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Additional file 1: Table 1. Mother’s bargaining power, autonomy, and restriction of movement: Rotated factor loadings (pattern matrix) and unique variances – 2005 round. Table 2. Mother’s bargaining power, autonomy, and restriction of movement: Rotated factor loadings (pattern matrix) and unique variances – 2011/12 round. Table 3. Multilevel ordered logistic regression (controlling for past history of mishaps).

Additional file 1: Delphi participant characteristics; Domains used to determine severity that participants felt overlapped so much they should be combined; the UC-FJAMQ; Within and between-individuals correlation matrices; and Factor loadings for within- and between-individuals analyses.

Additional file 1. Shows the survey questionnaire utilised for data collection from eligible woman.

Additional file 1.

Objectives: We investigated whether a Mediterranean-style diet (MedDiet) supplemented with fish oil can improve mental health in adults suffering depression. Methods: Adults with self-reported depression were randomized to receive fortnightly food hampers and MedDiet cooking workshops for 3 months and fish oil supplements for 6 months, or attend social groups fortnightly for 3 months. Assessments at baseline, 3 and 6 months included mental health, quality of life (QoL) and dietary questionnaires, and blood samples for erythrocyte fatty acid analysis. Results: n = 152 eligible adults aged 18–65 were recruited (n = 95 completed 3-month and n = 85 completed 6-month assessments). At 3 months, the MedDiet group had a higher MedDiet score (t = 3.95, P < 0.01), consumed more vegetables (t = 3.95, P < 0.01), fruit (t = 2.10, P = 0.04), nuts (t = 2.29, P = 0.02), legumes (t = 2.41, P = 0.02) wholegrains (t = 2.63, P = 0.01), and vegetable diversity (t = 3.27, P < 0.01); less unhealthy snacks (t = −2.10, P = 0.04) and red meat/chicken (t = −2.13, P = 0.04). The MedDiet group had greater reduction in depression (t = −2.24, P = 0.03) and improved mental health QoL scores (t = 2.10, P = 0.04) at 3 months. Improved diet and mental health were sustained at 6 months. Reduced depression was correlated with an increased MedDiet score (r = −0.298, P = 0.01), nuts (r = −0.264, P = 0.01), and vegetable diversity (r = −0.303, P = 0.01). Other mental health improvements had similar correlations, most notably for increased vegetable diversity and legumes. There were some correlations between increased omega-3, decreased omega-6 and improved mental health. Discussion: This is one of the first randomized controlled trials to show that healthy dietary changes are achievable and, supplemented with fish oil, can improve mental health in people with depression. Refereed/Peer-reviewed

Refereed/Peer-reviewed

Background/objectives: Major depression has a negative impact on quality of life, increasing the risk of premature death. It imposes social and economic costs on individuals, families and society. Mental illness is now the leading cause globally of disability/lost quality life and premature mortality. Finding cost-effective treatments for depression is a public health priority. We report an economic evaluation of a dietary intervention for treating major depression. Methods: This economic evaluation drew on the HELFIMED RCT, a 3-month group-based Mediterranean-style diet (MedDiet) intervention (including cooking workshops), against a social group-program for people with major depression. We conducted (i) a cost-utility analysis, utility scores measured at baseline, 3-months and 6-months using the AQoL8D, modelled to 2 years (base case); (ii) a cost-effectiveness analysis, differential cost/case of depression resolved (to normal/mild) measured by the DASS. Differential program costs were calculated from resources use costed in AUD2017. QALYs were discounted at 3.5%pa. Results: Best estimate differential cost/QALY gain per person, MedDiet relative to social group was AUD2775. Probabilistic sensitivity analysis, varying costs, utility gain, model period found 95% likelihood cost/QALY less than AUD20,000. Estimated cost per additional case of depression resolved, MedDiet group relative to social group was AUD2,225. Conclusions: A MedDiet group-program for treating major depression was highly cost-effective relative to a social group-program, measured in terms of cost/QALY gain and cost per case of major depression resolved. Supporting access by persons with major depression to group-based dietary programs should be a policy priority. A change to funding will be needed to realise the potential benefits. Refereed/Peer-reviewed

