Volume 167 Issue 5

Early discharge and risk for postnatal depression Anthea R Hickey, Philip M Boyce, David Ellwood and Allen D Morris-Yates For editorial comment, see Buist Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - References - Authors' details - - ©MJA1997 Abstract Objective: To determine whether early discharge ( < 72 hours) after childbirth increased the risk for women developing postnatal depression. Design: Prospective cohort design consisting of an initial interview, and six-weekly assessments for 24 weeks using a self-report questionnaire and the Edinburgh Postnatal Depression Scale (EPDS). Women discharged within 72 hours were compared with the remaining women. Setting: Tertiary referral hospital in western Sydney, New South Wales, 1993. Participants: All 749 women delivering over a three-month period were recruited. Of the 522 participants, 425 women completed the study. Main outcome measures: Women scoring > 13 on the EPDS on two or more occasions were considered potential "cases" of postnatal depression. The diagnosis was confirmed using the Structured Clinical Interview for DSM-III-R disorders (SCID). Results: Of the 153 women (36%) discharged early, 22 women (14.4%) developed postnatal depression over the study period compared with 20 of the 272 women (7.4%) who had standard length of stay. Women who were discharged within 72 hours had a significantly increased risk for developing postnatal depression (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.07-4.21). This risk persisted when other sociodemographic, obstetric and psychosocial risk factors were controlled for in a logistic regression analysis (OR, 3.06; 95% CI, 1.22-7.69). Conclusion: Women planning early discharge after childbirth should be carefully assessed before discharge and follow-up should be rigorous. The potential to develop postnatal depression should be considered in all women choosing early discharge from hospital. MJA 1997; 167: 244-247 Introduction Over the past 20 years, technological advances have contributed to improved maternal and infant outcomes. In parallel, women have become more involved in their obstetric care: wanting to be more informed, be able to make choices and have childbirth demedicalised and "normalised". One initiative aimed at normalising the process has been early discharge programs, enabling women to return home earlier after childbirth than had been traditional. Women's desire for early discharge has fitted in well with the financial constraints put upon health care systems; reduced length of stay is seen as desirable because it reduces the cost of obstetric care. Postpartum studies have reported early-discharge programs to be a safe, cost-effective and satisfying alternative to the standard length of hospital stay among low-risk mothers and their infants.1-5 While these studies have shown that early discharge has no adverse physical effects, the only psychological effects examined have been women's satisfaction about making a choice or taking control of discharge rather than psychological morbidity.5,6 As postnatal depression is a common disorder which may have a long-term impact on the mother and her infant,7 the psychological outcome after childbirth is increasingly being recognised as important.8 Postnatal depression is associated with psychosocial factors, such as an excess of adverse life events, lack of social support, dysfunctional personality style and a past history of depression.8,9 Obstetric factors, such as emergency caesarean section, have also been implicated,10,11 but the impact of early discharge has not been extensively examined. The aim of our study was to investigate whether early discharge following childbirth had an effect on the development of postnatal depression in a heterogeneous sample of women. Methods Subjects All women who delivered at the Nepean Hospital, NSW, over a three-and-a-half-month period in 1993 were invited to participate in the study. Women were excluded from the study if their baby was stillborn, born with congenital abnormalities, adopted out, transferred to another hospital, or if the mother was diagnosed as suffering from puerperal psychosis. Early discharge was defined as discharge within 72 hours (the definition used at Nepean Hospital). Survey instruments Questionnaire: A self-report questionnaire was used to assess social and demographic circumstances. Socioeconomic status was determined according to a status-ranking list of occupations in Australia,12 using the women's partner's occupation (or her parents' occupation when this was not appropriate). A nine-item personality scale was included that identified different personality traits, scored on a 5-point Likert scale. Factor analysis of this personality scale identified "vulnerable" and "resilient" personality dimensions. The vulnerable personality dimension included being a worrier, nervy, timid and unassertive, sensitive, liable to emotional outbursts and needing to do things right. This scale is reliable (Cronbach α= 0.75), and is associated with increased risk for postnatal depression (Boyce P