Tyranny of distance? The health of mid-age women living in five geographical areas of Australia

Cohort study comparison of Mental Health and Wellbeing Services delivered by The Royal Flying Doctor Service, across Far North and Central West Queensland

Background

Understanding cultural differences between geographical regions is essential in delivering culturally appropriate healthcare. We aimed to describe the characteristics and outcomes of diverse clients using the Far North Mental Health and Wellbeing Service (FNS) and the Central West Health and Wellbeing Service (CWS).

Methods

We conducted a cohort study within Queensland, Australia, on all clients who received a mental health therapy session at either the FNS or the CWS. Patient data was prospective data collected form July 2019 to December 2020.

Findings

There were1202 clients, with a median number of individual contacts per-client of 3.0 (IQR 2.0-6.0). There was 428 (35.6% 95% CI 32.90-38.39) males and 772 (64.2% 95% CI 61.44-66.94) females with a median age across the genders of 38.0 (IQR 28.0-51.0). There was 505 (42.0% 95% CI 39.20-44.86) identifying as Indigenous and 697 (58.0% 95% CI 55.14-60.80) as non-Indigenous Australians. The FNS had a significantly higher proportion of Indigenous clients (n=484; 54.8% 95% CI 51.46-58.13) as compared to the CWS (n=21; 6.6% 95% CI 4.12-9.89). Of the 1202 clients, 946 (78.7% 95% CI 76.28-80.99) had a socio-economic classification of ‘most disadvantaged’, consisting of 740 (83.8%) clients from the FNS and 206 (64.6%) clients from the CWS. The majority of presentations were for neurotic, stress-related and somatoform disorders (n=568; 47.3%), followed by mood affective disorders (n=310; 25.8%). The overall number of treatments strategies employed was 10798, equalling a median of 6.0 (IQR 4.0-9.0) strategies per-client, with the leading strategies being counselling/psychosocial (n=1394; 12.9%), reflective listening (n=1191; 11.0%), and strengths based reasoning (n=1116; 10.3%). There were 511 (42.5%) clients who completed the Kessler Psychological Distress Scale (K10/K5), with 493 (41.0%) clients not offered as deemed not culturally appropriate by the treating team. The mean initial K10/K5 score was 23.7 (SD 9.4) which significantly decreased (p<0.001) to 18.0 (SD 10.0) at final consultation.

Interpretation

This study highlighted client socioeconomic differences between two geographically remote mental health services. It is essential that services are regionally co-designed to ensure cultural appropriateness.

Funding

No funding to declare.

Increasing Fruit and Vegetable Variety over Time Is Associated with Lower 15-Year Healthcare Costs: Results from the Australian Longitudinal Study on Women's Health

Healthcare costs are lower for adults who consume more vegetables; however, the association between healthcare costs and fruit and vegetable varieties is unclear. Our aim was to investigate the association between (i) baseline fruit and vegetable (F&V) varieties, and (ii) changes in F&V varieties over time with 15-year healthcare costs in an Australian Longitudinal Study on Women's Health. The data for Survey 3 (n = 8833 women, aged 50-55 years) and Survey 7 (n = 6955, aged 62-67 years) of the 1946-1951 cohort were used. The F&V variety was assessed using the Fruit and Vegetable Variety (FAVVA) index calculated from the Cancer Council of Victoria's Dietary Questionnaire for Epidemiological Studies food frequency questionnaire. The baseline FAVVA and change in FAVVA were analysed as continuous predictors of Medicare claims/costs by using multiple regression analyses. Healthy weight women made, on average, 4.3 (95% confidence interval (CI) 1.7-6.8) fewer claims for every 10-point-higher FAVVA. Healthy weight women with higher fruit varieties incurred fewer charges; however, this was reversed for women overweight/obese. Across the sample, for every 10-point increase in FAVVA over time, women made 4.3 (95% CI 1.9-6.8) fewer claims and incurred $309.1 (95% CI $129.3-488.8) less in charges over 15 years. A higher F&V variety is associated with a small reduction in healthcare claims for healthy weight women only. An increasing F&V variety over time is associated with lower healthcare costs.