Research applying residential property value as a socioeconomic status measure is increasing. The literature includes several measures of residential property value socioeconomic status, all of which highlight location as an important component. This paper examines the drivers of the location component of residential property value that form the basis of its application as a socioeconomic status measure. The metropolitan area of Adelaide, South Australia, is used as a study area to analyse the composition and context embodied in residential property location value. The focus of this paper is to provide an understanding of the drivers of residential property value calculated as the relative location factor, deliberately constructed to reflect the effect on value due to location. The analysis reduced the traditional composition measures of social structure into a smaller number of factors using principal component analysis and regressed these against relative location factor. A spatial lens was applied to the results using Moran’s I to visualise the composition and context influence embodied in relative location factor. The results provided a significantly enhanced understanding of both the composition and context of socioeconomic status wealth that may be a more suitable socioeconomic status measure than the traditional composition measures of income, education and occupation. This paper provides an original interpretation of the contribution and use of residential property location value enabling a broader understanding of socioeconomic status, concluding that relative location factor provided a more informed measure of socioeconomic status, capable of enhancing social science and health research and policy formation. Refereed/Peer-reviewed

In 2018, the World Health Organization set a goal to increase the proportion of breast cancers identified at an early stage. Early detection allows for more effective treatment and a reduction in the risk of death from breast cancer. Poor access may restrict participation in screening, diagnostic and treatment services, with flow-on effects on stage at diagnosis and survival. This paper presents spatial analysis of travel time to breast screening services in New South Wales, Australia to measure the geographic accessibility of services to the population they serve. The travel time surface was created using a friction surface that estimates the time required to traverse each pixel within a global grid, and a least cost path algorithm to find the optimised route from each output pixel to the breast screen services. The friction surface was derived using a set of input layers, with the roads layer being the most critical for defining travel times. The generated surface of travel time to breast screen services in New South Wales has shown that over 90% of the population are within 20 min' drive time of either a fixed or mobile breast screen service and that 100% of the population are within 100 min' drive time of a breast screen service. The ability to identify and measure spatial variations in geographic accessibility via travel time is vital to plan breast screening services and reduce inequalities in health outcomes. Refereed/Peer-reviewed

Background The study investigated the self-assessed mental and general health status of informal carers in Australia. It evaluated the influence of carer’s health behaviours, namely physical activity, smoking and drinking status, along with their social connectedness and workforce engagement on their health status. Methods The study used a retrospective longitudinal design using data from the Household Income and Labour Dynamics of Australia survey, waves 5–15 (2005–2015). It included individuals aged 15 years and older from Australian households surveyed over a period of 11 years. The sample consisted of 23,251 individuals. The outcome measures included: mental health, general health and physical functioning domains of the Short Form 36 Questionnaire, a widely used multi-dimensional measure of health-related quality of life. Using fixed effects regression and following individuals over time, the analysis took care of the issue of individuals self-selecting themselves as carers due to some predisposing factors such as age, poor health, socioeconomic status and sedentary behaviour. Results There were statistically significant carer-noncarer status differences in mental (Beta = − 0.587, p = 0.003) and general health (Beta = − 0.670, p = 0.001) outcomes. Aging had a modifying impact on carers’ mental and general health outcomes. Older carers coped better with their caregiving responsibilities than younger ones. Moreover, while physical activities had a positive influence on both mental and general health for non-carers, with more activities generating better health outcomes, it only had a modifying impact on carers’ mental health. Furthermore, the study found that moderate levels of social drinking had beneficial modifying impact on carers’ mental and general health. Conclusion This study added value to the literature on informal carers’ mental and general health in Australia by identifying some of the protective and risk factors. The study found the modifying effects of carers’ age, health behaviours such as physical activity, smoking and drinking status on their health. Finally, the study identified an apparent beneficial link between moderate levels of social drinking and carer health that needs to be further explored with more targeted future research.