M, Hickey A R, Greenstock J A and Talley N J, Nepean Hospital, unpublished data). Interview: A semi-structured interview (conducted by A R H) was used to assess obstetric history, satisfaction with the labour, whether the delivery was congruent with expectations, the quality of the woman's social support, her personal and family psychiatric history, and the quality of her intimate relationships. We also obtained obstetric details from the labour ward computerised database. Edinburgh Postnatal Depression Scale (EPDS):13 The EPDS is a specifically designed measure of postnatal depression that has shown reliability and validity for the postpartum period.14-16 It consists of a 10-item self-report scale, with each item scored 0-3. A score of 13 or above is indicative of postnatal depression. It is not contaminated by symptoms (e.g., fatigue, weight loss, broken sleep) which may be reported by healthy nursing mothers. Tennant and Andrews life events scale:17,18 A self-report scale comprising 10 relevant life events (e.g., death of a family member or close friend, moving house, marriage); subjects were asked whether each event had happened to her over the past 12 months. A modified version of this scale was used in our study. Structured Clinical Interview for DSM-III-R (SCID):19 The SCID was administered to confirm postnatal depression "caseness". Postnatal depression was defined as meeting the criteria for major depression according to the Diagnostic and statistical manual of mental disorders, third edition, revised (DSM-III-R).20 Procedure The women were recruited immediately after delivery and asked if they would participate in a longitudinal study of postnatal depression. Women who agreed were given an initial semi-structured interview on the second or third day post partum, a self-report questionnaire and a baseline EPDS. The women were assessed a further four times -- at six, 12, 18 and 24 weeks post partum. At each interval, the women were posted the EPDS, a self-report questionnaire (consisting of questions on the baby's condition and feeding patterns as well as the quality of the women's relationship) and a stamped self-addressed envelope for returning the forms. Women who scored > 13 on the EPDS on two occasions (excluding their baseline EPDS score) were further interviewed using the SCID to determine postnatal depression "caseness". An equal number of women who scored < 13 on the EPDS were randomly selected and interviewed using the SCID. Statistical analysis Statistical analysis was performed using the SPSS computer program.21 Women were categorised as "cases" or "non-cases" of postnatal depression and into early and standard length of stay. Categorical data were analysed using odds ratios (OR), and chi-squared and t tests were used for comparing groups on dimensional data. A logistic regression analysis was used to determine whether length of stay remained a risk factor when controlling for other risk factors. Results Sample Of the 749 women who delivered during the three-and-a-half month period, 522 women (69.7%) agreed to participate in the study. Full data were available for 425 women (81.4%). The mean age of the sample was 26.9 years (standard deviation [SD], 5.0; range, 15-43), 367 women (86.4%) were married or in a de facto relationship, 58 women (13.6%) were single or separated, and 184 women (43.3%) were primiparous. The average period of formal education was 11.4 years (SD, 1.9; range, 9-15). Twenty-six women did not meet the inclusion criteria, 122 refused to participate in the study and 79 were unable to be contacted. There were no statistically significant differences in demographic and obstetric details between women who consented to participate and women who did not consent. The 97 women who withdrew from the study or had insufficient data were more likely to be younger (t = 5.91; P < 0.01), unemployed (chi-squared = 33.37; P < 0.01), single or separated (chi-squared = 59.46; P < 0.01) and have fewer years of formal education (t = 3.47; P < 0.01) compared with women who had full data. Forty-two women (9.9%) were categorised as having major depression, based upon scoring > 13 on the EPDS on two occasions and meeting DSM-III-R criteria for major depression. All of these women met "caseness" criteria for major depression on the SCID. None of the sample of women who screened negative (< 13) on the EPDS and were interviewed using the SCID met "caseness" criteria for major depression. Length of stay The average length of stay in hospital following delivery was 90.9 hours (SD, 43.1 hours; range, 16-307). Of the 425 participants in the study, 153 women (36%) were discharged within 72 hours (early-discharge group) and 272 women (64%) were discharged after 72 hours (standard-length-of-stay group). We compared sociodemographic and risk factors for the early-discharge and standard-length-of-stay groups of women. The early-discharge group were more likely to be multiparous (71.2% v. 48.5%; OR, 2.63; 95% confidence interval [CI], 1.69-4.10), have fewer years of formal education (11.01 years v. 11.5 years; t = 3.09; P < 