Mastering Linked Datasets: The Future of Emergency Health Care Research.

Objectives: The aim of this work is to describe routine integration of prehospital emergency health records into a health master linkage file, delivering ongoing access to integrated patient treatment and outcome information for ambulance-attended patients in Queensland.Methods: The Queensland Ambulance Service (QAS) data are integrated monthly into the Queensland Health Master Linkage File (MLF) using a linkage algorithm that relies on probabilistic matches in combination with deterministic rules based on patient demographic details, date, time and facility identifiers. Each ambulance record is assigned an enduring linkage key (unique patient identifier) and further processing determines whether each record matches with a corresponding hospital emergency department, admission or death registry record. In this study, all QAS electronic ambulance report form (eARF) records from October 2016 to December 2018 where at least 1 key linkage variable was present (n = 1,771,734) were integrated into the MLF.Results: The majority of records (n = 1,456,502; 82.2%) were for transported patients, and 90.1% (n = 1,312,176) of these transports were to public hospital facilities. Of these transport records, 93.9% (n = 1,231,951) matched to emergency department (ED) records and 59.3% (n = 864,394) also linked to admitted patient records. Of ambulance non-transport records integrated into the MLF, 23.6% (n = 74,311) matched with ED records.Conclusion: This study demonstrates robust linkage methods, quality assurance processes and high linkage rates of data across the continuum of care (prehospital/emergency department/admitted patient/death) in Queensland. The resulting infrastructure provides a high-quality linked dataset that facilitates complex research and analysis to inform critical functions such as quality improvement, system evaluation and design.

Heatwaves and mortality in Queensland 2010-2019: implications for a homogenous state-wide approach.

Heatwaves are a significant cause of adverse health outcomes and mortality in Australia, worsening with climate change. In Queensland, the northeastern-most state, little is known about the impact of heatwaves outside of the capital city of Brisbane. This study aims to explore the impact of heatwaves on mortality across various demographic and environmental conditions within Queensland from 2010 to 2019. The Excess Heat Factor was used to indicate heatwave periods at the Statistical Area 2 (SA2) level. Registered deaths data from the Australian Bureau of Statistics and heatwave data from the Bureau of Meteorology were matched using a case-crossover approach. Relative risk and 95% confidence intervals were calculated across years, regions, age, sex, rurality, socioeconomic status, and cause of death. Heatwaves were associated with a 5% increase in all-cause mortality compared to deaths on non-heatwave days, with variability across the state. The risk of death on a heatwave day versus a non-heatwave day varied by heatwave severity. Individuals living in urban centers, the elderly, and those living in regions of lower socioeconomic status were most impacted by heatwave mortality. The relative risk of dying from neoplasms, nervous system conditions, respiratory conditions, and mental and behavioral conditions increased during heatwaves. As heatwaves increase in Queensland due to climate change, understanding the impact of heatwaves on mortality across Queensland is important to tailor public health messages. There is considerable variability across communities, demographic groups, and medical conditions, and as such messages need to be tailored to risk.

Quantifying the hospital and emergency department costs for women diagnosed with breast cancer in Queensland.

PURPOSE: With increasing rates of cancer survival due to advances in screening and treatment options, the costs of breast cancer diagnoses are attracting interest. However, limited research has explored the costs to the Australian healthcare system associated with breast cancer. We aimed to describe the cost to hospital funders for hospital episodes and emergency department (ED) presentations for Queensland women with breast cancer, and whether costs varied by demographic characteristics. METHODS: We used a linked administrative dataset, CancerCostMod, limited to all breast cancer diagnoses aged 18 years or over in Queensland between July 2011 and June 2015 (n = 13,285). Each record was linked to Queensland Health Admitted Patient Data Collection and Emergency Department Information Systems records between July 2011 and June 2018. The cost of hospital episodes and ED presentations were determined, with mean costs per patient modelled using generalised linear models with a gamma distribution and log link function. RESULTS: The total cost to the Queensland healthcare system from hospital episodes for female breast cancer was AUD$309 million and AUD$12.6 million for ED presentations during the first 3 years following diagnosis. High levels of costs and service use were identified in the first 6 months following diagnosis. Some significant differences in cost of hospital and ED episodes were identified based on demographic characteristics, with Indigenous women and those from lower socioeconomic backgrounds having higher costs. CONCLUSION: Hospitalisation costs for breast cancer in Queensland exert a high burden on the healthcare system. Costs are higher for women during the first 6 months from diagnosis and for Indigenous women, as well as those with underlying comorbidities and lower socioeconomic position.

