38; P<0.001). Macronutrient dietary interventions were effective in reducing the incidence of preterm delivery (SMD -0.19, 95% CI -0.34 to -0.04; P=0.01). No effects were seen for other outcomes. Dietary interventions showed some small, but significant differences in pregnancy outcomes including a reduction in the incidence of preterm birth. Further high-quality RCTs, investigating micronutrient provision from food, and combination dietary intervention, are required to identify maternal diet intakes that optimise pregnancy outcomes.

Introduction Population aging is associated with a rising burden of non-communicable disease, profoundly impacting health policy and practice. Adopting and adhering to healthy lifestyles in middle or older age can protect against morbidity and mortality. Retirement brings opportunities to reconfigure habitual lifestyles and establish new routines. This study examines the longitudinal association between retirement and a range of lifestyle risk behaviors among a large population-based sample of Australian adults. Methods Study sample included working adults aged =45 years at baseline (2006¿2009, N=23,478¿26,895). Lifestyle behaviors, including smoking, alcohol use, physical activity, diet, sedentary behavior, and sleep, were measured at both baseline and follow-up (2010). Logistic regression models estimated the odds of having each risk factor at follow-up and multiple linear regression models calculated the change in the total number of risk factors, adjusted for baseline risk and other covariates. Sociodemographic characteristics and reasons for retirement were tested as potential effect modifiers. Results During the 3.3-year follow-up, about 11% of respondents retired. Retirement was associated significantly with reduced odds of smoking (AOR=0.74); physical inactivity (AOR=0.73); excessive sitting (AOR=0.34); and at-risk sleep patterns (AOR=0.82). There was no significant association between retirement and alcohol use or fruit and vegetable consumption. Change in the total number of lifestyle risk factors differed significantly by reason for retirement. Conclusions In a large population-based Australian cohort, retirement was associated with positive lifestyle changes. Health professionals and policymakers should consider developing special programs for retirees to capitalize on the healthy transitions through retirement.

Objective This study aims to assess the association between sleep and successful aging among Chinese¿=60 years of age. Methods Data were collected from the baseline survey of the China Health and Retirement Longitudinal Study. Two self-reported questions about sleep quality and duration were examined. Successful aging was defined following Rowe and Kahn's multidimensional model. To assess the adjusted association between sleep and successful aging, multivariable logistic regression was applied. Results The average number of self-reported hours of sleep was 6.2¿±¿2.0 among older Chinese people. Successful aging was related to sleep duration, with the proportion of those adults considered to be aging successfully falling into the following sleep duration categories (<6¿h ¿ 7.8%; 6¿h ¿ 16.3%; 7¿h ¿ 19.1%; 8¿h ¿ 14.7%; and¿=9¿h ¿ 12.8%). The plots between sleep duration and successful aging were an inverse U-shape. Participants who slept less than 6¿h per day had lower odds ratios of successful aging [odds ratio (OR)¿=¿0.52, 95% confidence interval (CI) 0.40¿0.67] relative to those who slept for 7¿h per day. Compared with those who reported poor sleep less than once a week, older people who reported poor sleep five to seven days a week showed a lower ratio of successful aging (OR¿=¿0.29, 95% CI 0.21¿0.39). Conclusion Older age, shorter or longer sleep, and poor sleep were related to lower odds of, rates of successful aging. Most older Chinese adults experience insufficient sleep and poor sleep quality, which could be an important influential factor in successful aging.

Objective To assess whether diet quality before or during pregnancy predicts adverse pregnancy and birth outcomes in a sample of Australian women. Design The Dietary Questionnaire for Epidemiological Studies was used to calculate diet quality using the Australian Recommended Food Score (ARFS) methodology modified for pregnancy. Setting A population-based cohort participating in the Australian Longitudinal Study on Women's Health (ALSWH). Subjects A national sample of Australian women, aged 20-25 and 31-36 years, who were classified as preconception or pregnant when completing Survey 3 or Survey 5 of the ALSWH, respectively. The 1907 women with biologically plausible energy intake estimates were included in regression analyses of associations between preconception and pregnancy ARFS and subsequent pregnancy outcomes. Results Preconception and pregnancy groups were combined as no significant differences were detected for total and component ARFS. Women with gestational hypertension, compared with those without, had lower scores for total ARFS, vegetable, fruit, grain and nuts/bean/soya components. Women with gestational diabetes had a higher score for the vegetable component only, and women who had a low-birth-weight infant had lower scores for total ARFS and the grain component, compared with those who did not report these outcomes. Women with the highest ARFS had the lowest odds of developing gestational hypertension (OR=0·4; 95 % CI 0·2, 0·7) or delivering a child of low birth weight (OR=0·4; 95 % CI 0·2, 0·9), which remained significant for gestational hypertension after adjustment for potential confounders. Conclusions A high-quality diet before and during pregnancy may reduce the risk of gestational hypertension for the mother.

AIM: To describe and compare the mental health and physical functioning of community-dwelling men aged 70 years and over who live alone, and those who live with their partner/spouse.

