Is inequity undermining Australia's 'universal' health care system? Socio-economic inequalities in the use of specialist medical and non-medical ambulatory health care.

OBJECTIVES: To quantify need-adjusted socio-economic inequalities in medical and non-medical ambulatory health care in Australia and to examine the effects of specific interventions, namely concession cards and private health insurance (PHI), on equity. METHODS: We used data from a 2004 survey of 10,905 Australian women aged 53 to 58 years. We modelled the association between socio-economic status and health service use--GPs, specialists, hospital doctors, allied and alternative health practitioners, and dentists--adjusting for health status and other confounding variables. We quantified inequalities using the relative index of inequality (RII) using Poisson regression. The contribution of concession cards and PHI in promoting equity/inequity was examined using mediating models. RESULTS: There was equality in the use of GP services, but socio-economically advantaged women were more likely than disadvantaged women to use specialist (RII=1.41, 95% CI:1.26-1.58), allied health (RII=1.21,1.12-1.30), alternative health (RII=1.29,1.13-1.47) and dental services (RII=1.61,1.48-1.75) after adjusting for need, and they were less likely to visit hospital doctors (RII=0.74,0.57-0.96). Concession cards reduced socio-economic inequality in GP but not specialist care. Inequality in dental and allied health services was partly explained by inequalities in PHI. CONCLUSIONS AND IMPLICATIONS: Substantial socio-economic inequity exists in use of specialist and non-medical ambulatory care in Australia. This is likely to exacerbate existing health inequalities, but is potentially amenable to change.

A longitudinal analysis of older Australian women's consultations with complementary and alternative medicine (CAM) practitioners, 1996-2005.

OBJECTIVE: to determine the factors associated with complementary and alternative medicine (CAM) use among older Australian women over time. METHODS: a longitudinal analysis of postal questionnaires completed in 1996, 1999, 2002 and 2005 as part of the Australian Longitudinal Study on Women's Health. RESULTS: the percentage of women who consulted a CAM practitioner in the years 1996, 1999, 2002 and 2005 were 14.6%, 12.1%, 10.9% and 9.9%, respectively. Use of CAM increased as the number of reported symptoms increased and physical health deteriorated, for non-urban residents compared to urban residents. CONCLUSION: use of CAM amongst older women appears to be strongly influenced by poor physical health. There is also a suggestion that lack of access to conventional health care providers increases CAM use. There is also an overall decline in the use of CAM among older women as they age.

Alcohol consumption and physical health-related quality of life in older women using the transformation of SF-36 to account for death.

Moderate alcohol consumption has been associated with health benefits in several studies, but few studies investigating such association for elders have been done. So, we explored the relationship between alcohol intake and changes in physical health-related quality of life (HRQoL). As analyses of longitudinal HRQoL data excluding diseased participants produced overestimated results, we compared the methods with and without incorporating death and estimated valid physical HRQoL and its decline over time. Study subjects were women from the Australian Longitudinal Study on Women's Health, ages 70-75 years at Survey 1 in 1996 (n = 12,432), and were followed-up at 3 yearly intervals for 6 years. Alcohol consumption was divided into seven categories to identify harmful alcohol levels for older women. We measured Physical Component Score (PCS) of Medical Outcomes Study Short-Form (SF-36), and applied the transformed PCS incorporating death as a valid score to estimate HRQoL changes for each alcohol group with adjustment for potential confounders. Significant declines of values were observed and the values of 'non-drinker' and 'rare drinker' were lower than the other groups during 6 years in both PCS and the transformed PCS. Analysis of the PCS showed significant Alcohol x Time interaction effects for non-drinker and rare drinker groups, as the scores were overestimated towards higher values at Survey 2 due to loss to follow-up of women who died. In the transformed PCS, these interaction effects diminished, and a clearer dose-response relationship between alcohol and physical HRQoL was observed at the third survey. We examined the influence of deaths on the study conclusions with using PCS and its transformed value which included deaths. Being a nondrinker of alcohol was associated with greater risk of mortality and poorer physical HRQoL. Moderate alcohol consumption was not harmful, and may carry some health benefits for older women.

Diet quality is associated with higher nutrient intake and self-rated health in mid-aged women.