Changes in Training, Lifestyle, Psychological and Demographic Factors, and Associations With Running-Related Injuries During COVID-19

The primary purpose of this study was to examine how the type and magnitude of changes in running behavior, as a consequence of COVID-19 pandemic restrictions, influence running-related injuries. Secondarily, we aimed to examine how lifestyle and psychosocial well-being measures may influence running behavior change. An online survey was advertised to individuals over the age of 18 that currently run or have previously participated in running for exercise. The survey questions examined injury history and new injuries sustained during COVID-19 restrictions, as well as changes related to training behavior changes, training environment changes, social behaviors, and psychosocial well-being. Changes reflected differences in running behaviors prior to COVID-19 restrictions (1 month prior to COVID-19 restrictions being imposed) and during COVID-19 restrictions (May 5 to June 10, 2020). A total of 1,035 runners were included in the analysis. Current injuries sustained during COVID-19 occurred in 9.5% of the runners. Injured runners made a greater number of total changes (p = 0.031) as well as training-related (p = 0.042) and environment-related (p = 0.017) changes compared with uninjured runners. A significant relationship was found between injury and those that reported less time to exercise to changes in work environment (p = 0017). This study highlights the multi-dimensional nature of running-related injuries and the need to consider the interaction of multiple changes in running behavior, rather than isolating single factors. Greater understanding of the underlying causes of running-related injuries can help reduce the risk of future injury.

Lower Vegetable Variety and Worsening Diet Quality Over Time Are Associated With Higher 15-Year Health Care Claims and Costs Among Australian Women

BACKGROUND

The relationship between diet quality and health care costs is unclear.

OBJECTIVE

The aim of this study was to investigate the relationship between baseline diet quality and change in diet quality over time, with 15-year cumulative health care claims/costs.

DESIGN

Data from a longitudinal cohort study were analyzed.

PARTICIPANTS/SETTING

Data for survey 3 (2001) (n = 7,868) and survey 7 (2013) (n = 6,349 both time points) from the 1946-1951 cohort of the Australian Longitudinal Study on Women's Health were analyzed.

MAIN OUTCOME MEASURES

Diet quality was assessed using the Australian Recommended Food Score (ARFS). Fifteen-year cumulative Medicare Benefits Schedule (Australia's universal health care coverage) data were reported by baseline ARFS quintile and category of diet quality change ("diet quality worsened" [ARFS change ≤ -4 points], "remained stable" [-3 ≤ change in ARFS ≤3 points], or "improved" [ARFS change ≥4 points]).

STATISTICAL ANALYSES

Linear regression analyses were conducted adjusting for area of residence, socioeconomic status, lifestyle factors, and private health insurance status.

RESULTS

Consuming a greater variety of vegetables at baseline but fewer fruit and dairy products was associated with lower health care costs. For every 1-point increment in the ARFS vegetable subscale, women made 3.3 (95% CI, 1.6-5.0) fewer claims and incurred AU$227 (95% CI, AU$104-350 [US$158; 95% CI, US$72-243]) less in costs. Women whose diet quality worsened over time made more claims (median, 251 claims; quintile 1, quintile 3 [Q1; Q3], 168; 368 claims) and incurred higher costs (AU$15,519; Q1; Q3, AU$9,226; AU$24,847 [US$10,793; Q1; Q3, US$6,417; US$17,281]) compared with those whose diet quality remained stable (median, 236 claims [Q1; Q3, 158; 346 claims], AU$14,515; Q1; Q3, AU$8,539; AU$23,378 [US$10,095; Q1; Q3, US$5,939; US$16,259]).