Background Comorbid conditions frequently coexist with asthma in older adults and can alter the natural history of asthma, complicating management and affecting overall prognosis and survival. Objectives This study investigates the impact of asthma on mortality among older women, with a specific interest in influence of comorbidities and social factors on survival of older women with asthma. Design Participants were from the Australian Longitudinal Study on Women's Health and were born between 1921 and 1926. Cox proportional hazards were used to evaluate mortality rates for women with and without asthma, after adjustment for comorbidities and other factors. Results Of 10,413 women aged 73¿78, 829 (8%) reported having been diagnosed by a doctor for asthma. Women with asthma had a higher likelihood of heart disease, hypertension, thrombosis, bronchitis/emphysema, osteoporosis and major illnesses (p¿<¿0.0001). Asthma was associated with increased risk of death (HR¿=¿1.31, 95%CI 1.18¿1.45, p¿<¿0.0001). After adjusting for age, demographic factors, comorbidities, risk factors, residential area and social support, women with asthma retained a 17% increased risk of death compared to women without asthma (HR¿=¿1.17, 95%CI 1.03¿1.32, p¿=¿0.016). Conclusion Older women with asthma have a higher rate of mortality compared with other women of the same age. This increased risk of death remains after age, demographic factors, comorbidities, risk factors, residential area and social support have been taken into account.

Objective: To provide an accurate representation of the economic burden of arthritis by estimating the adjusted incremental healthcare cost of arthritis at multiple percentiles and reporting the cost trends across time. Methods: A healthcare cost study based on health survey and linked administrative data, where costs were estimated from the government's perspective in dollars per person per year. Quantile regression was used to estimate the adjusted incremental cost at the 25th, 50th, 75th, 90th, and 95th percentiles. Results: Data from 4287 older Australian women were included. The median incremental healthcare cost of arthritis was, in 2012 Australian dollars, $480 (95% CI: $498¿759) in 2009; however, 5% of individuals had 5-times higher costs than the ¿average individual¿ with arthritis. Healthcare cost of arthritis did not increase significantly from 2003 to 2009. Conclusion: Healthcare cost of arthritis represents a substantial burden for the governments. Future research should continue to monitor the economic burden of arthritis.

A substantial amount of healthcare and costs are attributable to arthritis, which is a very common chronic disease. This paper presents the results of a systematic review of arthritis cost studies published from 2008 to 2013. MEDLINE, Embase, EconLit databases were searched, as well as governmental and nongovernmental organization websites. Seventy-one reports met the inclusion/exclusion criteria, and 24 studies were included in the review. Among these studies, common methods included the use of individual-level data, bottom-up costing approach, use of both an arthritis group and a control group to enable incremental cost computation of the disease, and use of regression methods such as generalized linear models and ordinary least squares regression to control for confounding variables. Estimates of the healthcare cost of arthritis varied considerably across the studies depending on the study methods, the form of arthritis and the population studied. In the USA, for example, the estimated healthcare cost of arthritis ranged from $1862 to $14,021 per person, per year. The reviewed study methods have strengths, weaknesses and potential improvements in relation to estimating the cost of disease, which are outlined in this paper. Caution must be exercised when these methods are applied to cost estimation and monitoring of the economic burden of arthritis.

Aim: To estimate the prevalence of diabetes, heart disease, hypertension and stroke in self-report and hospital data in two cohorts of women; measure sensitivity and agreement between data sources; and compare between cohorts. Methods: Women born between 1946-1951 and 1921-1926 who participated in the Australian Longitudinal Study on Women's Health (ALSWH); were New South Wales residents; and admitted to hospital (2004-2008) were included in the present study. The prevalence of diabetes, heart disease, hypertension and stroke was estimated using self-report (case1 at latest survey, case2 across multiple surveys) and hospital records. Agreement (kappa) and sensitivity (%) were calculated. Logistic regression measured the association between patient characteristics and agreement. Results: Hypertension had the highest prevalence and estimates were higher for older women: 32.5% case1, 45.4% case2, 12.8% in hospital data (1946-1951 cohort); 57.8% case1, 73.2% case2, 38.2% in hospital data (1921-1926 cohort). Agreement was substantial for diabetes: ¿=0.75 case1, ¿=0.70 case2 (1946-1951 cohort); ¿=0.77 case1, ¿=0.80 case2 (1921-1926 cohort), and lower for other conditions. The 1946-1951 cohort had 2.08 times the odds of agreement for hypertension (95% CI 1.56 to 2.78; P<0.0001), and 6.25 times the odds of agreement for heart disease (95% CI 4.35 to 10.0; P<0.0001), compared with the 1921-1926 cohort. Conclusion: Substantial agreement was found for diabetes, indicating accuracy of ascertainment using self-report or hospital data. Self-report data appears to be less accurate for heart disease and stroke. Hypertension was underestimated in hospital data. These findings have implications for epidemiological studies relying on self-report or administrative data.

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.