OBJECTIVE: To develop a diet quality score reflecting adherence to national dietary recommendations for the Australian Longitudinal Study on Women's Health (ALSWH) and to compare this against energy standardized nutrient intakes and indices of health. DESIGN: Cross-sectional survey in a nationally representative sample of mid-aged women participating in a cohort study. SUBJECTS: Data from 9,895 women aged 50-55 who participated in the 2001 survey and had four or less missing values on their food frequency questionnaires were used to calculate the Australian Recommended Food Score (ARFS) based on adherence to Australian Dietary Guidelines. MEASURE OF OUTCOME: Correlates of ARFS were investigated including, mean nutrient intakes and indices of self-rated health and health service use. Associations were examined using ANOVA for continuous variables and Chi-squared tests for categorical variables. Area of residence and educational attainment were used as covariates in all modeling, to adjust for sampling frame and socioeconomic status. RESULTS: The maximum ARFS was 74, with a mean of 33.0 +/- 9.0 and 21% achieving a score > 40. Higher ARFS was associated with indicators of higher socio-economic status, better self-rated health and lower health service use, p<0.0001, higher intakes of micronutrients and lower percentage of energy as total or saturated fat, p<0.0001. CONCLUSIONS: The Australian Recommended Food Score can be used to rank mid-aged women in terms of diet quality and nutrient intake and is associated with indices of self-rated health and health service use. The ARFS can be used to measure future associations with health outcomes and mortality.

Longitudinal analysis of alcohol consumption and health of middle-aged women in Australia.

AIMS: To assess the prospective association between alcohol consumption and self-rated health: in particular whether there is a relationship between stable alcohol intake and health; whether health is affected by changes in alcohol consumption; whether having a chronic condition alters the relationships between stable and changing alcohol intake and health; and whether the health of longer-term abstainers is different from more recent and intermittent abstainers. DESIGN: Longitudinal analysis of a prospective, population-based study. SETTING: Australia. PARTICIPANTS: A total of 13 585 randomly selected 45-50-year-old women surveyed in 1996, of whom 9396 (69%) were resurveyed in 1998, 2001 and 2004. MEASUREMENTS: Estimates for the General Health subscale of the SF-36 for different levels of alcohol intake adjusted for having a chronic condition, depression, smoking and other factors. FINDINGS: Longitudinal models of consistent alcohol intake showed mean scores for general health of moderate drinkers were significantly better than that of non-drinkers [mean difference = 4.3, standard error (SE) = 0.61], occasional drinkers (mean difference = 3.1, SE = 0.52) and heavy drinkers (mean difference = 2.1, SE = 1.00). Among moderate drinkers, a decrease or variation in alcohol consumption was associated with a significant decline of three to four points in general health. Similar results were obtained when women with an existing chronic condition were excluded from these models. The health of recent abstainers and intermittent drinkers was the same as longer-term abstainers. CONCLUSIONS: Consistent moderate drinkers had the best health even after adjustment for having a chronic condition, depression and life-style factors. Poorer health was associated with decreased alcohol intake among occasional and moderate drinkers.

Alcohol consumption of Australian women: results from the Australian Longitudinal Study on Women's Health.

INTRODUCTION AND AIMS: Alcohol misuse is responsible for extensive personal harm and high societal costs. Research related specifically to women's alcohol consumption is important due to gender differences in clinical outcomes and disease progression. DESIGN AND METHODS: This study examines longitudinal changes in the patterns of alcohol consumption associated with harm in the long term (chronic) and short term (acute) as defined by the Australian National Health and Medical Research Council. Results are presented for three age cohorts (18 - 23 years, 45 - 50 years and 70 - 75 years) using data from the Australian Longitudinal Study on Women's Health 1996 - 2003. Initial response rates for the study were 41%, 54% and 36% for the Younger, Mid-aged and Older cohort, respectively. RESULTS: The percentages of women that initiated usual weekly consumption in excess of 140 g of alcohol, designated as long-term risky or high risk consumption, between surveys 1 and 2 were 2.7%, 2.1% and 1.7% (Younger, Mid-aged and Older cohorts, respectively). Similarly, between surveys 1 and 2, 7.8% of younger women and 2.5% of mid-aged women initiated consumption of 50 g of alcohol on one occasion at least weekly, placing them at risk of alcohol-related harm in the short-term weekly. Examining data across the three time-points in the Younger cohort, 0.3% of women were at risk of alcohol-related harm in the long term across all three time-points, and 9.2% were at risk at one or two time-points. The percentage of younger women at risk of alcohol-related harm in the short term at least weekly was 3.4% at risk at all three time-points and 24% at risk at one or two time-points. DISCUSSION AND CONCLUSIONS: This study indicates that there is a small percentage of women who maintain levels of alcohol consumption associated with increased risk of morbidity and mortality over time, but a much larger proportion of women that drink at hazardous levels sporadically during the life course. Prevention efforts may need to target transient high-risk alcohol consumers differently than consistently heavy alcohol consumers. Non-response bias and attrition may have caused the prevalence of both entrenched and episodic heavy consumption to be underestimated.