CONCLUSIONS

Greater vegetable variety was associated with fewer health care claims and costs; however, this trend was not consistent across other subscales. Worsening diet quality over 12 years was linked with higher health care claims and costs.

Aeromedical Retrieval for Stroke in Australia

INTRODUCTION

Rural, remote, and Indigenous stroke patients have worse stroke outcomes than urban Australians. This may be due to lack of timely access to expert facilities.

OBJECTIVES

We aimed to describe the characteristics of patients who underwent aeromedical retrieval for stroke, estimate transfer times, and investigate if flight paths corresponded with the locations of stroke units (SUs) throughout Australia.

METHODS

Prospective review of routinely collected Royal Flying Doctor Service (RFDS) data. Patients who underwent an RFDS aeromedical retrieval for stroke, July 2014-June 2018 (ICD-10 codes: I60-I69), were included. To define the locations of SUs throughout Australia, we accessed data from the 2017 National Stroke Audit. The main outcome measures included determining the characteristics of patients with an in-flight diagnosis of stroke, their subsequent pickup and transfer locations, and corresponding SU and imaging capacity.

RESULTS

The RFDS conducted 1,773 stroke aeromedical retrievals, consisting of 1,028 (58%) male and 1,481 (83.5%) non-Indigenous and 292 (16.5%) Indigenous patients. Indigenous patients were a decade younger, 56.0 (interquartile range [IQR] 45.0-64.0), than non-Indigenous patients, 66.0 (IQR 54.0-76.0). The most common diagnosis was "stroke not specified," reflecting retrieval locations without imaging capability. The estimated median time for aeromedical retrieval was 238 min (95% confidence interval: 231-244). Patients were more likely to be transferred to an area with SU and imaging capability (both p < 0.0001).

CONCLUSION

Stroke patients living in rural areas were younger than those living in major cities (75 years, Stroke Audit Data), with aeromedically retrieved Indigenous patients being a decade younger than non-Indigenous patients. The current transfer times are largely outside the time windows for reperfusion methods. Future research should aim to facilitate more timely diagnosis and treatment of stroke.

Improving diet quality over nine-years is associated with less weight gain in mid-age Australian women: A cohort study

BACKGROUND AND AIMS

Most studies measure baseline diet quality exclusively and hence the impact of longitudinal changes in dietary intake in relation to weight change is not considered. Therefore, this study aimed to examine whether change in diet quality over nine-years was associated with weight change over the same period in mid-age Australian women.

METHODS AND RESULTS

Healthy mid-age (45-49 years) women from the Australian Longitudinal study on Women's Health (ALSWH) were eligible a valid total energy intake (TEI) was reported at baseline (n = 2381), determined using Goldberg cut-offs. Diet quality was measured by the Australian Recommended Food Score (ARFS) using data derived from a validated food frequency questionnaire. Multiple linear regressions were used to evaluate relationships between change in diet quality and weight in mid-age women (n = 1999). Women in the highest tertile of ARFS change improved diet quality [mean ± SD] [7 ± 4 points], while those in the lowest [-9 ±5 points] and middle [-1±2 points] tertiles had worse diet quality at follow-up. Overall, mean weight gain was 2.3 ± 7.2 kg over nine years. Those in the highest tertile of ARFS change gained significantly less weight, compared to the lowest tertile; β = -1.2 kg [95% CI: -2.31, -0.11; p = 0.03] after adjustment for changes in confounders and baseline weight, baseline ARFS, and total energy intake.

CONCLUSIONS

Improving diet quality could be an important strategy for promoting modest weight loss and potentially contribute to preventing weight gain in mid-age women, which is important for metabolic health.