Background The development of comorbidities has become increasingly relevant with longer-term cancer survival. Objective To assess the pattern of comorbidities among Australian women with breast cancer treated with tamoxifen or an aromatase inhibitor. Design Retrospective cohort study using Pharmaceutical Benefits Scheme (PBS) data (10% sample) from January 2003 to December 2014. Dispensing claims data were used to identify comorbidities and classified with the Rx-Risk-V model. The breast cancer cohort had tamoxifen or an aromatase inhibitor dispensed between 2004 and 2011 with no switching between types of endocrine therapy. Comparisons were made between the breast cancer cohort and specific control groups (age- and sex-matched at 1:10 ratio without any dispensing of anti-neoplastic agents during the study period) for the development of five individual comorbidities over time using Cox regression models. Results Women treated with tamoxifen had a higher incidence of cardiovascular conditions, diabetes, and pain or pain-inflammation, but a lower incidence of hyperlipidaemia compared with non-cancer control groups, as indicated by PBS data. Women treated with aromatase inhibitors were more likely to develop cardiovascular conditions, osteoporosis, and pain or pain-inflammation compared with non-cancer control groups. The risks of hyperlipidaemia and osteoporosis were significantly lower among tamoxifen users compared with aromatase inhibitor users. Conclusions Women with hormone-dependent breast cancer treated with an endocrine therapy had a higher risk of developing specified comorbid conditions than women without cancer, with different comorbidity profiles for those on tamoxifen versus aromatase inhibitors. Further research into the causes and mechanism of development and management of comorbidities after cancer is needed.

© 2016 Public Health Association of Australia Objective: When using area-level disadvantage measures, size of geographic unit can have major effects on recorded socioeconomic cancer disparities. This study examined the extent of changes in recorded socioeconomic inequalities in cancer survival and distant stage when the measure of socioeconomic disadvantage was based on smaller Census Collection Districts (CDs) instead of Statistical Local Areas (SLAs). Methods: Population-based New South Wales Cancer Registry data were used to identify cases diagnosed with primary invasive cancer in 2000–2008 (n=264,236). Logistic regression and competing risk regression modelling were performed to examine socioeconomic differences in odds of distant stage and hazard of cancer death for all sites combined and separately for breast, prostate, colorectal and lung cancers. Results: For all sites collectively, associations between socioeconomic disadvantage and cancer survival and distant stage were stronger when the CD-based socioeconomic disadvantage measure was used compared with the SLA-based measure. The CD-based measure showed a more consistent socioeconomic gradient with a linear upward trend of risk of cancer death/distant stage with increasing socioeconomic disadvantage. Site-specific analyses provided similar findings for the risk of death but less consistent results for the likelihood of distant stage. Conclusions: The use of socioeconomic disadvantage measure based on the smallest available spatial unit should be encouraged in the future. Implications for public health: Disadvantage measures based on small spatial units can more accurately identify socioeconomic cancer disparities to inform priority settings in service planning.

Rationale and objectives: In epidemiological research, it is essential to account for the confounding effects of factors such as age, stage, and comorbidity for accurate prediction of cancer outcomes. There are several internationally developed and commonly used comorbidity indices. However, none are regarded as the gold-standard method. This study will assess and compare the predictive validity of established indices for use in a South Australian (SA) colorectal cancer (CRC) population against a local index. Furthermore, the prognostic influence of comorbidity on survival is investigated. Methods: A population-based study of patients diagnosed with CRC from 2003 to 2012 and linked to in-hospital data to retrieve comorbidity information was conducted. The predictive performance of established indices, Charlson comorbidity index (CCI), National Cancer Institute comorbidity index (NCI), Elixhauser comorbidity index (ECI), and C3 index was evaluated using the Fine and Gray competing risk regression and reported using measures of calibration and discrimination, area under the curve (AUC), and Brier score. Furthermore, to identify the optimal index, a local CRC comorbidity index (CRCCI) was also developed and its performance compared with the established indices. Results: Comorbidity models adjusted for age, sex, and stage showed that all indices were good predictors of mortality as measured by the AUC (CCI: 0.738, NCI: 0.742, ECI: 0.733, C3: 0.739). CRCCI had similar mortality prediction as established indices (CRCCI: 0.747). There was a significant increase in cumulative risk of noncancer and CRC-specific mortality with increase in comorbidity scores. The two most prevalent comorbidities were hypertension and diabetes. Conclusions: The existing indices are still valid for adjusting for comorbidity and accurately predicting mortality in an SA CRC population. Internationally developed indices are preferred when policymakers and researchers wish to compare local study results with those of studies (national and international) that have used these indices. Comorbidity is a predictor of mortality and should be considered when assessing CRC survival Refereed/Peer-reviewed