The characteristics of middle aged Australian women who consult acupuncturists.

BACKGROUND: Although an increase in the use of acupuncture in recent years has been identified, there are few studies that focus attention upon the characteristics of acupuncture users. This survey aimed at providing a first step towards addressing this significant research gap. METHODS: This study was conducted as part of the Australian Longitudinal Study on Women's Health, and examined the characteristics of acupuncture users among middle aged Australian women between 50 and 55 years old. Data were collected on demographic measures, health status and health service use. RESULTS: The paper reports on 11 202 middle aged women, surveyed in 2001. We estimate that 4.5% of middle aged women consult an acupuncturist. Women who consult an acupuncturist are less likely to be married or living in a de facto relationship, are more likely to have had a major personal illness in the previous year, to have suffered from a variety of symptoms or have significantly lower scores (ie poorer health) on all eight dimensions of the SF-36 health-related quality of life scale. Women who use acupuncture are also higher users of 'conventional' health services. CONCLUSIONS: While the development of a research base and clinical applications for acupuncture are ongoing, health professionals should be aware that acupuncture is currently being used by large numbers of middle aged women. In addition, given the relatively higher prevalence of acupuncture use reported in our study, it is important that further research explores acupuncture use in more detail and the relationship between women's health issues and their use and experience of acupuncture.

Predictors of dietary change and maintenance in the Women's Health Initiative Dietary Modification Trial.

OBJECTIVE: To identify predictors of dietary change to and maintenance of a low-fat eating pattern (<20% energy from fat, > or = 5 servings fruits/vegetables daily, and > or = 6 servings grains daily) among a cohort of postmenopausal women. Candidate predictors included intrapersonal, interpersonal, intervention program characteristics, and clinical center. DESIGN: Longitudinal study within the Women's Health Initiative Dietary Modification Trial. Dietary change was evaluated after 1 year of participation in the Women's Health Initiative Dietary Modification Trial, and dietary maintenance after 3 years. SUBJECTS: Postmenopausal women aged 50 to 79 years at baseline who were randomized to the intervention arm of the Women's Health Initiative Dietary Modification Trial (n=19,541). STATISTICAL ANALYSIS: Univariate and multivariate linear regression analysis was performed and associations evaluated between candidate predictors and each of the three dietary goals: percent energy from fat, fruit/vegetable servings, and grain servings. RESULTS: Year 1 (change) predictors of percent energy from fat (P<0.005) included being younger (beta=2.12; 70 to 79 years vs 50 to 59 years), more educated (beta=-.69; college vs high school), more optimistic (beta=-.07), attending more sessions (beta=-.69), and submitting more self-monitoring records (beta=-.74). At year 3 (maintenance), the predictors of percent energy from fat (P<0.005) included attending more sessions (beta=-.65) and submitting more self-monitoring scores (beta=-.71). The analytic model predicted 22% of the variance in fat intake at year 1 and 27% at year 3 (P<0.01). CONCLUSIONS: The strongest predictors of dietary change and maintenance were attending intervention sessions and self-monitoring dietary intake. Novel was the finding that optimism predicted dietary change.

Annual health assessments for older Australian women: uptake and equity.