Patient co-payments for women diagnosed with breast cancer in Australia.

PURPOSE: Among Australian women, breast cancer is the most commonly diagnosed cancer. The out-of-pocket cost to the patient is substantial. This study estimates the total patient co-payments for Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for women diagnosed with breast cancer and determined the distribution of these costs by Indigenous status, remoteness, and socioeconomic status. METHODS: Data on women diagnosed with breast cancer in Queensland between 01 July 2011 and 30 June 2012 were obtained from the Queensland Cancer Registry and linked with hospital and Emergency Department Admissions, and MBS and PBS records for the 3 years post-diagnosis. The data were then weighted to be representative of the Australian population. The co-payment charged for MBS services and PBS prescriptions was summed. We modelled the mean co-payment per patient during each 6-month time period for MBS services and PBS prescriptions. RESULTS: A total of 3079 women were diagnosed with breast cancer in Queensland during the 12-month study period, representing 15,335 Australian women after weighting. In the first 3 years post-diagnosis, the median co-payment for MBS services was AU$ 748 (IQR, AU$87-2121; maximum AU$32,249), and for PBS prescriptions was AU$ 835 (IQR, AU$480-1289; maximum AU$5390). There were significant differences in the co-payments for MBS services and PBS prescriptions by Indigenous status and socioeconomic disadvantage, but none for remoteness. CONCLUSIONS: Women incur high patient co-payments in the first 3 years post-diagnosis. These costs vary greatly by patient. Potential costs should be discussed with women throughout their treatment, to allow women greater choice in the most appropriate care for their situation.

A retrospective analysis of the prevalence and clinical outcomes of vitamin D deficiency in myeloma patients in tropical Australia.

PURPOSE: The aim of this descriptive study was to assess the prevalence of vitamin D deficiency in patients on active therapy for multiple myeloma in a tropical climate. We also tested for the association of vitamin D status on clinical outcomes. METHODS: This was a single centre, observational study performed in Townsville, Australia, which has a sunlight heavy, tropical climate. Patients on active therapy for multiple myeloma underwent testing of serum 25-hydroxyvitamin D (25(OH)D). Information on disease stage, skeletal morbidity and symptoms of peripheral neuropathy were collected from medical records and self-reported patient questionnaires. RESULTS: A total of 41 patients were included. With a median disease duration of 38 months, 27% were found to be vitamin D deficient. Patients with vitamin D deficiency had a higher likelihood of peripheral neuropathy compared with their non-vitamin D counterparts (73% vs. 33%, P = 0.03). Although those with vitamin D deficiency had more skeletal morbidity, this was not statistically significant (73% vs 50%, P = 0.19). Reduced 25(OH) D was associated with a poor performance status (P = 0.003). There was no association between vitamin D status and stage of myeloma. CONCLUSION: There is a relatively high prevalence of vitamin D deficiency in patients with myeloma in our study. This is despite a sunlight heavy, tropical climate. We report an association between vitamin D deficiency and peripheral neuropathy. Prospective interventional trials are required to further assess this.

Exploring Australian residents cycling engagement - Differences in self-reported cycling behaviour between urban and rural dwelling Queenslanders.