Objectives: To investigate the relationship between urinary incontinence (UI) and subsequent development of social dysfunction, using longitudinal data collected over 15 years from women aged 70 and older. Design: Longitudinal data from the Australian Longitudinal Study on Women's Health. Setting: Australia. Participants: Women born between 1921 and 1926 (aged 70¿75 in 1996, 85¿90 in 2011) (N = 12,432). Measurements: UI, social dysfunction, other health and demographic factors. Results: Generalized estimating equations were used to examine the association between social dysfunction and UI over time, adjusted for time, health, and social covariates. Social dysfunction and UI increased over time in older women. UI was associated with 30% greater odds of social dysfunction (P <.001), adjusted for time, health, and social covariates in the model with no time lag. UI was also associated with social dysfunction measured one survey period later (forward time lag) (odds ratio (OR) = 1.23, 95% confidence interval (CI) = 1.13¿1.34) and one survey period earlier (reverse time lag) (OR = 1.30, 95% CI = 1.19¿1.43), indicating an absence of causality. Social dysfunction was associated with living in urban areas, more health conditions, poor mental health, providing care for other people, and poor physical function. Conclusion: UI was associated with social dysfunction in older women, although the association did not appear to be causal but reflective of the women's overall level of function and general health. UI is not necessarily socially debilitating, unless a woman has other health problems.

Objectives We examined retirement transitions by gender, and different associations between retirement, physical function and mental health. Methods Data for 21,608 participants aged 55-69 from the 45 and Up Study were used. Generalised estimating equations were used to investigate longitudinal associations between retirement with psychological distress (Kessler score, K10) and physical dysfunction across two time points, by gender separately. Results Retirement in men was associated with a 25% relative increase in mean physical dysfunction score (p < 0.001) and a 2% relative increase in mean K10 score (p = 0.004), although men with high physical dysfunction score had a 6% increase in mean K10 score (p = 0.005) if retired. For women, retirement was associated with a 17% increase in mean physical dysfunction score (p < 0.001), with no association observed with the K10 score. Results were adjusted for demographic and health covariates. Conclusion Retirement is associated with physical dysfunction over time. Retirement is not associated with psychological distress among women, but retirement is associated with psychological distress among men who have a high level of physical dysfunction. The findings point to the importance of attending to the physical and mental health needs, around the retirement period, particularly for men with poor physical health.

Background: No studies have been conducted to explore the associations between dietary patterns and obesity among older Chinese people, by considering gender and urbanization level differences. Methods: We analyzed data from the 2009 China Health and Nutrition Survey (2745 individuals, aged e 60 years). Dietary data were obtained using 24 h-recall over three consecutive days. Height, Body Weight, and Waist Circumference were measured. Exploratory factor analysis was used to identify dietary patterns. Multinomial and Poisson regression models were used to examine the association between dietary patterns and Body Mass Index (BMI) status/central obesity. Results: The prevalence of general and central obesity was 9.5% and 53.4%. Traditional dietary pattern (high intake of rice, pork and vegetables) was inversely associated with general/central obesity; modern dietary pattern (high intake of fruit, fast food, and processed meat) was positively associated with general/central obesity. The highest quartile of traditional dietary pattern had a lower risk of general/central obesity compared with the lowest quartile, while an inverse picture was found for the modern dietary pattern. These associations were consistent by gender and urbanization levels. Conclusions: Dietary patterns are associated with general/central obesity in older Chinese. This study reinforces the importance of a healthy diet in promoting healthy ageing in China.

The objective of the study was to perform a systematic review to identify and appraise outcome measures and measures of pain that are used to assess the experience of pain by older people with osteoarthritis, and to assess whether these measures are effective at capturing the multidimensional nature of the experience of this pain. A systematic review of five electronic databases from January 1996 to March 2013 was done. Inclusion criteria were cohort/observational and cross-sectional studies; specific diagnosis of OA; employed outcome measures of pain and/or health and/or quality of life which included questions about pain; and considered older adults. Articles were reviewed for methodological quality using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. A total of 14 publications met the inclusion criteria, and 11 discrete studies were included in the review. The studies used 21 different outcome measures, utilizing 13 measures of pain. Sensory, affective and cognitive dimensions of pain were captured by the measures, albeit studies predominantly measured intensity or severity alone. Measures of pain used in epidemiological studies do not adequately capture the multidimensional nature of the experience of pain in osteoarthritis. There is a fraught complexity in the multidimensionality of the experience of pain in osteoarthritis, and studies exploring osteoarthritis pain in older people should attempt to capture this multidimensionality by employing multiple valid and reliable outcome measures that capture specific dimensions of the pain experience.

Background: Physical health has been demonstrated to mediate the mental health and mortality risk association. The current study examines an alternative hypothesis that mental health mediates the effect of physical health on mortality risk. Methods: Participants (N = 14,019; women = 91%), including eventual decedents (n = 3,752), were aged 70 years and older, and drawn from the Dynamic Analyses to Optimise Ageing (DYNOPTA) project. Participants were observed on two to four occasions, over a 10-year period. Mediation analysis compared the converse mediation of physical and mental health on mortality risk. Results: For men, neither physical nor mental health was associated with mortality risk. For women, poor mental health reported only a small effect on mortality risk (Hazard Risk (HR) = 1.01; p < 0.001); more substantive was the risk of low physical health (HR = 1.04; p < 0.001). No mediation effects were observed. Conclusions: Mental health effects on mortality were fully attenuated by physical health in men, and partially so in women. Neither mental nor physical health mediated the effect of each other on mortality risk for either gender. We conclude that physical health is a stronger predictor of mortality risk than mental health.