Change in Diet Quality over 12 Years in the 1946-1951 Cohort of the Australian Longitudinal Study on Women's Health

Understanding patterns of dietary change over time can provide important information regarding population nutrition behaviours. The aims were to investigate change in diet quality over 12 years in a nationally representative sample of women born in 1946-1951 and to identify characteristics of women whose diet quality changed over time. The Australian Recommended Food Score (ARFS) was measured in 2001 (n = 10,629, mean age 52.1 years) and 2013 (n = 9115; n = 8161 for both time points) for the mid-aged cohort from the Australian Longitudinal Study on Women's Health. Participants were categorised by tertiles of baseline diet quality and also classified as 'diet quality worsened' (ARFS decrease ≤ -4 points, n = 2361), 'remained stable' (-3 ≤ change in ARFS ≤ 3 points, n = 3077) or 'improved' (ARFS increase ≥ 4 points, n = 2723). On average, ARFS total and subscale scores remained relatively stable over time (mean [SD] change 0.3 [7.6] points) with some regression to the mean. Women whose diet quality worsened were more likely to be highly physically active at baseline compared with women whose diet quality improved (p < 0.001). Among women with poor diet quality initially (lowest baseline ARFS tertile, n = 2451, mean [SD] baseline ARFS 22.8 [4.5] points), almost half (47%, n = 1148) had not improved after 12 years, with women less likely to be in the healthy weight range (41% compared to 44%) and be never smokers (56% versus 62%, p < 0.05) compared with those whose diet improved. Diet quality remained relatively stable over 12 years' follow up among mid-aged women. Almost half of those with poor baseline diet quality remained poor over time, emphasizing the need to target high-risk groups for nutrition interventions.

Better diet quality scores are associated with a lower risk of hypertension and non-fatal CVD in middle-aged Australian women over 15 years of follow-up

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.

Vegetable Nitrate Intakes Are Associated with Reduced Self-Reported Cardiovascular-Related Complications within a Representative Sample of Middle-Aged Australian Women, Prospectively Followed up for 15 Years

Nitric oxide (NO) facilitates anti-atherosclerotic effects. Vegetables are a major source of dietary nitrate. Experimental data indicates that dietary nitrate can significantly reduce major risk factors for atherosclerosis and subsequent cardiovascular disease (CVD), as nitrate can be metabolized to produce NO via the nitrate-nitrite-NO pathway. The purpose of this study was to prospectively investigate the association between habitual dietary nitrate intakes and the incidence of self-reported CVD-related complications within a representative sample of middle-aged Australian women (1946–1951 cohort of the Australian Longitudinal Study on Women’s Health). Women free from disease at baseline who had completed the food frequency questionnaire data were included. Generalized estimating equations were used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) across quartiles for nitrate intakes. Of the 5324 women included for analysis, there were 1951 new cases of CVD-related complications over 15-years of follow-up. Women reporting higher total dietary nitrate intakes (Q4 > 78.2 mg/day) and vegetable nitrate intakes (Q4 > 64.4 mg/day) were 25% and 27% reduced risk of developing CVD-related complications respectively, compared with women reporting low total (Q1 < 45.5 mg/day) and vegetable nitrate intakes (Q1 < 34.8 mg/day). Our findings were consistent with other observational data indicating that dietary nitrate may explain some of the cardiovascular benefits of vegetable consumption.

Dietary Nitrate and Diet Quality: An Examination of Changing Dietary Intakes within a Representative Sample of Australian Women

