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Introduction: Healthcare utilization often favors the higher-socioeconomic status (SES) and having chronic diseases may exacerbate this inequality. This study aims to examine the trends in health service use over time, the effect of SES on healthcare utilization, and the role of chronic diseases in this association. Methods: Data used in this study were from the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, 2015, and 2018, which is the first nationally representative survey of the middle-aged and older. The sample included people aged 45 years and older who responded to all the waves. A total of 10,922 adults were included in this study. Healthcare utilization was categorized into outpatient and inpatient service use and SES was measured by per-capita household expenditure. A multilevel zero-inflated negative binomial regression model was performed to analyze outpatient and inpatient service use, separately. Results: The rates of outpatient service use in 2011, 2013, 2015, and 2018 were 19.11%, 21.45%, 20.12%, and 16.32%, respectively, while the rates of inpatient service use were 8.40%, 13.04%, 14.17%, and 18.79%, respectively. Compared to individuals in the lowest quintile of per-capita household expenditure, those in higher quintiles had higher odds of outpatient service use (Q2: odds ratio = 1.233, p < 0.0001; Q3: 1.416, p < 0.0001; Q4: 1.408, p < 0.0001; or Q5: 1.439, p < 0.0001) and higher rates of inpatient service use (Q2: incidence rate ratio = 1.273, p < 0.0001; Q3: 1.773, p < 0.0001; Q4: 2.071, p < 0.0001; or Q5: 1.992, p < 0.0001). Additionally, having morbidity generally increased healthcare utilization, but did not play a significant role in moderating the relationship between SES and healthcare utilization. Conclusions: Healthcare utilization rates were overall low in China, but relatively high for people in higher quintiles of per-capita household expenditure or those with morbidity, compared to their counterparts. Policy actions are required to provide more health education to the public, to further optimize health insurance schemes targeting outpatient services, especially for the low-SES, and to establish new health delivery models for NCD management in the primary health care setting. [ABSTRACT FROM AUTHOR]

Background: An increase in healthcare utilization in response to universal health coverage may leave massive economic burden on individuals and households. Identifying catastrophic health expenditure helps us understand such burden. This study aims to examine the incidence of catastrophic health expenditure at various thresholds, explore its trend over years, and investigate whether it varies across socioeconomic status (SES). Methods: Data used in this study were from four waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013, 2015, and 2018. SES was measured by annual per-capita household expenditure, which was then divided into quintiles (Quintile 1 (Q1): the poorest - Quintile 5 (Q5): the wealthiest). Catastrophic health expenditure was measured at both a fixed threshold (40%) and a set of variable thresholds, where the thresholds for other quintiles were estimated by multiplying 40% by the ratio of average food expenditure in certain quintile to that in the index quintile. Multilevel mixed-effects logistic regression models were used to analyze the determinants of catastrophic health expenditure at various thresholds. Results: A total of 6,953 households were included in our study. The incidence of catastrophic health expenditure varied across the thresholds set. At a fixed threshold, 10.90%, 9.46%, 13.23%, or 24.75% of households incurred catastrophic health expenditure in 2011, 2013, 2015, and 2018, respectively, which were generally lower than those at variable thresholds. Catastrophic health expenditure often decreased from 2011 to 2013, and an increasing trend occurred afterwards. Compared to households in Q5, those in lower quintiles were more likely to suffer catastrophic health expenditure, irrespective of the thresholds set. Similarly, having chronic diseases and healthcare utilization increased the odds of catastrophic health expenditure. Conclusions: The financial protection against catastrophic health expenditure shocks remains a challenge in China, especially for the low-SES and those with chronic diseases. Concerted efforts are needed to further expand health insurance coverage across breadth, depth, and height, optimize health financing mechanism, redesign cost-sharing arrangements and provider payment methods, and develop more efficient expenditure control strategies. [ABSTRACT FROM AUTHOR]