0.01), to bottle feed in the first week post partum (20.9% v. 12.1%; OR, 1.91; 95% CI, 1.06-3.46), and report a poor relationship with parents (52.9% v. 40.1%; OR, 1.68; 95% CI, 1.11-2.56). They were also more likely to have a history of depression or postnatal depression, but this was not statistically significant (9.1% v. 4.4%; OR, 2.18; 95% CI, 0.92-5.19). The two groups did not differ with respect to age, marital or socioeconomic status, number of life events in the past year, or global satisfaction with their partner. Women in the early discharge group did not have a more vulnerable personality style and did not differ in baseline EPDS scores (5.1 v. 5.9; t = 0.24). Postnatal assessment The proportion of women who developed postnatal depression (as defined above) was higher among those discharged early than those discharged after three days. Three of the 13 women (23.1%) discharged within 24 hours, nine of the 58 women (15.5%) discharged between 24 and 48 hours, and 10 of the 82 women (12.2%) discharged between 48 to 72 hours developed postnatal depression. Of the 153 women discharged early (within 72 hours), 22 (14.4%) developed postnatal depression compared with 20 of the 272 women (7.4%) who had standard length of stay (OR, 2.12; 95% CI, 1.07-4.21). Of the 42 women who developed postnatal depression, 22 (52.4%) were discharged early. The possibility that the increased risk associated with early discharge could have arisen as a result of other, antecedent, risk factors for postnatal depression was examined using a hierarchical logistic regression,22 with postnatal depression as the dependent variable. Sociodemographic, historical, obstetric, and psychosocial factors (see below) were entered in the first step, baseline EPDS score in the second step and early discharge in the final step to see whether it would remain a risk factor after controlling for other risk factors. Sociodemographic factors: Age (5-yearly intervals), level of education (less or more than 10 years), social class (low or high socioeconomic status) and marital status (single, married or de facto relationship). Obstetric factors: Parity (multiparous or primiparous) and delivery type (spontaneous vaginal delivery, instrumental delivery or caesarean section). Psychosocial risk factors: Personality style (high or low vulnerability [extracted from the personality scale, with women scoring one standard deviation above the mean on the vulnerability component of the scale considered to be vulnerable]); quality of relationship with parents and in-laws (poor or good); satisfaction with relationship with partner (dissatisfied or satisfied); history of depression or postnatal depression; experience of none, one or two, or three or more life events over the previous 12 months; and whether they had had the desired-sex baby. When all sociodemographic, obstetric and psychosocial factors were entered, the model was highly significant (Box), with significantly increased risk for postnatal depression associated with dissatisfaction with partner relationship(s), reporting three or more life events in the past 12 months, and having a vulnerable personality. The model significantly improved (had better predictive power; chi-squared = 41.5; P < 0.0001) when baseline EPDS score was entered, and again when early discharge was entered. Early discharge increased the risk threefold (OR, 3.06; 95% CI, 1.22-7.69), after controlling for other risk factors. These results also support the more specific finding of early discharge, in which there was a 2.1-fold increased risk (95% CI, 1.07-4.21) of developing postnatal depression. Discussion Early discharge following childbirth is becoming more routine. It has been shown that neither maternal nor infant health is compromised by this practice; however, there is a paucity of research evaluating the psychological functioning of the mother following early discharge. We are aware of only one prospective study of the psychological morbidity associated with early discharge compared with customary length of stay in hospital. Beck et al.23 assessed depressive symptoms among 49 women at six and 12 weeks post partum using the Beck Depression Inventory (BDI).24 They found no significant difference between the early- versus standard-discharge groups on BDI scores. However, this study was confined to privately insured, primiparous women who had had uncomplicated pregnancy and labour. Therefore, their results have limited generalisability because most studies have identified that women opting for early discharge are more likely to be multiparous, older, have fewer years of formal education and lower socioeconomic status.25,26 While there have been no prospective studies on the psychological impact of early discharge in heterogeneous samples, one retrospective study found that women who reported that their postnatal hospital stay was too short were significantly more likely to have postnatal depression than those who reported the right length of stay.27 Our study shows that women discharged within three days of childbirth had an increased risk of developing