Dietary nitrate is increasingly linked to a variety of beneficial health outcomes. Our purpose was to estimate dietary nitrate consumption and identify key dietary changes which have occurred over time within a representative sample of Australian women. Women from the 1946–1951 cohort of the Australian Longitudinal Study on Women’s Health with complete food frequency questionnaire data for both 2001 and 2013 were included for analysis. Dietary nitrate intakes were calculated using key published nitrate databases. Diet quality scores including the Australian Recommended Food Score, the Mediterranean Diet Score and the Nutrient Rich Foods Index were calculated along with food group serves as per the Australian Dietary Guidelines. Wilcoxon matched pairs tests were used to test for change in dietary intakes and Spearman’s correlations were used to examine associations. In our sample of 8161 Australian women, dietary nitrate intakes were on average 65–70 mg/day, and we detected a significant increase in dietary nitrate consumption over time (+6.57 mg/day). Vegetables were the primary source of dietary nitrate (81–83%), in particular lettuce (26%), spinach (14–20%), beetroot (10–11%), and celery (7–8%) contributed primarily to vegetable nitrate intakes. Further, increased dietary nitrate intakes were associated with improved diet quality scores (r = 0.3, p < 0.0001). Although there is emerging evidence indicating that higher habitual dietary nitrate intakes are associated with reduced morbidity and mortality, future work in this area should consider how dietary nitrate within the context of overall diet quality can facilitate health to ensure consistent public health messages are conveyed.

Exploring women's experiences of health and well-being in remote northwest Queensland, Australia

Rural and remote environments are challenging places in which to achieve health and well-being. In this woman-centered, grounded theory study, I explored the meaning of health and well-being as well as how it is achieved from the perspective of women living in remote inland parts of Australia. The study was based on semistructured interviews with 23 women living in geographically remote areas. The findings are presented as a model of the capacity to flourish. Flourishing describes an optimal achievable state of well-being, delineated by four interrelated dimensions of experience: control, connecting, belonging, and identity. I identify individual, contextual, and structural factors that enable and constrain the capacity to flourish. The findings suggest that approaches to understanding and promoting women's health in remote areas should be more holistic and contextual.

Rurality, mobility, identity: women's use of complementary and alternative medicine in rural Australia

This article explores why women in rural and remote areas of Australia use complementary and alternative medicine (CAM) at higher rates than their counterparts in urban areas. Drawing on qualitative interviews with 60 women 60-65 years of age, currently living in rural Australia, we explore the possibility that CAM use in rural areas may be embedded in processes of spatialised identity-building and the health-creating practices of mobile, ex-urban, individuals who drive this process. We problematise previous explanations which suggest CAM use in rural areas is principally derived from a lack of biomedical service provision and enhanced community ties showing instead how and why identity and mobility are useful additional variables for understanding CAM use in rural areas.

Higher diet quality does not predict lower Medicare costs but does predict number of claims in mid-aged Australian women

Optimal dietary quality, indicated by higher diet quality index scores, reflects greater adherence to National dietary recommendations and is also associated with lower morbidity and mortality from chronic disease. Whether this is reflected in lower health care cost over time has rarely been examined. The aim of this study was to examine whether higher diet quality, as measured by the Australian Recommended Food Score (ARFS), was associated with lower health care costs within the mid-aged cohort of the Australian Longitudinal Study on Women's Health. We found that there was a statistically significant association between five year cumulative costs and ARFS, but in the opposite direction to that predicted, with those in the highest quintiles of ARFS having higher health care costs. However the number of Medicare claims over the six year period (2002-2007) was lower for those in the highest compared with the lowest quintile, p = 0.002. There is a need to monitor both costs and claims over time to examine health care usage in the longer term in order to determine whether savings are eventually obtained for those with the dietary patterns that adhere more closely to National recommendations.

Does sports club participation contribute to health-related quality of life?

Given the social nature of participation in sport, we hypothesized that club sports participants would have greater well-being and quality of life than participants in other forms of physical activity (PA).

PURPOSE

The purpose of this study was to examine health-related quality of life and life satisfaction in women who participate in three contrasting forms of PA: club sport, gym activities, and walking.

METHODS

This was a cross-sectional study of the relationship between type of PA setting and measures of health-related quality of life (Short-Form Health Survey [SF-36]) and life satisfaction in 818 women living in rural Victoria, Australia, in 2007. Data were also compared with those from a normative sample of 2345 women.

RESULTS

After adjustment for potential confounders (age, education, marital status, children aged <16 yr, perceived financial stress, and level of recreational PA), four of the eight SF-36 subscales, the SF-36 mental health component summary score, and life satisfaction were significantly higher in the club sport group than that in the other groups.

