Women's health across the life course and across the generations - Lessons from Australia

The International Longevity Centre-UK is an independent, non-partisan think-tank
dedicated to addressing issues of longevity, ageing and population change.
Women’s health across the
life-course and across the
generations – Lessons from
Australia
International Longevity Centre-UK

Welcome
Yvonne Sonsino
Partner at Mercer, Innovation Leader Europac

Women’s health across the life-
course and across the generations
Professor Julie Byles
Director, Australian Longitudinal Study on Women’s
Health, School of Medicine and Public Health, The
University of Newcastle - Australia

Women’s health over
the life-course and
across the
generations – Lessons
from Australia
Professor Julie Byles
Global Innovation Chair in Responsive Transitions in Health and Ageing
Head, ILC - Australia

Australian Longitudinal Study
on Women’s Health
To examine social, psychological, physical and environmental factors which
determine good health, and those which cause ill-health, in women
throughout adult life
– physical and mental health, symptoms,
diagnoses
– health service use, access and satisfaction
– health related behaviours
– social factors related to health and well-being
 To contribute to development of policy and practice in
key areas for women’s health
– National Health Priority Areas
– Health Targets e.g. Continence, Quality Use of
Medicines, National Tobacco Strategy, Obesity
Taskforce, Framework for Physical Activity,
Mental Health, Abuse, Dementia, End of Life ...
Funded by the Australian
Department of Health 1996-2021
…
www.alswh.org.au

2
58 PhDs conferred
19 Masters theses
18 Honours theses
680+ peer reviewed papers
1200+ researchers worldwide
470+ active data users
100+ substudies
8 current substudies
Collaborators
Substudies
Students
Publications &
Policy 50+ reports for government
Input into major health policies
A National Research Resource
1996-2017
20+
YEARS
58000
Women
on Women’s Health
58 PhDs conferred
19 Masters theses
18 Honours theses
100+ substudies
Collaborators
Substudies
Students
Publications &
1996-2017
20+
YEARS
58000
Women
Collaborators
Publications &
1996-2017
20+
YEARS
58000
Women
2
58 PhDs conferred
19 Masters theses
18 Honours theses
100+ substudies
Collaborators
Substudies
Students
Publications &
1996-2017
20+
YEARS
58000
Women
on Women’s Health
58 Ph
19 M
18 Ho
680+
1200+
470+
100+
8 curr
Collaborators
Substudies
Students
Publications &
Policy 50+ re
Input
A
1996 – 2018 …..
58 PhDs conferred
19 Masters theses
18 Honours theses
680+ peer reviewed pap
1200+ researchers world
100+ substudies
Collaborators
Substudies
Students
Publications &
Policy 50+ reports for governm
Input into major health p
A National Research Resour
1996-201
20+
YEARS
58000
Women
Australian Longitudin
on Women’
2
58 PhDs conferred
19 Masters theses
18 Honours theses
100+ substudies
Collaborators
Substudies
Students
Publications &
1996-2017
20+
YEARS
58000
Women
on Women’s Health
Four cohorts of women
• 1921-26
• 1946-51
• 1973-78
• 1989-95
Sampled from Medicare
National health
insurance
data base
Oversampling from
rural and remote areas

1996
1973-78
18-23
1946-51
45-50
1921-26
70-75
14247 13716 12432
Three Cohorts, over 40,000 women,
Three generations of women’s health
on Women’s Health, 1996
1996

2018
1989-95
23-38
1973-78
40-45
1946-51
67-72
1921-26
92-97
Four Cohorts, over 58,000 women,
Four generations of women’s health
on Women’s Health, 2018
2018

1921-26: 3 yearly Postal Surveys … 6 monthly
70-75………85-90 ………90+
Conditions/ symptoms/ procedures, Health Care
Use, medications, Health Insurance, SF-36 quality of
life, depression/anxiety, smoking alcohol, BMI, physical
activity, diet, sleep, life events, marital status, living
arrangements, housing, abuse, manage on income,
caring, support, optimism …
.. continence, memory, falls,
teeth, services, transport,
ADLs, housing,
volunteering, age
discrimination, social
activities
Surveys and data books www.alswh.org.au

Have we missed anything?
 Free text comments
 Qualitative data – allows us to get a sense of
how women cope with their everyday, as
they age and relation to life events
 Eg. Kennaugh R, Byles J, Tavener M.
Beyond widowhood: Do prior discovered
themes that describe the experiences of
older Australian widowed women persist
over time? Women and Health, 2016; 56(7):
827-42.
 56% of the women
 1,239,859 words
 women who wrote tended to have lower
physical function, poorer general health and
lower social function than women who did
not write- except for women > 82-87, where
there were no differences.
 Wide range of experiences
 Consistent narrative