Objectives: To examine the relationships of retirement and reasons for retirement with psychological distress in men and women at the age of 45-79 years. Method: Data from 202,584 Australians participating in the large-scale 45 and Up Study was used. Psychological distress was measured by the Kessler psychological distress scale. Associations between different work status and reasons for retirement with psychological distress were assessed for men and women at different ages using logistic regression. Results: Being fully retired or unemployed was associated with the high levels of psychological distress compared to being in paid work for men and women aged 45-64 (p < 0.0001), and for men aged 65-74 years (p = 0.0014). At the age of 75-79 years, there was no difference in psychological distress between different work statuses. Among retirees, retirement due to ill health, being made redundant or caring duty was associated with the high level of psychological distress. Conclusion: The association between work and mental health underscores the importance of policies and strategies to encourage and enable people to continue in the workforce after age 55, particularly for men. Important reasons for retirement with worse mental health outcomes include redundancy, ill health and needing to care for family or a friend. These circumstances will affect whether a person can continue working and their risk of poor mental health, and both considerations should be addressed in developing approaches for maintaining older workers or assisting them with their retirement transition.

Population ageing and its future implications for governments and individuals have been central to much policy debate and research targeted to retain older people in the workforce. This study identified workforce participation patterns across the adult life course for women and men entering later life, and explored the influences of various early and adult life socio-demographic circumstances. Data were collected from 1261 men and women aged 60 to 64. years in the Life History and Health (LHH) Survey (a sub-study of the Sax Institute's 45 and Up Study, Australia) in 2010-11. LHH provides detailed information on personal histories of paid work, socio-economic resources from childhood (number of books and father's occupation) and adult life factors such as educational attainment, marital histories, childcare and informal caring. Latent class analysis (LCA) was undertaken to identify patterns of workforce participation for participants across their adult life. Significant gender differences were confirmed. Further analysis (LCA with covariates) showed that women who reported having books during childhood, and those who had post-school qualification, were more likely to have mostly been in paid work and less likely to have not been in paid work; while ever partnered women had significantly higher odds of increasing part time work over time. Men who had reported ever having had informal caring activities were likely to have had decreasing participation in paid work over time, and were highly likely to be not in paid work after 55. years. Ever partnered status was protective for being in paid work for men. These findings indicate the need for gender-specific policies and strategies to enable continued workforce participation throughout adult life and into later working years, particularly for people who had fewer social or economic opportunities earlier in life.

Background/Objectives: Few studies have applied the Chinese Diet Balance Index (DBI) in evaluating dietary quality for Chinese people. The present cross-sectional study assessed dietary quality based on DBI for older people, and the associated factors, in four socioeconomically distinct regions in China. Methods: The China Health and Nutrition Survey (CHNS) involves 2745 older Chinese people, aged 60 or over, from four regions (Northeast, East Coast, Central and West) in 2009. Dietary data were obtained by interviews using 24 hour-recall over three consecutive days. Four indicators: Total Score (TS), Lower Bound Score (LBS), Higher Bound Score (HBS) and Diet Quality Distance (DQD) from DBI were calculated for assessing dietary quality in different aspects. Results: 68.9% of older people had different levels of excessive cereals intake. More than 50% of older people had moderate or severe surplus of oil (64.9%) and salt (58.6%). Intake of vegetables and fruit, milk and soybeans, water, and dietary variety were insufficient, especially for milk and soybeans. 80.8%of people had moderate or severe unbalanced diet consumption. The largest differences of DQD scores have been found for people with different education levels and urbanicity levels. People with higher education levels have lower DQD scores (p<0.001), and people living in medium and low urbanicity areas had 2.8 and 8.9 higher DQD scores than their high urbanicity counterparts (p<0.001). Also, significant differences of DQD scores have been found according to gender, marital status, work status and regions (p<0.001). Conclusion: DBI can reveal problems of dietary quality for older Chinese people. Rectifying unbalanced diet intake may lead to prevention of non-communicable diseases (NCDs). Dieticians and health care professionals need to increase dissemination and uptake of nutrition education, with interventions targeted at regions of lower socioeconomic status.

Introduction and Aims: To examine women's drinking behaviour relative to Australian guidelines and identify associated factors over the lifespan. Design and Methods: Data came from three prospective cohorts of the Australian Longitudinal Study on Women's Health aged 18-23 (n=14247), 45-50 (n=13715) and 70-75 years (n=12432) when first surveyed in 1996. The same women were re-surveyed at roughly 3-year intervals until 2012. At each survey, four drinking behaviours were based on two guidelines: long-term drinking (no more than two standard drinks per day) and episodic drinking (no more than four standard drinks on an occasion): (i) no risk (within both guidelines); (ii) low episodic risk (less than once a month); high episodic risk (at least once a month); long-term risk (more than two drinks per day regardless of episodic drinking). Results: No risk drinking increased with age, low episodic risk drinking remained almost constant between ages 18 and 39, and high episodic risk drinking declined rapidly. Few women drank at long-term risk. Factors associated with risky drinking varied with age; however, being a past or current smoker consistently increased the risk, and risks for smokers increased with age. Risky drinking was less likely to be practised by women providing care and needing help with daily tasks, or by pregnant women and those living with children. Discussion and Conclusions: Risky drinking behaviour should be addressed in younger women and in those who smoke. Interventions to reduce risky drinking, possibly in combination with reducing smoking, could be offered through general practice centres.