Background: Descriptive norms (what other people do) relate to individual-level dietary behaviour and health outcome including overweight and obesity. Descriptive norms vary across residential areas but the impact of spatial variation in norms on individual-level diet and health is poorly understood. This study assessed spatial associations between local descriptive norms for overweight/obesity and insufficient fruit intake (spatially-specific local prevalence), and individual-level dietary intakes (fruit, vegetable and sugary drinks) and 10-year change in body mass index (BMI) and glycosylated haemoglobin (HbA1c). Methods: HbA1c and BMI were clinically measured three times over 10 years for a population-based adult cohort (n = 4056) in Adelaide, South Australia. Local descriptive norms for both overweight/obesity and insufficient fruit intake specific to each cohort participant were calculated as the prevalence of these factors, constructed from geocoded population surveillance data aggregated for 1600 m road-network buffers centred on cohort participants' residential addresses. Latent growth models estimated the effect of local descriptive norms on dietary behaviours and change in HbA1c and BMI, accounting for spatial clustering and covariates (individual-level age, sex, smoking status, employment and education, and area-level median household income). Results: Local descriptive overweight/obesity norms were associated with individual-level fruit intake (inversely) and sugary drink consumption (positively), and worsening HbA1c and BMI. Spatially-specific local norms for insufficient fruit intake were associated with individual-level fruit intake (inversely) and sugary drink consumption (positively) and worsening HbA1c but not change in BMI. Individual-level fruit and vegetable intakes were not associated with change in HbA1c or BMI. Sugary drink consumption was also not associated with change in HbA1c but rather with increasing BMI. Conclusion: Adverse local descriptive norms for overweight/obesity and insufficient fruit intake are associated with unhealthful dietary intakes and worsening HbA1c and BMI. As such, spatial variation in lifestyle-related norms is an important consideration relevant to the design of population health interventions. Adverse local norms influence health behaviours and outcomes and stand to inhibit the effectiveness of traditional intervention efforts not spatially tailored to local population characteristics. Spatially targeted social de-normalisation strategies for regions with high levels of unhealthful norms may hold promise in concert with individual, environmental and policy intervention approaches. Refereed/Peer-reviewed

The relationship between the wellbeing of society and understanding of land market structure and behaviour is an important research theme for understanding socioeconomic status (SES). Traditional SES area based measures of income, occupation and education are generally applied in the examination of a broad spectrum of societal issues. This paper examines the contribution of understanding the spatial variation of SES based upon residential property sales data unrestricted by the traditional artificial geographic boundaries in which SES is assumed uniform. Originality lies in identifying the locational component of residential property wealth as a proxy for SES. It includes market behavioural characteristics that reflect both the context and composition at particular locations. This provides a broader understanding of SES than income, occupation and education. The analysis uses a hedonic regression model based on transactions of detached housing. The model is specified using only available property attributes as independent variables and is therefore blind to location. The residuals from this hedonic model are used to calculate the relative location factor (RLF) for each transaction property. These were interpolated as a continuous surface capable of predicting values at the individual property level or aggregated to a spatial unit relevant to the particular application. There was a significant correlation with the traditional SES indicators and health outcomes that have traditionally been shown to have a correlation with SES. Refereed/Peer-reviewed

Associations between local-area residential features and glycosylated hemoglobin (HbA 1c ) may be mediated by individual-level health behaviors. Such indirect effects have rarely been tested. This study assessed whether individual-level self-reported physical activity mediated the influence of local-area descriptive norms and objectively expressed walkability on 10-year change in HbA 1c . HbA 1c was assessed three times for adults in a 10-year population-based biomedical cohort (n = 4056). Local-area norms specific to each participant were calculated, aggregating responses from a separate statewide surveillance survey for 1600 m road-network buffers centered on participant addresses (local prevalence of overweight/obesity (body mass index ≥25 kg/m 2 ) and physical inactivity ( < 150 min/week)). Separate latent growth models estimated direct and indirect (through physical activity) effects of local-area exposures on change in HbA 1c , accounting for spatial clustering and covariates (individual-level age, sex, smoking status, marital status, employment and education, and area-level median household income). HbA 1c worsened over time. Local-area norms directly and indirectly predicted worsening HbA 1c trajectories. Walkability was directly and indirectly protective of worsening HbA 1c . Local-area descriptive norms and walkability influence cardiometabolic risk trajectory through individual-level physical activity. Efforts to reduce population cardiometabolic risk should consider the extent of local-area unhealthful behavioral norms and walkability in tailoring strategies to improve physical activity. Refereed/Peer-reviewed