OBJECTIVE: To measure utilisation of Enhanced Primary Care (EPC) health assessment items for women aged 75 years and over, and to describe health and socio-demographic characteristics of users and non-users. METHOD: Analysis of longitudinal survey and Medicare claims data from women in the Australian Longitudinal Study on Women's Health (ALSWH) aged 75 to 78 years when EPC items were introduced and who provided permission to access their Medicare records for the period 1999-2003 (n = 4,646). RESULTS: There was an increase in uptake of assessments over four years: from November 1999, 12% of eligible women had a health assessment during the following year; by October 2003, 49% had at least one health assessment ever. Few had repeat assessments. Women who visited a GP more often and who were satisfied with the number of GPs available were more likely to have an assessment in the first 12 months, and women who visited a GP more often, those taking more medications, and those caring for another were more likely to have at least one assessment in four years. Women in smaller rural and remote areas were less likely to have an assessment than women in urban areas. CONCLUSIONS: Most women are not having annual assessments and there is some geographic inequity.

Is there an association between the use of oral contraception and depressive symptoms in young Australian women?

PURPOSE: The purpose of this study was to explore the relationship between oral contraceptive pill (OCP) use and the experience of depressive symptoms among a representative sample of young Australian women. METHODS: The study sample comes from the Australian Longitudinal Study on Women's Health. Analysis was confined to women in the youngest cohort who responded to Survey 2, which was conducted in 2000 (n=9688) when they were aged between 22 and 27 years, and to Survey 3, which was conducted in 2003 (n=9081) when they were aged between 25 and 30 years. RESULTS: After adjusting for potential confounders, the odds of a nonuser experiencing depressive symptoms is not significantly different from that of an OCP user [odds ratio=1.05; 95% confidence interval (95% CI)=0.90-1.21]. Women who used OCP for reasons other than contraception were 1.32 (95% CI=1.07-1.62) times as likely to be depressed than women who used OCP for contraception. The percentage of women who reported experiencing depressive symptoms declined as the number of years of OCP use increased (p=.009). CONCLUSIONS: The results of this study suggest that, after adjusting for confounders, there is no independent effect of OCP use on depressive symptoms in young Australian women.

Transforming the SF-36 to account for death in longitudinal studies with three-year follow-up.

BACKGROUND: Analyses of longitudinal health-related quality of life data often exclude participants who die, which limits the generalizability of the results. Methods to incorporate death as a valid score in the Medical Outcomes Study Short-Form (SF-36) have been suggested but need to be evaluated in other populations. OBJECTIVES: We sought to apply a method of transforming the SF-36 Physical Component Score (PCS) to include death. A transformation to estimate the probability of being "healthy" in 3 years, based on the current PCS value, will be developed and validated. SUBJECTS: Women in the Australian Longitudinal Study on Women's Health (ALSWH), ages 70-75 years at Survey 1 in 1996 (n = 12,432), were followed-up at 3 yearly intervals for 6 years. RESULTS: The transformation derived from the ALSWH data provides evidence that the methodology for transforming the PCS to account for deaths is sound. The 3-year equation provided good estimates of the probability of being healthy in 3 years and the method allowed deaths to be included in an analysis of changes in health over time. CONCLUSIONS: For longitudinal studies involving the SF-36 in which subjects have died, we support the recommendation that both the PCS and its transformed value which includes deaths should be analyzed to examine the influence of deaths on the study conclusions. Using study data to derive empirical parameters for the transformations may be appropriate for studies with follow-up intervals of other lengths.

Attrition in longitudinal studies: who do you lose?

OBJECTIVE: To describe the risk factors for various types of attrition in three age cohorts of women in a longitudinal study and to discuss strategies to minimise attrition. METHODS: Analysis of survey data from the Australian Longitudinal Study on Women's Health, collected by mailed questionnaire. In 1996, the study recruited and surveyed a national random sample of 'younger' (18-23 years, n = 14,247), 'mid-age' (45-50 years, n = 13,716), and 'older' women (70-75 years, n = 12,432), and began a staggered cycle of mailed follow-up questionnaires: 1998 (mid-age), 1999 (older), 2000 (younger) and so on. Demographic, health and social risk factors for attrition were examined using multivariate analysis. RESULTS: Attrition at survey 2 was highest among younger women (32%), mainly because of participants not being contactable (21%), and lower among the older (16%) and mid-age women (10%). At survey 1, the survey 2 non-respondents were more likely to report having less education, being born in a non-English-speaking country and being a current smoker, in all cohorts, and had poorer health (mid-age and older cohort) and more difficulty managing on their income (younger and mid-age). CONCLUSION: Although the magnitude of different types of attrition was found to differ by age, there were several risk factors for attrition that remained consistent. These findings are important to inform future studies on ways to lessen or prevent systematic loss of participants. IMPLICATIONS: Recruitment and follow-up methods in longitudinal studies should be tailored to maximise retention of participants at higher risk of dropout.

