The Relationship Between Maternal Education and Child Health Outcomes in Urban Australian Children in the First 12 Months of Life.

OBJECTIVES: To describe the relationship between maternal education and child health outcomes at 12 months of age in a cohort of children in urban Australia, and to determine whether this relationship could be explained by the intermediate factors of maternal health behaviour and the social environmental context. METHODS: Data were derived from The Environments for Health Living Griffith Birth Cohort Study. Women attending their third trimester antenatal appointment at one of three public hospitals were recruited between 2006 and 2010 and invited to complete a 48-item, baseline self-administered questionnaire. Twelve months following the birth of their baby, a follow-up questionnaire consisting of 63 items was distributed. RESULTS: Women for whom complete follow-up data were not available were different from women who did complete follow-up data. The children of women with follow-up data-whom at the time of their pregnancy had not completed school or whose highest level of education was secondary school or a trade-had respectively a 59 and 57 % increased chance of having had a respiratory/infectious disease or injury in the first year of life (according to parent proxy-reports), compared to children of women with a tertiary education. When maternal behavioural and social environmental factors during pregnancy were included in the model (n=1914), the effect of secondary education was still evident but with a reduced odds ratio of 1.35 (95 % CI 1.07-1.72) and 1.19 (95 % CI 0.87-1.64), respectively. The effect of not having completed school was no longer significant. CONCLUSIONS: Results indicate that the relationship between maternal education and child outcomes may be mediated by maternal social environmental and behavioural factors. Results are likely an underestimation of the effect size, given the under representation in our cohort of participants with maternal characteristics associated with elevated risk of infant morbidity.

Data linkage capabilities in Australia: practical issues identified by a Population Health Research Network 'Proof of Concept project'.

OBJECTIVE: To describe the practical issues that need to be overcome to conduct national data linkage projects in Australia and propose recommendations to improve efficiency. METHODS: Review of the processes, documentation and applications required to conduct national data linkage in Australia. RESULTS: The establishment of state and national data linkage centres in Australia has placed Australia at the forefront of research linking health-related administrative data collections. However, improvements are needed to reduce the clerical burden on researchers, simplify the process of obtaining ethics approval, improve data accessibility, and thus improve the efficiency of data linkage research. CONCLUSIONS: While a sound state and national data linkage infrastructure is in place, the current complexity, duplication and lack of cohesion undermines any attempts to conduct research involving national record linkage in a timely manner. IMPLICATIONS: Data linkage applications and Human Research Ethics Committee approval processes need to be streamlined and duplication removed, in order to reduce the administrative and financial burden on researchers if national data linkage research is to be viable.

Standardising trauma monitoring: the development of a minimum dataset for trauma registries in Australia and New Zealand.

INTRODUCTION: Trauma registries are central to the implementation of effective trauma systems. However, differences between trauma registry datasets make comparisons between trauma systems difficult. In 2005, the collaborative Australian and New Zealand National Trauma Registry Consortium began a process to develop a bi-national minimum dataset (BMDS) for use in Australasian trauma registries. This study aims to describe the steps taken in the development and preliminary evaluation of the BMDS. METHODS: A working party comprising sixteen representatives from across Australasia identified and discussed the collectability and utility of potential BMDS fields. This included evaluating existing national and international trauma registry datasets, as well as reviewing all quality indicators and audit filters in use in Australasian trauma centres. After the working party activities concluded, this process was continued by a number of interested individuals, with broader feedback sought from the Australasian trauma community on a number of occasions. Once the BMDS had reached a suitable stage of development, an email survey was conducted across Australasian trauma centres to assess whether BMDS fields met an ideal minimum standard of field collectability. The BMDS was also compared with three prominent international datasets to assess the extent of dataset overlap. Following this, the BMDS was encapsulated in a data dictionary, which was introduced in late 2010. RESULTS: The finalised BMDS contained 67 data fields. Forty-seven of these fields met a previously published criterion of 80% collectability across respondent trauma institutions; the majority of the remaining fields either could be collected without any change in resources, or could be calculated from other data fields in the BMDS. However, comparability with international registry datasets was poor. Only nine BMDS fields had corresponding, directly comparable fields in all the national and international-level registry datasets evaluated. CONCLUSION: A draft BMDS has been developed for use in trauma registries across Australia and New Zealand. The email survey provided strong indications of the utility of the fields contained in the BMDS. The BMDS has been adopted as the dataset to be used by an ongoing Australian Trauma Quality Improvement Program.

Risk factors and obstetric complications of large for gestational age births with adjustments for community effects: results from a new cohort study.