ALSWH offspring, linkages and other
extensions
Australian
Longitudinal
Study on
Women’s
Health
INTERnational
Collaboration for a Life
Course Approach to
reproductive health and
chronic disease Events:
Interlace (NHMRC)
DYNOPTA
Men, Women and
Ageing: MWA
(NHMRC)
MBS/PBS
Hospital data
Cancer Registry
ACAP/HACC/R
AC
Blood,
Body Mass/
bone density,
Blood Pressure
Mothers and
their Children’s
Health: MatCH
(NHMRC)
Internet surveys
and mobile apps
Substudies
Qualitative data
1989-95 – 1 yearly
1973-78 – 3 yearly
1946-51 – 3 yearly
1921-26 – 6 monthly
Future health
services use and
aged care needs
Pooled data
Linked
data
New cohortsPhysical data
Data
collection/
Further
Follow up
Projections

1996
1973-78
18-23
1946-51
45-50
1921-26
70-75
14247 13716 12432
Three Cohorts, over 40,000 women,
Three generations of women’s health
on Women’s Health
Baseline Survey 1996
1996

Age and health-related quality of life SF36
0
10
20
30
40
50
60
70
80
90
100
1973-78 1946-51 1921-26

2018
1989-95
23-38
1973-78
40-45
1946-51
67-72
1921-26
92-97
on Women’s Health
Change in Physical Function Scores
2018

Changes in SF36 PF scores (trends)
1973-78
1946-51
1921-26
Menstrual,
Contraception Fertility,
PCOS
Pregnancy,
BMI, diet, smoking
Mental Health
Menopause
Arthritis
Breast Cancer
Hypertension
Work/retirement
Chronic disease,
multimorbidity,
disability, Falls,
need for care,
bereavement,
social isolation
Social circumstances, health behaviours, health care use

Deaths by April 2016
1973-78
1946-51
971 7%
1921-26
9318
75%
- 20% Coronary Heart
Disease
- 11% CVD
- 6% other heart disease
- 7% Alzheimer/Dementia
- 4% COPD
- 3% Diabetes
(all cancers 23.5 %)
118 1%
- 17% Breast Cancer
- 10% Lung Cancer
- 5% Colorectal Cancer
- 5% CVD
- 5% Ovarian Cancer

Changes in Physical Function
Surveys 1-6 6MF
Vigorous
activities
Walk 1km
Climb
stairs
Carry
groceries
Walk
100m
Bath/ feed
self
9% need help with daily
tasks
34% need help with
daily tasks
17% provide care
13% provide
care
>50% drive car
~77% live in house
19% live in apartment
<35% drive car
~ 58% live in house
20% live in apartment
15% retirement village
1921-26 cohort:
Are these women
ageing well?
Successful ageing?
Healthy Ageing?
17% diabetes
70% arthritis
17% asthma
40% heart disease
70% hypertension
12% stroke
(29% dementia)

ALSWH
Survey
Participated
in the
Survey
Died
Until
Survey
Not
participated
in the survey
No need
of help
with daily
task (%)
Physical
function
score>40
(%)
No major
chronic
conditions*
(%)
Successful
ageing (%)
Survey 1
70-75
12,432 - - 9137 80.42 60.24 52.22
Survey 2 10,434 639 1,359 8958 80.24 33.40 30.54
Survey 3 8,647 1351 2,434 8696 73.72 23.32 21.14
Survey 4 7,158 2407 2,867 8754 67.66 17.27 15.28
Survey 5
5,560 3737 3,135 83.29 60.68 14.91 12.64
Survey 6
85-90
4,055 5387 2,990 77.99 52.95 11.69 9.45
*includes arthritis of any kinds, heart diseases, stroke, diabetes, asthma, and cancer (excluding
skin cancer), and the conditions are considered as enduring i.e. if Yes at one earlier survey, then
Yes for all later surveys
“Successful” Ageing S4

Successful ageing and physical function (S4 79-84)
0
10
20
30
40
50
60
70
80
90
Vigorous walk >1K Climbing
several
stairs
Moderate Bending walk 1/2K Lifting Climbing
one flight of
stairs
Walk 100m Bathing
SF36 items limited a lot
Successful Not

Successful ageing and ADL disability (S4 79-84)
0
5
10
15
20
25
30
35
40
Toilet Eating Grooming Dressing
upper body
Dressing
lower body
Bathing Walking in
house
Transfer
Difficulty on ADL
Successful Not

http://www.who.int/ageing/events/world-report-2015-launch/en/
Healthy ageing

Patterns of change in physical function
(n= 5928 surviving women) )
14%
33%
38%
15%
Leigh L, Byles JE, Mishra GD.
Change in physical function
among women as they age:
Findings from the Australian
Longitudinal Study on Women’s
Health. Quality of Life Research.
2017; 26(4): 981-991.