A profile of middle-aged women who consult a chiropractor or osteopath: findings from a survey of 11,143 Australian women.

PURPOSE: The aim of this study is to examine the prevalence of chiropractic and osteopathy use and the profile of chiropractor/osteopath users among middle-aged Australian women. METHODS: This article reports on research conducted as part of the Australian Longitudinal Study on Women's Health. The focus of this article is the middle-aged women who responded to Survey 3 in 2001 when they were between the ages of 50 and 55 years. The demographic characteristics, health status, and health service use of chiropractic/osteopathy users and nonusers were compared using chi2 tests for categorical variables and t tests for continuous variables. RESULTS: We estimate that 16% of middle-aged women consult with a chiropractor or osteopath (after adjustment for the oversampling of rural women). Area of residence, education, and employment status were all statistically significantly associated with chiropractic and osteopath use. Specifically, women who live in nonurban areas were more likely to consult a chiropractor or osteopath, compared with women who live in urban areas. Women are significantly more likely to consult with a chiropractor/osteopath if they have had a major personal injury in the previous year, and women who use chiropractic/osteopathy are also high users of 'conventional' health services. CONCLUSIONS: Chiropractic/osteopathy use among women in Australia is substantial and cannot be ignored by those providing or managing primary health care services for women. It is essential that the interface and communication between chiropractors/osteopaths and other health care providers be highlighted and maximized to establish and maintain effective overall patient coordination and management.

The psychological health of sole mothers in Australia.

OBJECTIVE: To determine the psychological wellbeing of sole mothers in Australia. DESIGN: Cross-sectional analyses of survey data from The Australian Longitudinal Study on Women's Health. PARTICIPANTS: 9689 younger women (aged 22-27 years) surveyed in 2000 and 12 338 mid-age women (aged 47-52 years) surveyed in 1998. MAIN OUTCOME MEASURES: Demographic characteristics and economic status; prevalence of suicidal thoughts, self-harm, and psychoactive medication use; depression (Center for Epidemiologic Studies Depression Scale) and psychological health (the Mental Health Component Score of the Medical Outcome Short Form Health Survey [SF-36]). RESULTS: Among the younger women, sole mothers were more likely than other women to have experienced suicidal thoughts (odds ratio [OR], 2.18; 95% CI, 1.45-3.27) and self-harm (OR, 3.25; 95% CI, 1.97-5.38). Among the younger and mid-age women, sole mothers were the group most likely to have used medication for depression (ORs, 2.75 [95% CI, 1.76-4.30] and 2.29 [95% CI, 1.56-3.37], respectively). They were more than twice as likely to have experienced depression, and had significantly poorer psychological health (P < 0.001). After adjusting for economic status, only depression and psychological health remained significantly associated with sole motherhood, and the strength of these relationships was reduced. CONCLUSIONS: Economic status partly accounts for the relatively poorer psychological health of sole mothers. Sole mothers are more likely than other women to experience debilitating psychological health problems.

The sense of belonging to a neighbourhood: can it be measured and is it related to health and well being in older women?

This study investigates the sense of belonging to a neighbourhood among 9445 women aged 73-78 years participating in the Australian Longitudinal Study on Women's Health. Thirteen items designed to measure sense of neighbourhood were included in the survey of the older women in 1999. Survey data provided a range of measures of demographic, social and health-related factors to assess scale construct validity. Factor analysis showed that seven of the items loaded on one factor that had good face validity and construct validity as a measure of the sense of neighbourhood. Two of the remaining items related to neighbourhood safety and comprised a factor. A better sense of neighbourhood was associated with better physical and mental health, lower stress, better social support and being physically active. Women who had lived longer at their present address had a better sense of belonging to their neighbourhood, as did women living in non-urban areas and who were better able to manage on their income. Feeling safe in the neighbourhood was least likely in urban areas, increased in rural townships, and was most likely in rural and remote areas. Older women living alone felt less safe, as did women who were less able to manage on their income. This study has identified two sets of items that form valid measures of aspects of the social environment of older women, namely the sense of neighbourhood and feelings of safety. These findings make a contribution to our understanding of the relationship between feelings of belonging to a neighbourhood and health in older women.