CONCLUSION

Although cross-sectional research cannot establish causal links, the results suggest that participation in club sport may enhance the health benefits of PA.

A two-county comparison of the HOUSES index on predicting self-rated health

BACKGROUND

Mortality, incidence of most diseases, and prevalence of adverse health behaviours follow an inverse gradient with social class. Many proxies for socioeconomic status (SES) exist; however, each bears a different relation to health outcomes, probably following a different aetiological pathway. Additionally, data on SES can be quite difficult to gather. Five measures of SES were compared, including a novel measure, the HOUSES index, in the prediction of self-rated health (SRH) in two Midwestern settings, Olmsted County, Minnesota, and Jackson County, Missouri.

METHODS

Using a probability sampling design, a cross-sectional telephone survey was administered to a randomised sample of households. The questionnaire collected a variety of sociodemographic and personal health information. The dependent variable, SRH, was dichotomised into excellent/very good/good versus fair/poor health. Information for the HOUSES index was collected through public property records and corroborated through the telephone questionnaire. Participants were parents/guardians of children aged 1-17 residing in Olmsted County (n = 746) and Jackson County (n = 704).

RESULTS

The HOUSES index was associated with adverse SRH in Jackson County adults. All five SES measures were significant predictors in this group. Composite SES indices showed significant associations with SRH in Olmsted County adults.

CONCLUSIONS

The HOUSES index makes a unique contribution to the measurement of SES and prediction of health outcomes. Its utility is qualified by specific social contexts, and it should be used in concert with other SES indices.

Unravelling the extent of inequalities in health across urban and rural areas: evidence from a national sample in England

Studies of inequalities in health between rural and urban settings have produced mixed and sometimes conflicting results, depending on the national setting of the study, the level of geographic detail used to define rural areas and the health indicators studied. By focusing on morbidity data from a national sample of individuals, this study aims to examine the extent of inequalities in health between urban and rural areas, as well as inequalities in health across rural areas of England. Multilevel analyses for poor self-rated health, overweight and obesity, and common mental disorders are reported for a sample of 30,776 individuals aged 18 years and older (obtained from the Health Survey for England years 2000-2003 combined) and distributed across 3645 small areas classed in four categories: two groups of urban areas (Greater London area or 'other cities') and two types of rural settings (semi-rural areas or villages). Results show that rural dwellers were significantly less likely than residents of urban areas to report their health as being fair or poor and to report common mental disorders, independent of their socio-demographic characteristics. However, as for urban settlements, there were significant variations in health across semi-rural areas and across villages, indicating the presence of health inequalities within rural settings in England. These inequalities were not fully explained by the individual composition of the areas or by the available measures of area socioeconomic conditions, indicating that in rural contexts more specific factors may have significance for health. Different policies and services for health promotion and care may need to be targeted to different types of rural areas.

The physical environment and physical activity: a critical appraisal of review articles

BACKGROUND

Over the last few years an increasing number of studies investigating the association between the physical environment and physical activity have been published. Many reviews have also summarized this emerging body of research, and such review papers are frequently used by public health policymakers and researchers themselves to inform decision making.

METHODS

This paper systematically appraises methodologic aspects of literature reviews examining the relationship between physical activity and the physical environment published in peer-reviewed journals between 2000 and 2005. Eleven reviews and their antecedent source papers were examined.

RESULTS

The majority of these reviews omitted between one third and two thirds of the studies that could have been eligible for inclusion at the time they conducted the review. Methodologic information on how the review was conducted was not always provided. Furthermore, in some cases results of a study were reported incorrectly, or physical environmental aspects were conflated with social environmental or cognitive factors. Moreover, when results were reported incorrectly, physical environmental variables were almost always reported as significantly associated with physical activity, when these associations were nonsignificant, or were not assessed as part of the primary study.