ISSUE ADDRESSED: Cycling participation rates in Australia and Queensland remain low. Rural residents typically do not have distinct cycling infrastructure available for use. Investigating current cycling participation and barriers to cycling engagement will inform future work to promote cycling engagement. METHODS: Data were collected through the inclusion of cycling-related questions in the 2012 Queensland Social Survey. RESULTS: The majority of the sample had not cycled in the previous 12 months (66%; n = 831). Significantly more rural residents reported not cycling due to environmental concerns (P < 0.05) and preferring other modes of transport or exercise (P < 0.01). Rural cyclists (31.4%; n = 113) had higher levels of cycling engagement in the previous week (41.6% to 32.6% urban; χ2  = 7.83; n = 420; P < 0.05) but lower cycling durations than urban cyclists (41.6% rural residents cycling for 30+ minutes vs 57.4% urban residents; χ2  = 8.25; n = 418; P < 0.01). Rural cycling engagement was independently associated with being male (OR = 2.34; 95% CI = 1.40-3.91); sufficient physical activity engagement (OR = 1.86; 95% CI = 1.10-3.15); and having children at place of residence (1-2 children: OR = 3.21; 95% CI = 1.88-5.49; 3+ children: OR = 3.01; 95% CI = 1.17-7.75). CONCLUSIONS: One-third of all adults cycled in the previous 12 months irrespective of location; however reasons for not cycling varied by urban/rural location. Results indicate that environmental factors appear to be inhibiting cycling participation in rural areas. Advocating for government commitment for infrastructure development to support safe cycling across Queensland including outside of metropolitan areas is required. SO WHAT?: This research explores self-reported cycling engagement amongst a sample of urban and rural dwelling Queenslanders. Differences in cycling exposure and reasons for lack of engagement offer insights into what may encourage greater cycling participation.

Knowledge of childhood burn risks and burn first aid: Cool Runnings.

AIM: The high incidence of hot beverage scalds among young children has not changed in the past 15 years, but preventive campaigns have been scarce. A novel approach was used to engage mothers of young children in an app-based hot beverage scald prevention campaign 'Cool Runnings'. This paper provides baseline data for this randomised controlled trial (RCT). METHOD: Queensland-based mothers aged 18+ years with at least one child aged 5-12 months were recruited via social media to Cool Runnings, which is a two-group, parallel, single-blinded RCT. RESULTS: In total, 498 participants from across Queensland completed the baseline questionnaire. The most common source of burn first aid information was the internet (79%). One-third (33%) correctly identified hot beverage scalds as the leading cause of childhood burns, 43% knew the age group most at risk. While 94% reported they would cool a burn with water, only 10% reported the recommended 20min duration. After adjusting for all relevant variables, there were two independent predictors of adequate burn first aid knowledge: first aid training in the past year (OR=3.32; 95% CI 1.8 to 6.1) and smoking status (OR=0.17; 95% CI 0.04 to 0.7). CONCLUSION: In this study, mothers of young children were largely unaware how frequently hot beverage scalds occur and the age group most susceptible to them. Inadequate burn first aid knowledge is prevalent across mothers of young children; there is an urgent and compelling need to improve burn first aid knowledge in this group. Given the high incidence of hot beverages scalds in children aged 6-24 months, it is important to target future burn prevention/first aid campaigns at parents of young children. TRIAL REGISTRATION NUMBER: ACTRN12616000019404; Pre-results.

Non-urgent paediatric emergency department presentation: A systematic review.

There has been an increase in the use of the emergency department (ED) for non-urgent presentations. The aim of this systematic review was to identify the proportion, criteria and predictors of non-urgent ED presentations in paediatric populations. A search of multiple databases was conducted for articles published from inception of the databases to 20 August 2018, which reported the proportion, criteria and predictors of non-urgent ED presentation in paediatric populations. Thirty-one articles met the inclusion criteria. The mean proportion of non-urgent paediatric ED presentations was 41.06 ± 15.16%. There appears to be a weak association between predisposing, enabling and needs factors and non-urgent ED use in paediatric populations. The findings of this review suggest that non-urgent ED use in paediatric populations is high. However, non-urgent ED use and the reasons for the visits in paediatric populations remain understudied.

A village-matched evaluation of providing a local supplemental food during pregnancy in rural Bangladesh: a preliminary study.