A longitudinal analysis of mid-age women's use of complementary and alternative medicine (CAM) in Australia, 1996-1998.

Complementary and Alternative Medicine (CAM) has become increasingly popular amongst healthcare consumers world-wide. As such, CAM is now an important public health issue with taking non-prescription medications. This paper constitutes an exploratory investigation into CAM use over time. As such, there is need for further research to provide in-depth examination of the adoption and relinquishment of CAM use over a longer time period. serious implications for healthcare organization and delivery. While previous studies have provided a profile of CAM users, there remains very limited analysis of CAM consumption over time. The purpose of this paper is to describe the changing use of CAM practitioners over time by 11,454 mid-age women in the Australian Longitudinal Study on Women's Health. Over the study period (1996-1998), 10% of women adopted the use of CAM and 9% relinquished CAM. The predominant factor found to be predictive of CAM adoption was changes in health status. Specifically, those women experiencing more illness over time are more likely to adopt CAM than those experiencing no change or better health. CAM relinquishment was associated with use of non-prescription medications, where women were more likely to relinquish CAM if they never used non-prescription medications or if they stopped.

The profile of women who consult alternative health practitioners in Australia.

OBJECTIVES: To compare the characteristics of complementary and alternative medicine (CAM) users and non-users among Australian women. DESIGN: Cross-sectional postal questionnaire conducted during 1996, forming the baseline survey of the Australian Longitudinal Study on Women's Health. PARTICIPANTS: Women aged 18-23 years (n = 14 779), 45-50 years (n = 14 099) and 70-75 years (n = 12 939), randomly selected from the Health Insurance Commission database, with over-sampling of women from rural and remote areas of Australia. MAIN OUTCOME MEASURES: Consultation with an alternative health practitioner in the 12 months before the survey. RESULTS: Women in the mid-age cohort were more likely to have consulted an alternative health practitioner in the previous year (28%) than women in the younger cohort (19%) or older cohort (15%). In all age groups, CAM users were more likely than CAM non-users to reside in non-urban areas, to report poorer health, have more symptoms and illness, and be higher users of conventional health services. CONCLUSIONS: Women in non-urban Australia are more likely to use CAM but do so in in parallel with conventional health services.

The decline in bulk-billing and increase in out-of-pocket costs for general practice consultations in rural areas of Australia, 1995-2001.

OBJECTIVE: To describe the changes in bulk-billing and out-of-pocket costs for Australian general practice consultations over the period 1995-2001. DESIGN: Retrospective analysis of 1996-2001 survey data from the Australian Longitudinal Study on Women's Health (ALSWH), linked with Medicare and Department of Veterans' Affairs (DVA) data on general practice consultations from 1995 to 2001. PARTICIPANTS: 22 633 women who gave consent to linkage of their ALSWH data with Medicare/DVA records. In 1996, women in the "young" cohort (n = 6219) were aged 18-23 years, those in the "mid-age" cohort (n = 8883) were aged 45-50 years, and those in the "older" cohort (n = 7531) were aged 70-75 years. OUTCOME MEASURES: Out-of-pocket costs paid by patients for general practice consultations, by calendar year, urban/rural area of residence, age, frequency of attendance, self-rated health, and education level. RESULTS: For each age group and year studied, the use of bulk-billing was lower in rural areas than in urban areas. For example, in 2000, the percentage of women in rural and urban areas, respectively, who had all their general practice consultations bulk-billed was 31% v 52% (young women), 24% v 45% (mid-age women) and 58% v 79% (older women). There has been a steady decline in bulk-billing for general practice consultations in rural areas since 1995. The average out-of-pocket cost per consultation for women in rural areas was higher than the cost for women living in urban areas. After adjusting for age, health and socioeconomic factors, women living in urban areas were more than twice as likely to have all their consultations bulk-billed as women living in rural areas: odds ratio (OR), 2.4 (95% CI, 2.1-2.7) (young women); OR, 2.5 (95% CI, 2.3-2.8) (mid-age women); OR, 2.6 (95% CI, 2.3-2.9) (older women). CONCLUSIONS: In Australia, the geographic differential in the cost of general practice consultations is widening. Policy changes are required to enable women in rural and remote areas to have access to affordable healthcare services.