(n= 5928 surviving women )
14%
33%
38%
15%
Baseline factors associated
with
POOR Physical Function
(Odds Ratio)
EDUCATION
- Higher education (OR 0.38)
62% less likely to have poor PF
EXERCISE
– Highest PA class (OR 0.04)
Low PA class (OR 0.19)
(OR 0.19)
BMI
- Overweight (OR 5.02)
- Obese (OR 26.2)
SMOKING
- Current smoker (OR 2.9)
Leigh, Byles,
Mishra 2016

BMI and Healthy Life Expectancy
Leigh L, Byles JE, Jagger C. BMI and
healthy life expectancy in old and
very old women. British Journal of
Nutrition, 2016; 116(4): 692-9.
TLE
15.75
HLE
10.63
years
TLE
12.37
HLE
8.17
years
TLE
14.66
HLE
8.08
years
TLE
15.94
HLE
9.84
years

(n= 5928 surviving women )
14%
33%
38%
15%
Baseline factors associated
with
POOR Physical Function (Odds
Ratio)
DISEASE
Arthritis (OR 11.1),
Stroke (OR 4.4),
Osteoporosis (OR 4.3),
Heart Disease (OR 4.9),
Diabetes (OR 3.5),
Hypertension (OR 3.2),
Bronchitis/emphysema (OR 2.4)
Asthma (OR 2.0).
COMORBIDITY OR ~ 3.0
Leigh, Byles,
Mishra 2016

Multiple morbidity
1921-26 cohort
5% diabetes
41% arthritis
12% asthma
12% heart disease
3% stroke
48% hypertension
17% diabetes
70% arthritis
17% asthma
40% heart disease
12% stroke
70% hypertension
(29% dementia)

What do the women’s comments tell us
about ageing well?
Comments from random samples of women:
 health rated good/very good/excellent (Good) at
Survey 1-5 (GGGGG)
 health rated Good at Survey 1 but later rated
Fair/poor (Poor) (eg. GGGGP, GGGPP, GGPPP,
GPPPP).
 health rated Poor at Survey 1 -5 (PPPPP)
 Health rated Poor at survey 1 but later rated Good (eg.
PGGGG, PPGGG, PPPGG, PPPPG).

Health – not without physical problems
Injuries – brought on by their own activities
Setbacks- likely to improve.
Conditions described as minor (even if not)
Positive outcomes of health care
Longstanding health problems.
More pessimistic about getting over events and
illnesses.
Vitality – Active and fit
Some slowing down with ageing. Slowing down
“everything is gradually wearing out” (s3)
Participation _Active Passive
Dancing, gardening, volunteer work reading
Life satisfaction and Identity
Generally satisfied with life.
Belief in themselves and proud of achievements
whether maternal, domestic or professional
Content
“Pathetic”
Not bored.
Good Health Poor Health

Health Care – Active and involved Less active
Generally satisfied with health care
Trust doctors, health care systems, and therapies.
Some concern with access to health care.
Some using CAM: “I seek natural therapies”
Difficulty accessing health care.
Difficulty affording health care.
Mistrust.
Mobility and physical function – Can do Can’t do
Adapt to increasing difficulties and limitations to
physical function.
Generally still able to drive
Describe what they can’t do (rather than what they
can do or hope to do)
Talked about not being able to drive
Social
Positive relationships, supportive family, good
friends
May be caring for husband
Negative as well as positive relationships
Difficulty maintaining relationships
Carer burden / Loss of spouse.
Optimistic Less optimistic
Internal locus of control “I keep well”
“I don’t sit and wait for things to happen”
“you reap what you sew”
“hope” “grateful” ‘Lucky” “Fortunate”
“I hope I will not be around for the next survey. I
have no desire to stay alive when I can no longer
function independently” (s3)
Good Health Poor Health