BACKGROUND: Prenatal balanced protein energy supplementation consumed by undernourished women improves mid-upper arm circumference in early infancy. This study aimed to identify whether locally produced maternal food-based supplementation improved anthropometric measures at birth and early infancy. METHODS: A village-matched evaluation, applying principles of a cluster randomised controlled trial, of a locally produced supplemental food to 87 undernourished pregnant women. 12 villages (intervention: n = 8; control: n = 4) in Pirganj sub-district, Rangpur District, northern Bangladesh. Daily supplements were provided. RESULTS: Anthropometric data at birth were available for 77 mother-infant dyads and longer-term infant growth data for 75 infants. Mid-upper arm circumference (MUAC) was significantly larger in infants of mothers in the intervention group compared with the control group at 6 months (p < 0.05). The mean birth weight in babies of supplemented mothers (mean: 2·91 kg; SD: 0·19) was higher than in babies of mothers in the control group (mean: 2·72 kg; SD: 0·13), and these changes persisted until 6 months. Also, the proportion of low birth weight babies in the intervention group was much lower (event rate = 0.04) than in the control group (event rate = 0.16). However, none of these differences were statistically significant (p > 0·05; most likely due to small sample size). The intervention reduced the risk of wasting at 6 months by 63.38% (RRR = 0.6338), and of low birth weight by 88·58% (RRR = 0.8858), with NNT of 2.22 and 6.32, respectively. Only three pregnant women require this intervention in order to prevent wasting at 6 months in one child, and seven need the intervention to prevent low birth weight of one child. CONCLUSIONS: Locally produced food-based balanced protein energy supplementation in undernourished pregnant women in northern Bangladesh resulted in larger MUAC in infants at 6 months. Further research, with larger sample sizes, is required to confirm the role of locally produced supplementation for undernourished pregnant women on weight and linear growth in newborns and infants. TRIAL REGISTRATION: This research was registered with the ISRCTN registry (ISRCTN97447076). This project had human research ethical approval from the James Cook University (Australia) Ethics committee (H4498) and the Bangladesh Medical Research Council (BMRC/NREC/2010-2013/58).

Labour force participation and the cost of lost productivity due to cancer in Australia.

BACKGROUND: In Australia, 40% of people diagnosed with cancer will be of working age (25-64 years). A cancer diagnosis may lead to temporary or permanent changes in a person's labour force participation, which has an economic impact on both the individual and the economy. However, little is known about this economic impact of cancer due to lost productivity in Australia. This paper aims to determine the labour force participation characteristics of people with cancer, to estimate the indirect cost due to lost productivity, and to identify any inequality in the distribution of labour force absence in Australia. METHODS: This study used national cross-sectional data from the 2015 Survey of Disability, Ageing and Carers, conducted by the Australian Bureau of Statistics (ABS). The ABS weighted each component of the survey to ensure the sample represented the population distribution of Australia. The analysis was limited to people aged 25-64 years. Participants were assigned to one of three health condition groups: 'no health condition', 'cancer', and 'any other long-term health condition'. A series of logistic regression models were constructed to determine the association between health condition and labour force participation. RESULTS: A total of 34,393 participants surveyed were aged 25-64 years, representing approximately 12,387,800 Australians. Almost half (46%) of people with cancer were not in the labour force, resulting in a reduction of $1.7 billion to the Australian gross domestic product (GDP). Amongst those in the labour force, people with no health condition were 3.00 times more likely to be employed full-time compared to people with cancer (95% CI 1.96-4.57), after adjusting for age, sex, educational attainment and rurality. Amongst those with cancer, people without a tertiary qualification were 3.73 times more likely to be out of the labour force (95% CI 1.97-7.07). CONCLUSIONS: This paper is the first in Australia to estimate the national labour force participation rates of people with cancer. People with cancer were less likely to be in the labour force, resulting in a reduction in Australia's GDP. Cancer survivors, especially those without a tertiary qualification may benefit from support to return to work after a diagnosis.

Socio-economic composition of low-acuity paediatric presentation at a regional hospital emergency department.

AIM: Despite increasing rates of emergency department (ED) utilisation, little is known about low-acuity presentations in children ≤5 years. The aims of the study were to estimate the proportion and cost of low-acuity presentations in children ≤5 years presenting to the ED and to determine the relative effect of socio-economic status (SES) on paediatric low-acuity presentations at the ED. METHODS: This is a retrospective observational study of children ≤5 years presenting to the Cairns Hospital ED over 4 years. A multivariate logistic regression model was used to assess the association between SES and low-acuity presentations. Cost of low-acuity presentations was calculated based on triage score and admission status, using costs obtained from the National Hospital Cost Data Collection. RESULTS: A total of 23 086 children were included in the study, of whom 56.7% were male (mean age = 1.85 ± 1.63 years). Approximately one-third of ED visits were low-acuity presentations (32.4%), and low-acuity presentations increased progressively with SES. In multivariate analysis, children from families with very high SES were twice as likely to have a low-acuity presentation (odds ratio 2.17; 95% confidence interval, 1.66-2.85). Low-acuity ED presentations cost the health-care system in excess of A$895 000-A$1 110 000 per year. CONCLUSIONS: These findings demonstrate that a significant proportion of paediatric ED visits are of low acuity and that these visits yield a substantial cost to the health system. Further research is required regarding care givers' rationale and potentially other reasons underlying these low-acuity ED presentations.