There are few studies reporting the association between lifestyle and mortality among the oldest old in developing countries. We examined the association between food habits, lifestyle factors and all-cause mortality in the oldest old (=80 years) using data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). In 1998/99, 8959 participants aged 80 years and older took part in the baseline survey. Follow-up surveys were conducted every two to three years until 2011. Food habits were assessed using an in-person interview. Deaths were ascertained from family members during follow-up. Cox and Laplace regression were used to assess the association between food habits, lifestyle factors and mortality risk. There were 6626 deaths during 31,926 person-years of follow-up. Type of staple food (rice or wheat) was not associated with mortality. Daily fruit and vegetable intake was inversely associated with a higher mortality risk (hazard ratios (HRs): 0.85 (95% CI (confidence interval) 0.77¿0.92), and 0.74 (0.66¿0.83) for daily intake of fruit and vegetables, respectively). There was a positive association between intake of salt-preserved vegetables and mortality risk (consumers had about 10% increase of HR for mortality). Fruit and vegetable consumption were inversely, while intake of salt-preserved vegetables positively, associated with mortality risk among the oldest old. Undertaking physical activity is beneficial for the prevention of premature death.

Little is known about the macronutrient intake status of older Chinese people. The present study evaluated the macronutrient intake status of older Chinese people (aged =A 60 years), investigated whether they had intake levels that met the Dietary Reference Intakes (DRI), and explored the associations between macronutrient intakes and age groups, sex, education levels, work status, BMI groups, urbanicity levels and four socio-economic regions of China (Northeast, East Coast, Central and Western). Dietary intake data of 2746 older Chinese with complete dietary intake data in the Longitudinal China Health and Nutrition Survey (2009 wave) carried out across four diverse regions were analysed. Dietary intake data were obtained by interviews using 24A h recalls over three consecutive days. The MUFA:SFA ratios were calculated based on the Chinese Food Composition Table. Less than one-third of the older Chinese people included in the present study had intake levels meeting the adequate intake for carbohydrate-energy and fat-energy; less than one-fifth had intake levels meeting the recommended nutrient intake for protein-energy; and more than half of the older people had fat-energy intakes higher than the DRI. There were strong associations between the proportions of energy from the three macronutrients and education levels, urbanicity levels and the four socio-economic regions of China, with older people living in the East Coast region having different patterns of macronutrient-energy intakes when compared with those living in the other three regions. Macronutrient intakes across different urbanicity levels in the four regions revealed considerable geographical variations in dietary patterns, which will affect the risk factors for non-communicable diseases. Clinical interventions and public health policies should recognise these regional differences in dietary patterns.

Background Although many people survive an initial stroke, little is known about long-term impacts of stroke on survival. Methods Data from the Australian Longitudinal Study on Women's Health were used to compare 12-year survival rates in older women with prevalent stroke, incident stroke, and no stroke. Cox regression models were fitted to assess the effect of lifestyle and demographic characteristics on the relationship between stroke and all-cause mortality. The "no stroke" group was used as the reference category in all statistical models. Results At baseline, 4% of the women reported a previous stroke (prevalent stroke). At survey 2 in 1999, a further 3% reported having a stroke between 1996 and 1999 (incident stroke). Stroke was significantly associated with reduced long-term survival. Age-Adjusted hazards ratios (HRs) were: 1.64 (1.43-1.89) for the "prevalent stroke" group and 2.29 (1.97-2.66) for the "incident stroke" group. Adjusting for comorbidities reduced the HRs, but the risk of death was still significantly higher in the 2 stroke groups. Adjusting for demographic and lifestyle factors did not make any further difference to the relationship between stroke and survival. However, obesity and past smoking were also risk factors for mortality. Conclusions This study highlights the long-term impacts of stroke on life expectancy and the importance of comorbidities and other lifestyle factors in affecting poststroke survival.

Problem Ghana¿s population is ageing. In 2011, the Government of Ghana requested technical support from the World Health Organization (WHO) to help revise national policies on ageing and health.

Ageing is a dynamic process, and trends in the health status of older adults aged at least 60 years vary over time because of several factors. We examined reported trends in morbidity and mortality in older adults during the past two decades to identify patterns of ageing across the world. We showed some evidence for compression of morbidity (ie, a reduced amount of time spent in worse health), in four types of studies: 1) of good quality based on assessment criteria scores; 2) those in which a disability-related or impairment-related measure of morbidity was used; 3) longitudinal studies; or 4) studies undertaken in the USA and other high-income countries. Many studies, however, reported contrasting evidence (ie, for an expansion of morbidity), but with different methods, these measures are not directly comparable. Expansion of morbidity was more common when trends in chronic disease prevalence were studied. Our secondary analysis of data from longitudinal ageing surveys presents similar results. However, patterns of limitations in functioning vary substantially between countries and within countries over time, with no discernible explanation. Data from low-income countries are very sparse, and efforts to obtain information about the health of older adults in less-developed regions of the world are urgently needed. We especially need studies that focus on refining measurements of health, functioning, and disability in older people, with a core set of domains of functioning, that investigate the effects of these evolving patterns on the health-care system and their economic implications.