Impact of Ageing on Health and Aged
Care Use
- GP Visits
- Pathology Services
- Specialists visits
- Hospital admissions
- Aged Care
2018

https://www.alswh.org.au Byles et al. Major Report to Department
of Health, 2017
Increase in number of GP visits across four
cohorts
Figure 3-1. Mean annual number of GP services by women across the life course (1989-95, 1973-
78, 1946-51, 1921-26 cohorts). 1
1989-95 cohortOriginal ALSWH cohorts
18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90
Average age
0
5
10
15
20
MeanMBSclaims
1973-78 cohort 1946-51 cohort 1921-26 cohort

115
26 cohort who were in their last 12 months of life and those who were not (Figure 6-13). However, from
the age of 81, the number of GP services by women in their last 12 months of life was much higher than
for other women of the same age who were not in their last year of life. This difference became greater
with increases in age, largely due to progressively fewer services being used by surviving women at
the oldest ages.
Figure 6-13. Mean annual number of GP services by women in the 1921-26 cohort, classified
according to whether women are in the last year of life.
YesNo12 months before death
70 75 80 85 90 95
Age
0
5
10
15
20
MeanMBSclaims
1921-26 cohort
https://www.alswh.org.au Byles et al. Major Report to Department
of Health, 2017

Hospital use
1936 surviving women NSW Hospital Data
Four-class LCA model representing hospital admission
profiles from 2001-2010 for surviving women from the 1921-
1926 cohort
(Dolja Gore, Harris, Kendig and Byles 2015)
17%
21%
38%
25%
Not in urban areas, widowed,
Arthritis, Heart disease, stroke, COPD,
Poor PF, More likely to die in next 2
years
Fall
Less hypertension, less UI

Percentage of women who were admitted to
hospital each month: heart disease, with or
without dementia (unpublished data)
HOSPITAL USE LAST 2 YRS OF LIFE
WOMEN WITH HEART DISEASE
24 months before death death

HOSPITAL USE LAST 2 YRS OF LIFE
Percentage of women who were admitted to hospital each month: stroke,
with or without dementia.
death24 months before death
WOMEN WITH STROKE

Rahman 2017
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
%OFWOMEN
YEAR
Basic HACC High-level HACC and CACP RAC Non-user Death
74-79 85-90
ALSWH Long Term Care Use 2001-11 (n=12,432)
23%
Died no
RAC
30%
RAC
Forder
et al.
2017

Percentage of women in Permanent Residential Care for
each month: heart disease, with or without dementia.
death24 months before death

Percentage of women in Permanent Residential Care for each month:
stroke, with or without dementia.
24 months before death death

2018
1989-95
23-38
1973-78
40-45
1946-51
67-72
1921-26
92-97
on Women’s Health
Prospects for future generations
2018

18 21 20 23 26 29 32 35 38 41 44 47 50 53 56 59 62 65 68 71 74 77 80 83 86 89
Average age at survey
20
25
30MeanBMI
1989-95 1973-78 cohort 1946-51 cohort 1921-26 cohort
Trends in health risks:
overtime and across successive cohorts
Ow/obese 32% 20% 45% 45% 63% 47% 43%
Smoke 19% 26.5% 13% 15% 5%
Diabetes 1% <1% 3% 3% 12.5% 5% 17%
Arthritis 20% 51% 41% 70%
Smoke less .. … heavier …… more
chronic disease

… 20 years on
More diabetes, more
heart disease, more
arthritis, more
asthma, decreased
workability, more
health care use …
need for preventive
health care is greater
than ever.
Note that there are no projections for the 1921-26 cohort as they have all reached the age of
90, which is the maximum age for our analyses.
Figure 4-3: Average BMI projections from 2015 to 2035 for each cohort (1989-95, 1973-78,
1946-51, and 1921-26). The circles represent actual data from ALSWH and the lines
represent the predicted change in mean BMI for each cohort separately for the next 20
years.
4.4. Projected obesity prevalence over the next 20 years
Other studies have shown that excess burden on the healthcare system is largely associated
with obesity rather than overweight (Korda et al., 2015). Therefore, the focus of the following
analyses is on obesity and the impact of obesity on healthcare service utilisation. To forecast
the prevalence of obesity by age for each cohort over the next twenty years, a generalised
linear mixed model was fitted to the data using a log-log link function (Figure 4-4; Appendix
10 20 30 40 50 60 70 80 90 100
Age
20
22
24
26
28
30
MeanBMI
PredictedObserved

Acknowledgements
ALSWH is funded by the Australian Government Department of
Health.
We are grateful to the women who participate in ALSWH by
providing survey data.

www.alswh.org.au

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