CONCLUSIONS

Users of reviews in this field should be aware that there are significant methodologic variations among them, and that some reviews may include only a sample of the relevant primary studies. However, this is difficult to determine given the frequent incompleteness of review method reporting. Greater standardization in the reporting of review methods may assist with future efforts to summarize studies of the relationship between physical environments and physical activity.

Understanding the relationship between town size and physical activity levels: A population study

Little is known about the relationship between town size and physical activity levels. A representative population sample survey was used to identify activity and environmental barrier differences between residents in diverse town sizes (n=7916). Binary logistic regression analysis identified residents in large cities (>100,000 people) were 15% less likely to be sedentary for overall activity classifications in comparison to small town dwellers (<1000 people) (OR=0.85; 95%Cl=0.74-0.99). Barriers to physical activity participation differed by town size; smaller town residents reported a higher prevalence of infrastructural barriers, whereas larger city residents cited personal constraints. Community physical activity interventions should address issues associated with town size.

Clarifying the relationships between health and residential mobility

Health-selective migration within countries has been implicated as one of the mechanisms by which spatial disadvantage is created and maintained. However, there is conflicting evidence on the nature of the relationship between health and mobility, caused in part by diverse definitions, and age and sex differences. This paper uses the first two waves of data for the middle-aged cohort (aged 45-50 in 1996) of the Australian Longitudinal Study on Women's Health to investigate the relationship between four sets of health variables with subsequent local moves (within the same postcode), longer distance moves (between postcodes) and inter-regional migration from rural and remote areas 'up' the urban hierarchy. After adjusting for socio-economic and marital status, short and longer distance mobility among these middle-aged Australian women was positively associated with long-term and chronic poor health and being a smoker. Moves between postcodes and rural-to-urban migration were positively associated with multiple recent visits to a medical specialist. Our findings are consistent with UK and US studies that have found mobility to be more strongly associated with poor health than good health in mature adults. As the population ages, the health of receiving areas may be adversely affected by relatively unhealthy in-migrants seeking amenities not provided in their former place of residence.

Developing a conceptual understanding of rural health practice

OBJECTIVE

This study presents a set of concepts underpinning rural practice that could assist teaching health and medical students.

OUTCOME

Five concepts, important in distinguishing rural health practice, are presented and discussed. These are rural-urban health differentials, access, confidentiality, cultural safety and team practice. Together these concepts impact the ways in which rural health professionals provide care, due to fewer services, greater distances, smaller populations, less choice of services and smaller workforce.

CONCLUSION

These concepts introduce students to some of the positive and negative aspects of rural practice, as well as opportunities for rural practitioners to have a diverse practice, to become involved in all aspects of health and to initiate change. They provide an understanding of rurality from which health students can learn from their practical experiences during rural placements.

Is rural medicine a separate discipline?

BACKGROUND

The Australian College of Rural and Remote Medicine was established in 1997 to meet what rural doctors perceived as their unmet educational and professional needs. However, the issue of just how different rural practice is from urban practice remains a topic of debate.

METHODS

This paper explores the scope of rural medical practice, through the use of clinical scenarios and a synthesis of the research literature, to determine if rural medical practice is emerging as a distinct discipline in Australia.

CONCLUSION

Rural and remote medical practice is different, and additional, to urban practice, in the context, content and process of care. Three of the four criteria for determining rural medical practice as a distinct discipline exist in Australia. The fourth criteria: sufficient external recognition of rural medicine as a distinct discipline, awaits resolution.

WHAT THIS PAPER ADDS

This paper examines a key issue that has been a source of conflict between the relevant stakeholders for a decade. By placing the differences between rural and urban medical practice within a framework, supported by published work, this paper describes what is required to justify rural medical practice as a distinct discipline for the first time.

Correlates of adults' participation in physical activity: review and update

PURPOSE

To review and update the evidence relating to the personal, social, and environmental factors associated with physical activity (PA) in adults.