postnatal depression. This increased risk is not the result of other well recognised risk factors for postnatal depression, such as experiencing life stresses, having a dysfunctional personality style, unsatisfactory interpersonal relationships28 or a history of depression. When these risk factors were controlled in a logistic regression analysis, early discharge was still a significant risk for postnatal depression, with an odds ratio of 3.06. Therefore, early discharge exerted an independent effect on the development of postnatal depression and was not simply a proxy for other, pre-existing, risk factors. We also found that one-third of the women who stayed in hospital for more than five days also experienced postnatal depression. However, they had all experienced complicated labours and some infants had been in neonatal intensive care for a prolonged period, which may have contributed to the higher rates of postnatal depression. Women discharged within three days of giving birth may be at an increased risk of postnatal depression because they have had insufficient time to recover from and work through the experience of childbirth. They may still be tired from the physical demands of childbirth and have to return to the stresses of everyday life, which includes looking after a household, their new baby and, in many cases, other children. This additional stress so soon after childbirth may increase the risk of depression. The "blues" are minor, transient depressive symptoms which generally arise on the third to fifth day post partum. Therefore, women on an early-discharge program leave hospital before the onset of the "blues". If they return to an environment where there is insufficient support, experiencing the "blues" may lead to depressive symptoms being perpetuated and contribute to the development of postnatal depression. Finally, women discharged early go home without having properly established breastfeeding, and therefore without the supervision and round-the-clock support of midwives to help them with the inevitable difficulties (e.g., breast engorgement, change in milk flow, unable to latch the baby correctly, leading to cracked, sore nipples) that arise after the milk "comes in" (generally on the third day). These difficulties can lead to an irritable baby and a tired, depressed mother. The association we found between early discharge and postnatal depression merely suggests causality. A prospective controlled study with women randomly assigned to early- or standard-discharge programs (controlling for parity, social support and past history) is needed to identify any causal link between early discharge and postnatal depression. The association between early discharge and postnatal depression has major public health implications. While health services are having to cut costs, early discharge may result in short-term cost savings. However, the consequences of postnatal depression could lead to escalating health care costs in the long term. Women entering an early-discharge program need a careful assessment, particularly those at risk for postnatal depression (e.g., poor family support or a history of depression). The possibility of postnatal depression should be kept in mind for all women who have been discharged early when they return for their postnatal check-ups. The EPDS could be used as a routine screen for such women. Finally, women with a history of postnatal depression should have counselling if they are considering early discharge and be advised that a longer hospital stay may reduce their risk of recurrent depression. References Yanover MJ, Jones D, Miller MD. Perinatal care of low-risk mothers and infants: Early discharge with home care. N Engl J Med 1976; 294: 702-705. Avery MD, Fournier LC, Jones PL, Sipovic CP. An early postpartum hospital discharge program: implementation and evaluation. J Obstet Gynecol Neonatal Nurs 1982; 11: 233-235. Burnell I, McCarthy M, Chamberlain GVP, et al. Patient preference and postnatal hospital stay. J Obstet Gynaecol 1982; 3: 43-47. Lemmer CM. Early discharge: outcomes of primiparas and their infants. J Obstet Gynecol Neonatal Nurs 1987; 16: 230-236. Hall WA, Carty EM. Managing the early discharge experience: taking control. J Adv Nurs 1993; 18: 574-582. Kenny P, King MT, Cameron S, Shiell A. Satisfaction with postnatal care -- the choice of home or hospital. Midwifery 1993; 9: 146-153. Murray L, Cooper PJ, Stein A. Postnatal depression and infant development. BMJ 1991; 302: 978-979. Boyce PM, Stubbs JM. The importance of postnatal depression [editorial]. Med J Aust 1994; 161: 471-472. O'Hara MW, Swain AM. Rates and risks of postpartum depression -- a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54. Boyce PM, Todd AL. Increased risk of postnatal depression after emergency caesarean section. Med J Aust 1992; 157: 172-174. Murray L, Cartwright W. The role of obstetric factors in postpartum depression. J Reprod Infant Psychol 1993; 11: 215-219. Congalton AA, Cheshire FW. Status and prestige in Australia. Melbourne: Chesire Publishing Pty Ltd, 1969. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: 782-786. Harris B, Huckle P, Thomas R, et al. The use of rating scales to identify post-natal depression. Br J Psychiatry 1989; 154: 813-817. Murray L, Carothers AD. The validation of the Edinburgh Postnatal Depression Scale on a community sample. Br J Psychiatry 1990; 157: 288-290. Boyce PM, Stubbs JM, Todd AL. The Edinburgh Postnatal Depression Scale: validation for an Australian sample. Aust N Z J Psychiatry 1993; 27: 472-476. Tennant C, Andrews G. A scale to measure the cause of life events. Aust N Z J Psychiatry 1977; 11: 163-167. Brugha T, Bebbington P, Tennant C, Hurry J. The list of threatening experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psychol Med 1985; 15: 189-194. Spitzer RL, Williams JBW, Gibbon M, First MB. Structured Clinical Interview for DSM-III-R: SCID user's guide for the structured clinical interview for DSM-III-R. Washington: American Psychiatric Press Inc, 1990. American Psychiatric Association. Diagnostic and statisitical manual of mental disorders, third edition revised (DSM-III-R). Washington DC: American Psychiatric Association, 1987. SPSS: Statistical package for the social sciences [computer program], release 6.1. Chicago, Ill: SPSS Inc, 1994. Fleiss JL, Williams JBW, Dubro AF. The logistic regression analysis of psychiatric data. J Psychiatr Res 1986; 20: 195-209. Beck CT, Reynolds MA, Rutowski P. Maternity blues and postpartum depression. J Obstet Gynecol Neonatal Nurs 1992; 21: 287-293. Beck AT, Ward CH, Mendelson M, et al. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561-571. Scott A. A cost analysis of early discharge and domiciliary visits versus standard hospital care for low-risk obstetric clients. Aust J Public Health 1994; 18: 96-100. Mitchell SD, Counsell AM, Geddis DC. Planned early discharge from New Zealand maternity hospitals. N Z Med J 1993; 106: 152-154. Astbury J, Brown S, Lumley J, Small R. Birth events, birth experiences and social differences in postnatal depression. Aust J Public Health 1994; 18: 176-184. O'Hara MW, Zekoski EM. Postpartum depression: a comprehensive review. In: Kumar R, Brockington IF, editors. Motherhood and mental illness 2: causes and consequences. London: Wright, 1988: 17-63. (Received 17 Feb, accepted 5 June 1997) Authors' details Department of Psychological Medicine, Nepean Hospital, Penrith, NSW. Anthea R Hickey, Psychologist, BPsych, MMedSc; Philip M Boyce, MD, FRANZCP, Professor of Psychiatry; Allen D Morris-Yates, BA(Hons), Senior Research Officer. Department of Obstetrics and Gynaecology, Canberra Hospital, ACT. David Ellwood, FRACOG, DPhil(Oxon), Professor of Obstetrics and Gynaecology. Reprints: Prof P M Boyce, Department of Psychological Medicine, Nepean Hospital, PO Box 63, Penrith, NSW 2751. E-mail: pboyceATmail.usyd.edu.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Anthea R Hickey · Philip M Boyce · David Ellwood · Allen D Morris-Yates

Men's estimates of prostate cancer risk and self-reported rates of screening Jeanette E Ward, Ann-Maree Hughes, Geoffrey H L Hirst and Lorraine Winchester For editorial comment, see Stricker & Eisinger Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - ©MJA1997 Abstract Objective: To determine rates of prostate cancer screening and predictors of men's participation in this screening in the light of national recommendations against prostate cancer screening. Design: Community-based study (computer-assisted telephone survey). Setting: Central Sydney Area Health Service. Participants: Randomly selected men aged 40-80 years. Results: 340 men participated (65% response rate). While the true lifetime (0-74 years) risk of developing or dying from prostate cancer is reported to be one in 18 (6%) and one in 65 (1.5%), respectively, 37% of respondents thought that at least one in five men (20%) would develop prostate cancer before the age of 75 years and 11% that one in five (20%) would die from it. Twenty-two per cent of men aged 50 years or over had been screened for prostate cancer within the previous 12 months. Ever worrying about prostate cancer and bothersome urinary symptoms independently predicted the probability of screening within the previous year. Sociodemographic characteristics such as age, occupation and country of birth were not associated with screening. Conclusions: Public health initiatives to discourage prostate cancer screening should focus particularly on men with bothersome urinary symptoms and those who worry about prostate cancer. Accurate information about the low risks of dying from prostate cancer needs to be communicated, and the speculative nature of current evidence in support of screening as a means of reducing this risk should be emphasised. MJA 1997; 167: 250-253 Introduction Despite repeated advice to the contrary, screening for prostate cancer is being requested by patients and conducted by doctors. Advice against screening has come from a policy statement for health professionals released in 1995 by the Australian Cancer Society,1 and a 1996 report of a multidisciplinary committee convened by the Australian Health Technology