Background: Many epidemiological studies that focus on pregnancy rely on maternal self-report of perinatal outcomes. The aim of this study was to evaluate the agreement between self-reported perinatal outcomes (gestational hypertension with or without proteinuria, gestational diabetes, premature birth and low birth weight) in a longitudinal study and linked to administrative data (medical records). Methods: Self-reported survey data from the Australian Longitudinal Study on Women's Health was linked with the New South Wales Perinatal Data Collection. Agreement between the two sources was evaluated using percentage agreement and kappa statistics. Analyses were conducted at two levels by: i) the mother and ii) each individual child. Results: Women reliably self-report their perinatal outcomes (=87 % agreement). Gestational hypertension with or without proteinuria had the lowest level of agreement. Mothers' reports of perinatal outcomes were more reliable when evaluated by child. Restricting the analysis to complete and consistent reporting further strengthened the reliability of the child-specific data, increasing the agreement from >92 to >95 % for all outcomes. Conclusions: The present study offers a high degree of confidence in the use of maternal self-reports of the perinatal outcomes gestational hypertension, gestational diabetes, preterm birth and low birth weight in epidemiological research, particularly when reported on a per child basis. Furthermore self-report offers a cost-effective and convenient method for gathering detailed maternal perinatal histories.

The aim of this study is to identify patterns of sleep difficulty in older women, to investigate whether sleep difficulty is an indicator for poorer survival, and to determine whether sleep difficulty modifies the association between disease and death. Data were from the Australian Longitudinal Study on Women's Health, a 15-year longitudinal cohort study, with 10¿721 women aged 70-75¿years at baseline. Repeated-measures latent class analysis identified four classes of persistent sleep difficulty: troubled sleepers (N¿=¿2429, 22.7%); early wakers (N¿=¿3083, 28.8%); trouble falling asleep (N¿=¿1767, 16.5%); and untroubled sleepers (N¿=¿3442, 32.1%). Sleep difficulty was an indicator for mortality. Compared with untroubled sleepers, hazard ratios and 95% confidence intervals for troubled sleepers, early wakers, and troubled falling asleep were 1.12 (1.03, 1.23), 0.81 (0.75, 0.91) and 0.89 (0.79, 1.00), respectively. Sleep difficulty may modify the prognosis of women with chronic diseases. Hazard ratios (and 95% confidence intervals) for having three or more diseases (compared with 0 diseases) were enhanced for untroubled sleepers, early wakers and trouble falling asleep [hazard ratio¿=¿1.86 (1.55, 2.22), 1.91 (1.56, 2.35) and 1.98 (1.47, 2.66), respectively], and reduced for troubled sleepers [hazard ratio¿=¿1.57 (1.24, 1.98)]. Sleep difficulty in older women is more complex than the presence or absence of sleep difficulty, and should be considered when assessing the risk of death associated with disease.

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.

Objectives/Background: Young women are at a risk of poor sleep, but the extent to which their sleep difficulties remain chronic is not known. Little is also known about the frequency of seeking health care for sleep and satisfaction with that health care. This longitudinal study investigated these issues over nine years in women who reported sleep difficulties over the preceding 12 months. Patients/Methods: Data from the Australian Longitudinal Study on Women's Health were analysed (N = 9683). Information on self-reported sleep difficulties, help seeking, and health-care satisfaction was obtained from four surveys collected from 2000 (aged 22-27 years) to 2009. Generalized estimating equations were conducted to calculate odds ratios (OR) for the likelihood of women who reported sleep difficulties in 2000 to report sleep difficulties at subsequent surveys. Results: The prevalence of self-reported sleep difficulties 'often' was consistent at 9.1-10.8%. Women who reported sleep difficulties 'often' in 2000 had a markedly increased risk of continued sleep difficulties 'often' over the subsequent 9 years [2003: OR (95% confidence interval, CI) = 11.07 (8.03-15.27); 2006: 12.19 (8.08-16.88); 2009: 10.70 (7.57-15.12)]. Of women who reported sleep difficulties 'often' in 2000 (N = 981), 45.1% had persistent sleep problems and 21.1% experienced relapse of symptoms. About one-third of women who reported sleep problems 'often' sought help. Conclusion: Self-reported frequent sleep difficulties in non-depressed young women strongly predicted a continuation of this level of sleep difficulty over a decade, even if help is sought. Current health practice may not be breaking the ongoing chronicity of sleep difficulties in young women.

Objectives: The ability of older people to mobilise within and outside their community is dependent on a number of factors. This study explored the relationship between spatial mobility and psychological health among older adults living in Australia.