METHODS

Systematic review of the peer-reviewed literature to identify papers published between 1998 and 2000 with PA (and including exercise and exercise adherence). Qualitative reports or case studies were not included.

RESULTS

Thirty-eight new studies were located. Most confirmed the existence of factors already known to be correlates of PA. Changes in status were noted in relation to the influence of marital status, obesity, smoking, lack of time, past exercise behavior, and eight environmental variables. New studies were located which focused on previously understudied population groups such as minorities, middle and older aged adults, and the disabled.

CONCLUSION

The newly reported studies tend to take a broader "ecological" approach to understanding the correlates of PA and are more focused on environmental factors. There remains a need to better understand environmental influences and the factors that influence different types of PA. As most of the work in this field still relies on cross-sectional studies, longitudinal and intervention studies will be required if causal relationships are to be inferred.

Capital assets and intercultural borderlands: socio-cultural challenges for natural resource management

In their design or implementation, many natural resource management (NRM) programs ignore critical socio-cultural dimensions of the challenge to advance sustainability. Building on particular ideas about culture and human ecosystems, we combine the strengths of the capital assets model of sustainability and the idea of intercultural borderlands to respond to this gap. To advance our thesis about the utility of these tools, we critically reviewed and analysed a cross-disciplinary literature relating to the socio-cultural dimensions of NRM. This paper stems from that labour and examines particular tensions that arise in land management as a result of Australians' specific colonial and postcolonial legacies. These tensions--related to ethnicity, gender, population, age and health--are among the threads in the larger tapestry that comprises the socio-cultural dimensions of NRM. For the Australian case, they are central, longstanding and persistent, and thus worthy of analysis; and they are applicable in general terms to other places with similar histories of settlement and land use.

Number of social roles, health, and well-being in three generations of Australian women

The relation between multiple social roles and health is a particular issue for women, who continue to take major responsibility for childcare and domestic labor despite increasing levels of involvement in the paid workforce. This article analyzes Survey 1 data from the Australian Longitudinal Survey on Women's Health to explore relations between role occupancy and health, well-being, and health service use in three generations of Australian women. A total of 41,818 women in three age groups (young, 18-23; mid-age, 40-45; older, 70-75) responded to mailed surveys. Young and mid-age women were classified according to their occupancy of five roles--paid worker, partner, mother, student, and family caregiver--whereas older women were classified according to occupancy of partner and caregiver roles only. Common symptoms (headaches, tiredness, back pain, difficulty sleeping), diagnosis of chronic illness, and use of health services were compared across groups characterized by number of roles. Comparisons were also conducted on the physical and mental component scores of the SF-36 and perceived stress, with and without adjustment for confounders. Among young women, the best health was associated with occupancy of one role; among mid-age women, those with three or more roles were in the best health; and for older women, those with one role were in the best health. Young women with none or with four or more roles, and mid-age and older women with none of the defined social roles tended to be in the poorest health. Different patterns of results may be explained by differences in the extent to which women at different life stages feel committed to various social roles, and to the extent to which they are able to draw on social, material, and economic supports.

Faecal occult blood test: current practice in a rural Queensland community

The findings of a recent telephone survey of 604 residents (50-74 years of age) in a rural community in Queensland are presented. The survey focused on the participants' knowledge concerning the faecal occult blood test (FOBT) and their previous testing history. Responses were analysed in terms of gender, age and education differences. More than half of all participants were aware of the FOBT, and 109 (18%) had undergone FOBT in the past. Fewer understood the importance of "health checks without symptoms" than the "advantage of early treatment". The most common reasons to use FOBT were: "prevention" and "I want to know if I have cancer". A person's gender, age and education were shown to be associated with their knowledge and beliefs. These results suggest an increase in the use of the FOBT with time (in relation to previous surveys), but a poor understanding of its place in promoting health.