Examination of Child and Adolescent Hospital Admission Rates in Queensland, Australia, 1995-2011: A Comparison of Coal Seam Gas, Coal Mining, and Rural Areas.

Objectives At present, coal seam gas (CSG) is the most common form of unconventional natural gas development occurring in Australia. Few studies have been conducted to explore the potential health impacts of CSG development on children and adolescents. This analysis presents age-specific hospitalisation rates for a child and adolescent cohort in three study areas in Queensland. Methods Three geographic areas were selected: a CSG area, a coal mining area, and a rural area with no mining activity. Changes in area-specific hospital admissions were investigated over the period 1995-2011 in a series of negative binomial regression analyses for 19 International Classification of Diseases (ICD) chapters, adjusting for sociodemographic factors. Results The strongest associations were found for respiratory diseases in 0-4 year olds (7% increase [95% CI 4%, 11%] and 6% increase [95% CI 2%, 10%] in the CSG area relative to the coal mining and rural areas, respectively) and 10-14 year olds (9% increase [95% CI 1%, 18%] and 11% increase [95% CI 1%, 21%] in the CSG area compared to the coal mining and rural areas, respectively). The largest effect size was for blood/immune diseases in 5-9 year olds in the CSG area (467% increase [95% CI 139%, 1244%]) compared to the rural area with no mining activity. Conclusions for Practice Higher rates of hospitalisation existed in the CSG area for certain ICD chapters and paediatric age groups, suggesting potential age-specific health impacts. This study provides insights on associations that should be explored further in terms of child and adolescent health.

A comprehensive systematic review of stakeholder attitudes to alternatives to prospective informed consent in paediatric acute care research.

BACKGROUND: A challenge of performing research in the paediatric emergency and acute care setting is obtaining valid prospective informed consent from parents. The ethical issues are complex, and it is important to consider the perspective of participants, health care workers and researchers on research without prospective informed consent while planning this type of research. METHODS: We performed a systematic review according to PRISMA guidelines, of empirical evidence relating to the process, experiences and acceptability of alternatives to prospective informed consent, in the paediatric emergency or acute care setting. Major medical databases and grey sources were searched and results were screened and assessed against eligibility criteria by 2 authors, and full text articles of relevant studies obtained. Data were extracted onto data collection forms and imported into data management software for analysis. RESULTS: Thirteen studies were included in the review consisting of nine full text articles and four abstracts. Given the heterogeneity of the methods, results could not be quantitatively combined for meta-analysis, and qualitative results are presented in narrative form, according to themes identified from the data. Major themes include capacity of parents to provide informed consent, feasibility of informed consent, support for alternatives to informed consent, process issues, modified consent process, child death, and community consultation. CONCLUSION: Our review demonstrated that children, their families, and health care staff recognise the requirement for research without prior consent, and are generally supportive of enrolling children in such research with the provisions of limiting risk, and informing parents as soon as possible. Australian data and perspectives of children are lacking and represent important knowledge gaps.

Combining Technology and Research to Prevent Scald Injuries (the Cool Runnings Intervention): Randomized Controlled Trial.