Advisory Committee on the basis that the evidence did not meet accepted criteria for benefits, risks and costs.2 In addition, the National Health and Medical Research Council (NHMRC) evidence-based guidelines for the management of men with uncomplicated lower urinary tract symptoms (LUTS)3 state that there is no evidence that prostate specific antigen (PSA) tests are required for men with uncomplicated LUTS as men with these symptoms are at no greater risk of prostate cancer than asymptomatic men.4 Data indicating that screening is occurring come from the Department of Veterans' Affairs,5 as well as surveys of urologists6 and general practitioners (unpublished data). In describing this "conundrum", Horner identified a pressing need for research to support educational programs for men, focusing on "strategies to combat uninformed patient demand".7 While the Australian Health Technology Advisory Committee guidelines advocate national action involving the NHMRC,2 the need for health services to intervene actively at a local level to discourage prostate cancer screening has also been recognised in New South Wales.8 In the absence of more recent data, we used the opportunity of a large population-based study about men's health to determine the prevalence and predictors of participation in screening for prostate cancer in the area defined by the Central Sydney Area Health Service. Methods The study was approved by the Royal Prince Alfred Hospital Ethics Review Committee. Community sampling Two thousand names, addresses and telephone numbers within the 35 postcodes constituting the Central Sydney area were randomly selected from the Electronic White Pages.9 To maximise participation rates, each household received a one-page letter outlining the Men's Health Study and anticipating telephone contact, supported by a media release to further publicise the study. The initial sample size of 2000 was estimated to be sufficient to provide between 250-350 completed surveys given an estimated prevalence of 38%10 of eligible male respondents in contacted households and a conservative consent rate. Computer-assisted telephone interview survey A market research company with computer-assisted telephone interview facilities contacted all 2000 households between 26 November and 12 December 1996 on weekdays between 1500 and 2100. Where the first contact was unsuccessful, a further five attempts were made at different times and on different days. Men aged between 40 and 80 years residing in the household and fluent in English were eligible to participate. If there was more than one man in the household meeting these criteria, the one with the most recent birthday was asked to participate. Due to the sensitive nature of the survey, all telephone interviewers were mature females with previous experience in conducting health-related surveys. A briefing session for interviewers was conducted to address potential difficulties with medical jargon, to ensure sensitivity towards the issues and to standardise the interviews. Survey instrument At the beginning of the interview, respondents were asked standard sociodemographic questions, as well as whether they had ever been diagnosed with a urological condition and questions modified from the International Prostate Symptom Score11 to assess the presence of and degree of "bother" attributable to urinary symptoms. We then asked respondents five questions about prostate cancer. 1. "Have you ever worried that you might have prostate cancer?" Those answering "yes" were asked "For what reasons?". 2. "Have you had any test to detect prostate cancer in the last 12 months?" Those answering "yes" were asked to name the test(s). 3. "Have you heard of any tests for prostate cancer?" 4. "Out of 100 Australian men, how many or what percentage do you think will get prostate cancer before the age of 75?" If the respondent was unable to quantify his response, the interviewer was instructed to establish a range by saying "Would it be more or less than 1%? Less than 5%? Between 5% and 9%? More than 10% or more than 20%?" until an answer was given. 5. "Out of 100 Australian men, how many or what percentage do you think will die from prostate cancer before the age of 75?" If necessary, an answer to this question was prompted in the same way as Question 4. For Questions 4 and 5, interviewers were unaware of the correct answers. Questions 4 and 5 were modelled on previous research. 