Objective: To qualify the psychosocial burden of osteoarthritis for older women and identify factors perceived to assist with psychological adjustment to the disease. Methods: Women who indicated being diagnosed/treated for osteoarthritis in the previous three years in the fifth survey of the Australian Longitudinal Study on Women's Health provided the sampling frame. Participants were randomly sampled until saturation was reached using a systematic process. Thematic content analysis was applied to the 19 semi-structured telephone interviews using a realist framework. Results: The findings indicate that the emotional burden of osteoarthritis is considerable, and the process of psychological adjustment complex. Older women with osteoarthritis have psychological difficulties associated with increasing pain and functional impairment. Psychological adjustment over time was attributed primarily to cognitive and attitudinal factors (e.g. stoicism, making downward comparisons and possessing specific notions about the cause of arthritis). This was a dynamic 'day to day' process involving a constant struggle between grieving physical losses and increasing dependence amidst symptom management. Conclusion: The findings of this study add to the current understanding of the complex processes involved in psychological adjustment over time. Targeted interventions focused on assisting women with arthritis redefine self-concepts outside the confines of caring responsibilities, coupled with public health education programs around understanding the destructive nature of arthritis are required. Understanding the destructive and (potentially) preventable nature of arthritis may facilitate early detection and increased uptake of appropriate treatment options for osteoarthritis that have the ability to modify disease trajectories.

Background: we aimed to identify multimorbidity patterns and relate these patterns to functional ability and decline. Methods: we included 7,270 participants of the older cohort of the Australian Longitudinal Study on Women's Health, who were surveyed every 3 years from 2002 to 2011. We used factor analysis to identify multimorbidity patterns from 31 selfreported chronic conditions among women aged 76-81 in 2002. We applied a linear increments model to account for attrition and related the multimorbidity patterns to functional ability and decline at subsequent surveys, as measured by activities of daily living (ADL) and instrumental activities of daily living (IADL). For each pattern, we determined mean ADL and IADL scores in the middle and highest third of factor score in comparison to a reference group. Results: we identified three multimorbidity patterns, labelled musculoskeletal/somatic (MSO), neurological/mental health (NMH) and cardiovascular (CVD). High factor scores for NMH, MSO and CVD were associated with significantly higher mean ADL and IADL scores (poorer functional ability) in 2005 compared with the reference group of low factor scores for all three factors. The CVD pattern was associated with the greatest decline in ADL between 2005 and 2011, whereas the NMH pattern was associated with the greatest decline in IADL. Conclusions: distinct multimorbidity patterns were differentially associated with functional ability and decline. Given the paucity of studies on multimorbidity patterns, future studies should seek to assess the reproducibility of our findings in other populations and settings, and investigate the potential implications for improved prediction of functional decline.

Dietary guidelines around the world recommend increased intakes of fruits and non-starchy vegetables for the prevention of chronic diseases and possibly obesity. This study aimed to describe the association between body mass index (BMI) and habitual fruit and vegetable consumption in a large sample of 246,995 Australian adults aged 45 + year who had been recruited for the "45 and Up" cohort study. Fruit and vegetable intake was assessed using validated short questions, while weight and height were self-reported. Multinomial logistic regression was used, by sex, to assess the association between fruit and vegetable intake and BMI. Compared to the referent normal weight category (BMI 18.5 to 24.9), the odds ratio (OR) of being in the highest vegetable intake quartile was 1.09 (95% confidence interval (CI) 1.04-1.14) for overweight women (BMI 25.0-29.9) and 1.18 (95% CI 1.12-1.24) for obese women. The association was in the opposite direction for fruit for overweight (OR 0.85; 95% CI 0.80-0.90) and obese women (OR 0.75; 95% CI 0.69-0.80). Obese and overweight women had higher odds of being in the highest intake quartile for combined fruit and vegetable intake, and were more likely to meet the "2 and 5" target or to have five or more serves of fruit and vegetables per day. In contrast, overweight men were less likely to be in high intake quartiles and less likely to meet recommended target of 5 per day, but there was no consistent relationship between obesity and fruit and vegetable intake. Underweight women and underweight men were less likely to be in the highest intake quartiles or to meet the recommended targets. These data suggest that improving adherence to dietary targets for fruit and vegetables may be a dietary strategy to overcome overweight among men, but that overweight and obese women are already adhering to these targets. The association between fruit and vegetable intake and underweight in adults suggests that improving fruit and vegetables intakes are important for the overall dietary patterns of people in this group. © 2014 by the authors; licensee MDPI, Basel, Switzerland.

Background: Faced with the challenge of recruiting young adults for health studies, researchers have increasingly turned to the Internet and social networking sites, such as Facebook, as part of their recruitment strategy. As yet, few large-scale studies are available that report on the characteristics and representativeness of the sample obtained from such recruitment methods.

This study examines differences in uptake of the Medicare items rolled out in 2006 under the 'Better Access Scheme' (BAS) between rural and non-rural Australian women. It compares differences in women's uptake of the BAS services by area of residence (ARIA+) across time using the Australian Longitudinal Study of Women's Health (ALSWH) survey data linked to Medicare data. Women aged 28-33 years at the time the BAS was introduced that responded to the self-reported question on depression/anxiety and consented to linkage of their survey data with Medicare data (n=4316). Participants were grouped by ARIA+according to BAS use, diagnoses of anxiety/depression but no BAS use and other eligible women. Across all areas, women born 1973-1978 with a self-reported diagnosis of depression/anxiety or having treatment under the BAS had a significantly lower mean mental health score compared to other women. Significantly more women living in non-rural areas had used at least one service provided under the BAS initiative compared to women in outer regional, inner regional or remotes areas (21% versus 18% versus 13% versus 7%, respectively), and across all areas, 12% of women reported having a diagnosis of depression/anxiety but not been treated under the BAS. While there is a gradual uptake of the new BAS services, a large percentage of women who have a diagnosis of depression/anxiety have not been treated under the BAS. The data suggest that women in urban areas have been better able to take up the services compared to non-urban women. © 2014 National Rural Health Alliance Inc.