Objective: To compare how frequently selected chronic diseases developed in women with breast cancer receiving endocrine therapy, and in women without cancer.Design, Setting and Participants: Retrospective, rolling cohort study, analysing a random 10% sample of Pharmaceutical Benefits Scheme (PBS) data for the period 1 January 2003 - 31 December 2014. Women with breast cancer who first commenced endocrine therapy between January 2004 and December 2011 were identified, and age- and sex-matched (1:10) by comorbidity with control groups of women who did not have a dispensing record for antineoplastic agents during the study period or the comorbidity of interest at baseline.Main Outcome Measures: Development of any of eight pre-selected comorbidities, identified in PBS claims data with the RxRisk-V model.Results: Women with hormone-dependent breast cancer were significantly more likely than women in the control group to develop depression (overall hazard ratio [HR], 1.36; 95% CI, 1.26-1.46), pain or pain-inflammation (HR, 1.30; 95% CI, 1.23-1.38), osteoporosis (overall HR, 1.27; 95% CI, 1.17-1.39), diabetes (HR, 1.24; 95% CI, 1.10-1.41), cardiovascular disorders (overall HR, 1.22; 95% CI, 1.13-1.32), and gastric acid disorders (HR, 1.20; 95% CI, 1.13-1.28). The hazard ratios for developing cardiovascular disorders, depression and osteoporosis were highest during the first year of endocrine therapy. The risk of hyperlipidaemia was lower among women with breast cancer than in the control group (HR, 0.88; 95% CI, 0.81-0.96). There was no significant difference between the two groups in the risk of reactive airway diseases (HR, 1.05; 95% CI, 0.98-1.13).Conclusion: Comorbid conditions are more likely to develop in women who have been diagnosed with hormone-dependent breast cancer than in women without cancer. Our results further support the need to develop appropriate models of care to manage the multiple chronic disorders of breast cancer survivors. [ABSTRACT FROM AUTHOR]

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. Conclusion: 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. [ABSTRACT FROM AUTHOR]

Background: Individual-level health outcomes are shaped by environmental risk conditions. Norms figure prominently in socio-behavioural theories yet spatial variations in health-related norms have rarely been investigated as environmental risk conditions. This study assessed: 1) the contributions of local descriptive norms for overweight/obesity and dietary behaviour to 10-year change in glycosylated haemoglobin (HbA1c), accounting for food resource availability; and 2) whether associations between local descriptive norms and HbA1c were moderated by food resource availability.Methods: HbA1c, representing cardiometabolic risk, was measured three times over 10 years for a population-based biomedical cohort of adults in Adelaide, South Australia. Residential environmental exposures were defined using 1600 m participant-centred road-network buffers. Local descriptive norms for overweight/obesity and insufficient fruit intake (proportion of residents with BMI ≥ 25 kg/m2 [n = 1890] or fruit intake of <2 serves/day [n = 1945], respectively) were aggregated from responses to a separate geocoded population survey. Fast-food and healthful food resource availability (counts) were extracted from a retail database. Separate sets of multilevel models included different predictors, one local descriptive norm and either fast-food or healthful food resource availability, with area-level education and individual-level covariates (age, sex, employment status, education, marital status, and smoking status). Interactions between local descriptive norms and food resource availability were tested.Results: HbA1c concentration rose over time. Local descriptive norms for overweight/obesity and insufficient fruit intake predicted greater rates of increase in HbA1c. Neither fast-food nor healthful food resource availability were associated with change in HbA1c. Greater healthful food resource availability reduced the rate of increase in HbA1c concentration attributed to the overweight/obesity norm.Conclusions: Local descriptive health-related norms, not food resource availability, predicted 10-year change in HbA1c. Null findings for food resource availability may reflect a sufficiency or minimum threshold level of resources such that availability poses no barrier to obtaining healthful or unhealthful foods for this region. However, the influence of local descriptive norms varied according to food resource availability in effects on HbA1c. Local descriptive health-related norms have received little attention thus far but are important influences on individual cardiometabolic risk. Further research is needed to explore how local descriptive norms contribute to chronic disease risk and outcomes. [ABSTRACT FROM AUTHOR]