12 Data analysis Data were analysed using SAS13 and Epi Info.14 We used chi-squared tests to examine associations between knowledge of prostate cancer screening tests and eight respondent characteristics: age (40-49, 50-59, 60-69, 70-80 years); country of birth (Australia v. other); socioeconomic status based on occupation (manager/ administrator and professional/para-professional combined v. all other categories [tradesperson/clerk/salesperson and personal service worker/plant and machine operator/driver and labourer]);15 education (up to and including Intermediate or School Certificate [Year 10] v. Leaving or Higher School Certificate [Year 11 or 12] and beyond); moderate or severe "bother" from urinary symptoms (a score equal to or greater than six from a possible range of 0-18); ever worrying about prostate cancer (yes v. no); estimate of risk of developing prostate cancer (correct or lower estimate v. overestimate); and estimate of risk of death from prostate cancer (correct or lower estimate v. overestimate). Jelfs et al. report a lifetime risk of developing prostate cancer of one in 18 (6%).16 We considered an estimate of 10% or greater to be an overestimate of incidence risk. Using the Jelfs data,16 we calculated the lifetime risk of dying of prostate cancer as one in 65 (1.5%). We considered an estimate of 5% or greater as an overestimate of mortality risk. For the sample of men 50 years and over, we used chi-squared tests to determine associations between the outcome variable -- having had either a prostate specific antigen test, a digital rectal examination, or both, within the previous 12 months -- and these eight variables as well as knowledge of prostate cancer tests. Logistic regression analysis was performed, using significant univariate variables and any plausible non-significant variable. Results Response rate and characteristics of the sample Of 2000 randomly selected households, 1481 (74%) were ineligible. Of the remaining 519 households with an eligible male resident, 340 agreed (65% response rate). Men who refused were significantly older than those who participated (t27.49 = 4.19; P < 0.01). Compared with 1991 Census data12 (Box 1), the sample under-represented older men. No respondent indicated a past history of prostate cancer. Respondents' worry about prostate cancer, estimates of risk and knowledge of tests Ninety-nine men (29%) indicated they had ever worried about prostate cancer. The three most frequently cited reasons were: presence of urinary symptoms (36 men [11%]), age (26 men [8%]), and media publicity (24 men [7%]). Of the sample, 216 men (63%) overestimated lifetime risk of developing prostate cancer (Box 2). Respondents were significantly more likely to overestimate the risk of death from prostate cancer than the risk of developing it (McNemar's test, 10.800; df = 1; P = 0.001). Ever having worried about prostate cancer was not associated with correctly estimating the risk of developing it or the risk of dying from it. Of the total sample, 237 (70%) and 228 (67%) required no prompting to estimate lifetime risk of developing or dying from prostate cancer, respectively. One hundred and seventy-two men (51%) reported they had heard of one or more tests for prostate cancer. Respondents who had heard of any test were more likely to be managers or professionals than to have other occupations (chi-squared = 4.04; df = 1; P = 0.044) or were educated to Year 12 or beyond (chi-squared = 5.49; df = 1; P = 0.019). Knowledge of tests was unrelated to age, country of birth, perception of risk, "bother" from urinary symptoms or anxiety. Rates and predictors of prostate cancer screening within the previous 12 months Of the total sample, 52 men (15%) had had at least one prostate cancer screening test within the previous 12 months (Box 3). Almost all tests (97%) were reported by men 50 years or older, yielding an annual screening rate of 22% for this older group. For the subsample of 186 men aged 50 years or over, univariate analyses revealed only two variables to be significantly associated with having had a prostate cancer screening test within the past year: moderate or severe "bother" from urinary symptoms (chi-squared = 13.41; df = 1; P < 0.001), and "ever worrying" about prostate cancer (chi-squared = 18.38; df = 1; P < 0.001). Knowledge of available tests and other sociodemographic variables were not associated with having had a test within the past year. However, as age was a potential confounder, it was included with the two significant univariate associations in the logistic regression analysis. After adjustment, "bother" and "anxiety" remained independent predictors (Box 4). Discussion Just over one in five of the men in our study 50 years or over had had a prostate cancer screening test within the previous 12 months, a rate almost double that given in an earlier report of national claims data.5 Screening was significantly more likely among those who had ever worried about prostate cancer or were bothered by urinary symptoms. In contrast to research in other countries demonstrating that economic and ethnic factors influence participation in prostate cancer screening,17,18 our study showed no association between screening and men's occupation, education or country of birth. As a priority for public campaigns, men who experience uncomplicated LUTS -- nocturia, frequency, dribbling, urgency, hesitancy or reduced stream -- in the absence of haematuria need to be reassured that there is no empirical evidence of a relationship between such symptoms and early prostate cancer.3 Men's anxiety about prostate cancer may also be explained, in part, by their overestimation of the actual risks of prostate cancer. More than a third of respondents thought that at