BACKGROUND: New technologies, internet accessibility, social media, and increased smartphone ownership provide new opportunities for health researchers to communicate and engage target audiences. An innovative burn prevention intervention was developed using these channels. OBJECTIVE: The aim of this study was to evaluate the efficacy of Cool Runnings, an app-based intervention to increase knowledge of childhood burn risk (specifically hot beverage scalds) and correct burn first aid among mothers of young children. METHODS: This was a 2-group, parallel, single-blinded randomized controlled trial (RCT). Participants were women aged 18 years and above, living in Queensland, Australia, with at least 1 child aged 5-12 months at time of enrollment. The primary outcome measures were change in knowledge about risk of burns and correct burn first aid assessed via 2 methods: (1) overall score and (2) categorized as adequate (score=4) versus inadequate (score<4). Efficacy of gamification techniques was also assessed. RESULTS: In total, 498 participants were recruited via social media and enrolled. At the 6-month follow-up, 244 participants completed the posttest questionnaire. Attrition rates in both groups were similar. Participants who remained in the study did not differ from those lost to follow-up on any characteristics except education level. Although similar at baseline, intervention group participants achieved significantly greater improvement in overall knowledge posttest than control group participants on both primary outcome measures (overall knowledge intervention: mean [SD] of overall knowledge 2.68 [SD 1.00] for intervention vs 2.13 [SD 1.03] for control; 20.7% [25/121] adequate in intervention vs 7.3% [2/123] in control). Consequently, the number needed to treat was 7.46. Logistic regression showed participants exposed to the highest level of disadvantage had 7.3 times higher odds of improved overall knowledge scores than participants in other levels of disadvantage. There were also significant correlations between gamification techniques and knowledge change (P<.001). In addition, odds of knowledge improvement between baseline and 6-month follow-up was higher in participants with low-moderate app activity compared with no app activity (odds ratio [OR] 8.59, 95% CI 2.9-25.02) and much higher in participants with high app activity (OR 18.26, 95% CI 7.1-46.8). CONCLUSIONS: Despite substantial loss to follow-up, this RCT demonstrates the Cool Runnings app was an effective intervention for improving knowledge about risks of hot beverage scalds and burn first aid in mothers of young children. The benefits of combining gamification elements in the intervention were also highlighted. Given the low cost and large reach of smartphone apps to deliver content to and engage with targeted populations, the results from this RCT provide important information on how smartphone apps can be used for widespread injury prevention campaigns and public health campaigns generally. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616000019404; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369745&showOriginal=true&isReview=true (Archived by WebCite at http://www.webcitation.org/72b1E8gTW).

Barriers to adequate first aid for paediatric burns at the scene of the injury.

ISSUE ADDRESSED: The recommended first aid for burns, consisting of 20 minutes of cool running water (CRW) delivered within three hours of the injury, offers a simple yet effective means of improving health outcomes. The aim of this study was to determine patient and injury characteristics associated with inadequate CRW therapy among children with thermal burns, with the goal of identifying populations at greatest risk of undertreatment. METHODS: A cross-sectional study was performed on children treated at a large tertiary paediatric burns centre. First aid was evaluated as either "adequate" or "inadequate", and then descriptive analyses were conducted to examine differences between the groups in age, ethnicity, location and socioeconomic status, among others. RESULTS: From 2013 to 2016, the families of 2522 patients were interviewed. Overall, 31.3% of children received adequate CRW at the scene of the injury. Provision of adequate CRW did not significantly differ with sex, ethnicity or nationality. Factors that were associated with inadequate first aid included very young age and early adolescence (P < 0.001), rural or remote location (P = 0.045), low socioeconomic status (P = 0.030), radiant heat and flame burns (P < 0.001), as well as burns occurring at recreational sites, on farm/trade/industrial properties and in the street (P = 0.001). CONCLUSIONS: Although most burns occurred in close proximity to sources of CRW, first aid was poor across all demographics. The highest levels of undertreatment were found in children aged 0-2, adolescents aged 15-16, those living rurally or remotely, and the socioeconomically disadvantaged. SO WHAT?: The study highlights the need for improved public education of first aid for burn injuries.

Incidence and characteristics of low-speed vehicle run over events in rural and remote children aged 0-14 years in Queensland: an 11 year (1999-2009) retrospective analysis.