Background: The relationship between comorbidity and psychological distress is well documented, however the mechanism of this association is unclear. We aim to assess the extent to which the association between common chronic conditions and high scores on the Kessler Psychological Distress Scale (K10) measure of psychological distress vary according to comorbid conditions, disability, and sociodemographic circumstances. Methods: Analysis of self-reported cross-sectional data from the New South Wales 45 and Up Study, Australia, for 236,508 participants aged 45 years and over, using logistic regression modeling. Results: Self-reported heart attack/angina, other heart disease, stroke, and diabetes were all significantly associated with higher risk of high/very high K10 scores. These associations were attenuated, but remained statistically significant, when comorbidity, disability, and sociodemographic factors were added to the model.Men reporting needing help for daily tasks were nine times as likely to report high/very high K10 scores as those without this need, and women reporting needing help were seven times more likely to have high/very high K10 scores. Conclusions: Heart attack/angina, other heart disease, stroke, and diabetes are all significantly associated with psychological distress. However, these effects are partly explained by other comorbid conditions, limitations on physical functioning, and sociodemographic factors. These findings highlight the importance of developing public health policies that encompass psychological, physiological, and social domains, and provide crucial insights for clinicians in identifying and supporting those people at risk of psychological distress. © 2013 Wiley Periodicals, Inc.

Previous longitudinal studies have demonstrated that poor sleep may precede depression and anxiety. The current study examined the association between self-reported sleeping difficulties and new onset depression and anxiety in young women. A nationally representative sample of 9,683 young women from the Australian Longitudinal Study of Women's Health was analyzed. Women were surveyed in 2000 (aged 22 to 25 years), 2003, 2006, and 2009. Generalized estimating equations were used to examine the association between sleeping difficulties in 2000 and new-onset depression (excluding postnatal depression) and anxiety at each subsequent survey. Significant increased risk of new onset depression (odds ratio (OR) = 2.6 in 2003; OR = 4.4 in 2006; OR = 4.4 in 2009) and anxiety (OR = 2.4 in 2006; OR = 2.9 in 2009) was found at each follow-up survey in women who reported sleeping difficulties "often" in 2000. Further research is needed to uncover the mechanisms underlying the link between sleep problems and mental health. © 2014 Springer-Verlag Wien.

Aim: To identify the extent to which homes and neighbourhoods of older community-dwelling people are 'supportive'. Method: Cross-sectional survey, in-home observation and interviews involving 202 participants (75-79 years). Measures included SF-36 health-related quality of life and Late Life Function and Disability Instrument (LLFDI) scores, and self-reported home usability, access, safety and neighbourhood. Associations between home and neighbourhood characteristics were assessed using ¿2-tests, t-tests and Pearson correlations. Results: Older people rated neighbourhood satisfaction highly (3.0 men, 3.2 women; 4 being the highest score). Many homes failed objective adaptability and safety ratings, particularly bathrooms (80% did not have a shower grab rail, 77% did not have non-slip floors); 27% of homes scored =8 of 25 possible hazards. There were significant correlations between perceptions of housing and neighbourhood and SF-36 and disability scores. Conclusion: Many homes and neighbourhoods may not accommodate increased frailty or disability of older people into the future. © 2012 ACOTA.

Aim: This paper explored how gerontology experts described baby boomers, whether they challenged the popular image, and if they provided alternatives to the popularly reported baby boomer behaviours and characteristics. Methods: Qualitative interviews were conducted with ten experts from different areas across Australia. The interviews were semi-structured and guided by a 'sense-making' approach to explore the baby boomer construct and identify expert narratives that differed from the popularly tendered image. Results: The majority of experts were identified as baby boomers and made use of phrases associated with the popular baby boomer image, such as 'cashed up', 'reinventing retirement' and 'sea change'. Lifestyle and wealth were recognised as staple features of the popular image. To a lesser degree, the experts also recognised alternative characteristics and behaviours, including people with disabilities and those who struggle financially. Conclusions: Experts appeared to identify with the popular baby boomer label, but not necessarily the accompanying stereotypes.

Background: Arthritis is a significant contributor to illness, pain and disability and imposes a considerable burden upon the community. Pain is a cardinal symptom of arthritis and has significant implications on biopsychosocial wellbeing. The multidimensional nature of the experience of pain in arthritis has not been well defined in community-based samples. Aims: The two aims of this study are to generate profiles of pain from a community sample of older women and to compare profiles for women with and without arthritis. Methods: The sub study is a cross-sectional postal survey of 700 Australian community-based women. The survey includes a range of measures on health, arthritis and pain that will be used to examine the multidimensional nature of the experience of pain in arthritis and generate profiles of pain. Discussion: With no core set of measures for the evaluation of arthritis pain, this survey was created from an amalgamation of measures to capture multiple dimensions of pain. Findings from this study will assist in defining the symptom of pain in arthritis and may lead to further research in evidence-based treatment options for people with arthritis.