least one in five men would develop prostate cancer before the age of 74 years, and 11% thought that one in five would actually die from this disease before that age. Reasons for consistent overestimation of risk remain speculative but might reflect extensive media coverage of prostate cancer, possibly fuelled by commercial interests, which increases men's anxiety, and, in turn, raises their perception of risk.19 In contrast, McCormick20 has argued that informed public participation in screening should be founded on clear messages about absolute risk, the evidence from rigorous randomised trials for reduction in risk, the costs and adverse outcomes. Our study is the first to quantify a considerable gap between men's perceptions of risk and the actual risk. When provided with impartial information on an individual basis about the risks and unknown benefits of prostate cancer screening, men are less inclined to have a screening test.21 Given our collective failure to convey accurate health risk information to the public about risks for other cancers,9 risk reduction22 or screening,23 a systematic approach to the development, implementation and evaluation of a public health initiative to discourage prostate cancer screening is required. The recent release of the guidelines for the management of uncomplicated LUTS in men3 provides a focus for such an initiative. Our study suggests that men who are anxious about prostate cancer or have bothersome urinary symptoms represent priority target groups for educational messages via general practice, men's service and recreation clubs, mass media and peak groups such as the Council of the Ageing and the Consumers' Health Forum. Because of the limitations of our study, we also recommend that a dedicated survey about prostate cancer be conducted which examines in depth men's knowledge of indolent and aggressive cancer types, their health beliefs and attitudes towards early detection, their awareness of the speculative and controversial nature of screening, and their knowledge of treatment options and their effectiveness. Men's recall of the recommendations of their GP in either promoting or discouraging prostate cancer screening could also be ascertained. As female partners represent a key source of health information for men,24 a concurrent survey of partners of men in these age groups is also recommended. Acknowledgements The Men's Health Study was conducted for the NHMRC Working Party developing guidelines for the management of lower urinary tract symptoms in men with funds from the Commonwealth Department of Health and Family Services. We thank members of the Working Party for comments on survey protocols; the men who participated in the computer-assisted telephone interview and the Hunter Valley Research Foundation for diligent administration of the survey; Jo Williams and the Central Sydney Area Health Service Public Relations Unit for assisting with the media release; and Neil Donnelly for statistical advice. References Australian Cancer Society. Prostate cancer screening: guidelines for health professionals. Cancer Forum 1995; 19: 47-50. Australian Health Technology Advisory Committee. Prostate cancer screening. Canberra: AGPS, 1996. NHMRC clinical practice guidelines. The management of uncomplicated lower urinary tract symptoms in men. Canberra: AGPS, 1996. Catalona W, Ritchie J, Ahmann F, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol 1994; 151: 1283-1290. 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Canberra: AGPS, 1996: 69-72. McCormick J. Medical hubris and the public health: the ethical dimension. J Clin Epidemiol 1996; 49: 619-621. Wolf A, Nasser J, Wolf A, Schorling J. The impact of informed consent on patient interest in prostate-specific antigen screening. Arch Intern Med 1996; 156: 1333-1336. Hancock L, Sanson-Fisher RW, Redman S, et al. Knowledge of cancer risk reduction practices in rural towns of NSW. Aust N Z J Public Health 1996; 20: 529-537. Cockburn J, Redman S, Hill D, Henry E. Public understanding of medical screening. J Med Screen 1995; 2: 224-227. Norcross W, Ramirez C, Palinkas L. The influence of women on the health care-seeking behaviour of men. J Fam Pract 1996; 43: 475-480. (Received 24 Feb, accepted 22 May 1997) Subsequently cited in Prostate-specific antigen testing in Australia and association with prostate cancer incidence in New South Wales by David P Smith and Bruce K Armstrong, Med J Aust 1998; 169: 17-20 Authors' details Central Sydney Area Health Service, Needs Assessment & Health Outcomes Unit, Sydney, NSW. Jeanette E Ward, PhD, FAFPHM, Director; Ann-Maree Hughes, BEd, GradDipAppSci(Nursing), Research Assistant; Lorraine Winchester, BSocSc(Hons), Data Manager. Taylor Medical Centre, Brisbane, QLD. Geoffrey H L Hirst, MB BS, FRACS, Urologist. Reprints: Associate Professor J E Ward, Central Sydney Area Health Service, Needs Assessment & Health Outcomes Unit, PO Box 374, Camperdown, NSW 2050. E-mail: jward AT nah.rpa.cs.nsw.gov.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Jeanette E Ward · Anne-Maree Hughes · Lorraine Winchester