Consistent associations have been observed between macro-level urban sprawl and overweight/obesity, but whether residential proximity to urban centres predicts adiposity change over time has not been established. Further, studies of local-area walkability and overweight/obesity have generated mixed results. This study examined 4-year change in adults' waist circumference in relation to proximity to city centre, proximity to closest suburban centre, and local-area walkability. Data were from adult participants (n=2080) of a cohort study on chronic conditions and health risk factors in Adelaide, Australia. Baseline data were collected in 2000-03 with a follow-up in 2005-06. Multilevel regression models examined in 2015 the independent and joint associations of the three environmental measures with change in waist circumference, accounting for socio-demographic covariates. On average, waist circumference rose by 1.8cm over approximately 4years. Greater distance to city centre was associated with a greater increase in waist circumference. Participants living in distal areas (20km or further from city centre) had a greater increase in waist circumference (mean increase: 2.4cm) compared to those in proximal areas (9km or less, mean increase: 1.2cm). Counterintuitively, living in the vicinity of a suburban centre was associated with a greater increase in adiposity. Local-area walkability was not significantly associated with the outcome. Residential proximity to city centre appears to be protective against excessive increases in waist circumference. Controlled development and targeted interventions in the urban fringe may be needed to tackle obesity. Additional research needs to assess behaviours that mediate relationships between sprawl and obesity. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Although 49% of Australian residents have at least one overseas-born parent, little is known about children's longitudinal bodyweight transitions among the migrant population. This study examines the net associations between maternal region-of-birth and children's longitudinal bodyweight transitions between underweight, normal, and overweight/obese status from ages 2 to 17 years. A sample of 8889 children was drawn from seven waves of a national population-based cohort study, the Longitudinal Study of Australian Children, conducted between 2004 and 2016. A multistate approach was used to investigate (i) the net effect of mother's region-of-birth on children's bodyweight transitions, (ii) the net estimation of cumulative transition probabilities, and (ii) the net conditional bodyweight expectancy, controlling for child-, family-, and neighbourhood-factors associated with children's bodyweight. Our results showed children of Oceania and African mothers had unfavourable outcomes (i.e., lower remission from or higher incidence of underweight or overweight/obese status) than children of non-migrants. Toddlers with suboptimal bodyweight status (especially those from disadvantaged groups) had higher net cumulative probabilities of staying in that status as a 17-year-old adolescent unless they managed to transfer to normal weight in the primary school years. The 15-year bodyweight expectancy depended on the initial bodyweight status at age two years, with some children of migrant mothers affected longer by suboptimal bodyweight status. In Australia, region-of-birth related disparities in bodyweight started early and were of significant duration throughout development until late adolescence. Culturally tailored health programs should begin at least as early as two years of age. [ABSTRACT FROM AUTHOR]

Descriptive norms vary between places. Spatial variation in health-related descriptive norms may predict individual-level health outcomes. Such relationships have rarely been investigated. This study assessed 10-year change in glycosylated haemoglobin (HbA 1c ) in relation to local descriptive norms for overweight/obesity (n = 1890) and physical inactivity (n = 1906) in models accounting for features of the built environment. HbA 1c was measured three times over 10 years for a population-based biomedical cohort of adults in Adelaide, South Australia. Environmental exposures were expressed for cohort participants using 1600 m road-network buffers centred on participants' residential address. Local descriptive norms (prevalence of overweight/obesity [body mass index ≥25 kg/m 2 ] and of physical inactivity [<150 min/week]) were aggregated from responses to a separate geocoded population survey. Built environment measures were public open space (POS) availability (proportion of buffer area) and walkability. Separate sets of multilevel models analysed different predictors of 10-year change in HbA 1c . Each model featured one local descriptive norm and one built environment variable with area-level education and individual-level covariates (age, sex, employment status, education, marital status, and smoking status). Interactions between local descriptive norms and built environment measures were assessed. HbA 1c increased over time. POS availability and local descriptive norms for overweight/obesity and physical inactivity were each associated with greater rates of HbA 1c increase. Greater walkability was associated with a reduced rate of HbA 1c increase, and reduced the influence of the overweight/obesity norm on the rate of increase in HbA 1c . Local descriptive health-related norms and features of the built environment predict 10-year change in HbA 1c . The impact of local descriptive norms can vary according to built environment features. Little researched thus far, local descriptive norms may play an important role in the evolution of HbA 1c and thus cardiometabolic risk, over time. Further empirical research on local descriptive norms is necessary to understand how residential environments shape chronic disease risk. [ABSTRACT FROM AUTHOR]