INTRODUCTION: The main objective of this study is to describe incidence rates of low-speed vehicle run-over (LSVRO) events among children aged 0-14 years residing in Queensland from 1999 to 2009. A second objective was to describe the associated patterns of injury, with respect to gender, age group, severity, characteristics (host, vehicle and environment), and trends over time in relation to geographical remoteness. Final results are hoped to inform prevention policies. METHODS: In this statewide, retrospective, population-based study, data were collected on LSVRO events that occurred among children aged 0-14 years in Queensland from 1999 to 2009 from all relevant data sources across the continuum of care, and manually linked to obtain the most comprehensive estimate possible of the magnitude and nature of LSVRO events to date. Crude incidence rates were calculated separately for males and females, for fatal events, non-fatal events (hospital admissions and non-admissions, respectively), and for all LSVRO events, for each area of geographical remoteness (major cities, inner regional, outer regional, remote/very remote). Relative risks and 95% confidence interval were calculated, and trends over time were examined. Data on host, injury and event characteristics were also obtained to investigate whether these characteristics varied between areas of remoteness. RESULTS: Incidence rates were lowest among children (0-14 years) living in major cities (13.8/100 000/annum, with the highest recorded incidence in outer regional areas (incidence rate =42.5/100 000/annum). Incidence rates were higher for children residing outside major cities for both males and females, for every age group, for each of the 11 years of the study, and consequences of LSVRO events were worse. Young children aged 0-4 years were identified as those most at risk for these events, regardless of geographical location. Differences were observed as a function of remoteness category in relation to injury characteristics (eg injury type), and host characteristics (eg sociodemographic status), but there were no observed differences in environmental characteristics (eg time of day, day of week). Heavy vehicles such as four-wheel drives, utilities, trucks and tractors were more frequently involved in LSVRO events that occurred outside major cities. CONCLUSION: The results confirmed that children of all ages and genders residing outside of major cities in Queensland are more at risk of being involved in an LSVRO incident, and experience more severe consequences compared to children in major cities. Future research should address the specific risk factors and focus on engaging rural communities to assist in the prevention of LSVRO incidents.

How primary health care staff working in rural and remote areas access skill development and expertise to support health promotion practice.

INTRODUCTION: Health promotion is a key component of comprehensive primary health care. Health promotion approaches complement healthcare management by enabling individuals to increase control over their health. Many primary healthcare staff have a role to play in health promotion practice, but their ability to integrate health promotion into practice is influenced by their previous training and experience. For primary healthcare staff working in rural and remote locations, access to professional development can be limited by what is locally available and prohibitive in terms of cost for travel and accommodation. This study provides insight into how staff at a large north Queensland Aboriginal community controlled health service access skill development and health promotion expertise to support their work. METHODS: A qualitative exploratory study was conducted. Small group and individual semi-structured interviews were conducted with staff at Apunipima Cape York Health Council (n=9). A purposive sampling method was used to recruit participants from a number of primary healthcare teams that were more likely to be involved in health promotion work. Both on-the-ground staff and managers were interviewed. All participants were asked how they access skill development and expertise in health promotion practice and what approaches they prefer for ongoing health promotion support. The interviews were transcribed verbatim and analysed thematically. RESULTS: All participants valued access to skill development, advice and support that would assist their health promotion practice. Skill development and expertise in health promotion was accessed from a variety of sources: conferences, workshops, mentoring or shared learning from internal and external colleagues, and access to online information and resources. With limited funds and limited access to professional development locally, participants fostered external and internal organisational relationships to seek in-kind advice and support. Irrespective of where the advice came from, it needed to be applicable to work with Aboriginal and Torres Strait Islander remote communities. CONCLUSIONS: To improve health outcomes in rural and remote communities, the focus on health promotion and prevention approaches must be strengthened. Primary healthcare staff require ongoing access to health promotion skill development and expertise to increase their capacity to deliver comprehensive primary health care. Practice-based evidence from staff working in the field provides a greater understanding of how skill development and advice are accessed. Many of these strategies can be formalised through organisational plans and systems, which would ensure that a skilled health promotion workforce is sustained.

Opportunities Missed: A Cross-Sectional Survey of the Provision of Smoking Cessation Care to Pregnant Women by Australian General Practitioners and Obstetricians.

INTRODUCTION: Similar to other high-income countries, smoking rates in pregnancy can be high in specific vulnerable groups in Australia. Several clinical guidelines exist, including the 5A's (Ask, Advice, Assess, Assist, and Arrange), ABCD (Ask, Brief advice, Cessation, and Discuss), and AAR (Ask, Advice, and Refer). There is lack of data on provision of smoking cessation care (SCC) of Australian General Practitioners (GPs) and Obstetricians. METHODS: A cross-sectional survey explored the provision of SCC, barriers and enablers using the Theoretical Domains Framework, and the associations between them. Two samples were invited: (1) GPs and Obstetricians from a college database (n = 5571); (2) GPs from a special interest group for Indigenous health (n = 500). Dimension reduction for the Theoretical Domains Framework was achieved with factor analysis. Logistic regression was carried out for performing all the 5A's and the AAR. RESULTS: Performing all of the 5A's, ABCD, and AAR "often and always" was reported by 19.9%, 15.6%, and 49.2% respectively. "Internal influences" (such as confidence in counselling) were associated with higher performance of the 5A's (Adjusted OR 2.69 (95% CI 1.5, 4.8), p < .001), whereas "External influences" (such as workplace routine) were associated with higher performance of AAR (Adjusted OR 1.7 (95% CI 1, 2.8), p = .035). CONCLUSIONS: Performance in providing SCC to pregnant women is low among Australian GPs and Obstetricians. Training clinicians should focus on improving internal influences such as confidence and optimism. The AAR may be easier to implement, and interventions at the service level should focus on ensuring easy, effective, and acceptable referral mechanisms are in place. IMPLICATIONS: Improving provision of the 5A's approach should focus on the individual level, including better training for GPs and Obstetricians, designed to improve specific "internal" barriers such as confidence in counselling and optimism. The AAR may be easier to implement in view of the higher overall performance of this approach. Interventions on a more systemic level need to ensure easy, effective, and acceptable referral mechanisms are in place. More research is needed specifically on the acceptability of the Quitline for pregnant women, both Indigenous and non-Indigenous.

Ability of independently ambulant children with cerebral palsy to ride a two-wheel bicycle: a case-control study.

AIM: Limited information exists on the ability of children with cerebral palsy (CP) to ride a two-wheel bicycle, an activity that may improve health and participation. We aimed to describe bicycle-riding ability and variables associated with ability to ride in children with CP (Gross Motor Functional Classification System [GMFCS] levels I-II) compared with children with typical development. METHOD: This case-control study surveyed parents of 114 children with CP and 87 children with typical development aged 6 to 15 years (115 males, mean age 9y 11mo, standard deviation [SD] 2y 10mo). Kaplan-Meier methods were used to compare proportions able to ride at any given age between the two groups. Logistic regression was used to assess variables associated with ability to ride for children with CP and typical development separately. RESULTS: The proportion of children with CP able to ride at each level of bicycle-riding ability was substantially lower at each age than peers with typical development (p<0.001). While most children with typical development were able to ride independently by 10 years of age, 51% of children with CP classified as GMFCS level I and 3% of those classified as GMFCS level II had obtained independent riding in the community by 15 years of age. Variables associated with ability to ride for children classified as GMFCS level I were age and parent-rated importance of their child being able to ride. INTERPRETATION: Some independently ambulant children with CP can learn to ride a bicycle, in particular if they are classified as GMFCS level I. Variables associated with ability to ride deserve consideration in shaping future efforts for the majority of this population who are not yet able to ride.

The role of seasonality on the diet and household food security of pregnant women living in rural Bangladesh: a cross-sectional study.

OBJECTIVE: To investigate the association of seasonality with dietary diversity, household food security and nutritional status of pregnant women in a rural district of northern Bangladesh. DESIGN: A cross-sectional study was conducted from February 2013 to February 2015. Data were collected on demographics, household food security (using the Household Food Insecurity Access Scale), dietary diversity (using the women's dietary diversity questionnaire) and mid-upper arm circumference. Descriptive statistics were used to explore demographics, dietary diversity, household food security and nutritional status, and inferential statistics were applied to explore the role of seasonality on diversity, household food security and nutritional status. SETTING: Twelve villages of Pirganj sub-district, Rangpur District, northern Bangladesh. SUBJECTS: Pregnant women (n 288). RESULTS: Seasonality was found to be associated with dietary diversity (P=0·026) and household food security (P=0·039). Dietary diversity was significantly lower in summer (P=0·029) and spring (P=0·038). Food security deteriorated significantly in spring (P=0·006) and late autumn (P=0·009). CONCLUSION: Seasons play a role in women's household food security status and dietary diversity, with food security deteriorating during the lean seasons and dietary diversity deteriorating during the second 'lesser' lean season and the season immediately after. Interventions that aim to improve the diet of pregnant women from low-income, subsistence-farming communities need to recognise the role of seasonality on diet and food security and to incorporate initiatives to prevent seasonal declines.