BACKGROUND: High birth weight has serious adverse impacts on chronic health conditions and development in children. This study identifies the social determinants and obstetric complications of high birth weight adjusted for gestational age and baby gender. METHODS: Pregnant women were recruited from three maternity hospitals in South-East Queensland in Australia during antenatal clinic visits. A questionnaire was completed by each participant to elicit information on eco-epidemiological exposures. Perinatal information was extracted from hospital birth records. A hierarchical mixture regression model was used in the analysis to account for the heterogeneity of birth weights and identify risk factors and obstetric complications of births that were large for gestational age. A generalized linear mixed model was used to adjust for (random) "community" effects. RESULTS: Pre-pregnancy obesity (adjusted OR = 2.73, 95% CI = 1.49-5.01), previous pregnancy (adjusted OR = 2.03, 95% CI = 1.08-3.81), and married mothers (adjusted OR = 1.85, 95% CI = 1.00-3.42) were significantly associated with large for gestational age babies. Subsequent complications included the increased need for delivery by caesarean sections or instrumental procedures (adjusted OR = 1.98, 95% CI = 1.10-3.55), resuscitation (adjusted OR = 2.52, 95% CI = 1.33-4.79), and transfer to intensive/special care nursery (adjusted OR = 3.76, 95% CI = 1.89-7.49). Communities associated with a higher proportion of large for gestational age births were identified. CONCLUSIONS: Pre pregnancy obesity is the principal modifiable risk factor for large for gestational age births. Large for gestational age is an important risk factor for the subsequent obstetric complications. The findings improve the evidence-base on which to base preventive interventions to reduce the impact of high birth weight on maternal and child health.

The population approach to falls injury prevention in older people: findings of a two community trial.

BACKGROUND: There is a sound rationale for the population-based approach to falls injury prevention but there is currently insufficient evidence to advise governments and communities on how they can use population-based strategies to achieve desired reductions in the burden of falls-related injury. The aim of the study was to quantify the effectiveness of a streamlined (and thus potentially sustainable and cost-effective), population-based, multi-factorial falls injury prevention program for people over 60 years of age. METHODS: Population-based falls-prevention interventions were conducted at two geographically-defined and separate Australian sites: Wide Bay, Queensland, and Northern Rivers, NSW. Changes in the prevalence of key risk factors and changes in rates of injury outcomes within each community were compared before and after program implementation and changes in rates of injury outcomes in each community were also compared with the rates in their respective States. RESULTS: The interventions in neither community substantially decreased the rate of falls-related injury among people aged 60 years or older, although there was some evidence of reductions in occurrence of multiple falls reported by women. In addition, there was some indication of improvements in fall-related risk factors, but the magnitudes were generally modest. CONCLUSIONS: The evidence suggests that low intensity population-based falls prevention programs may not be as effective as those that are intensively implemented.

Rational allocation of Australia's research dollars: does the distribution of NHMRC funding by National Health Priority Area reflect actual disease burden?

OBJECTIVES: To explore National Health and Medical Research Council (NHMRC) funding for each National Health Priority Area (NHPA) over time and by grant type, and to quantify the relationship between grants awarded and a range of measures of societal burden of disease (BoD). DESIGN AND SETTING: We conducted a retrospective analysis of NHMRC funding for each NHPA from 2000 to 2008 to assess the strength of correlation between level of NHMRC funding and contribution of each health condition to BoD. Information on mortality, incidence, prevalence, "healthy" years of life lost due to disability (YLD), years of life lost due to premature mortality (YLL) and disability-adjusted life-years (DALYs) was obtained from the 2003 Australian BoD study. Information on health system expenditure for each NHPA was obtained from an Australian Institute of Health and Welfare report. MAIN OUTCOME MEASURES: Observed versus expected number of grants; amount of funding allocated to each NHPA; relative contribution of each NHPA health condition to BoD. RESULTS: 6099 new and continuing NHMRC grants were linked to NHPAs. Total NHMRC funding by NHPA was strongly correlated with YLL and DALYs, but there was no clear association between the amount of funding per NHPA and YLD or health system expenditure. Based on the proportional contribution of each NHPA health condition to total NHPA-related DALYs, a higher than expected number of grants was allocated to diabetes and cancer research, and a lower than expected number to injury and mental health research. CONCLUSIONS: Some of Australia's NHPAs are better funded than others. The NHMRC could begin to redress this imbalance by allocating research and workforce development funding to less well developed research areas to ensure appropriate resourcing that is commensurate with their contribution to BoD.

Contemporary New Zealand coefficients for the Trauma Injury Severity Score: TRISS(NZ).

AIMS: To develop local contemporary coefficients for the Trauma Injury Severity Score in New Zealand, TRISS(NZ), and to evaluate their performance at predicting survival against the original TRISS coefficients. METHODS: Retrospective cohort study of adults who sustained a serious traumatic injury, and who survived until presentation at Auckland City, Middlemore, Waikato, or North Shore Hospitals between 2002 and 2006. Coefficients were estimated using ordinary and multilevel mixed-effects logistic regression models. RESULTS: 1735 eligible patients were identified, 1672 (96%) injured from a blunt mechanism and 63 (4%) from a penetrating mechanism. For blunt mechanism trauma, 1250 (75%) were male and average age was 38 years (range: 15-94 years). TRISS information was available for 1565 patients of whom 204 (13%) died. Area under the Receiver Operating Characteristic (ROC) curves was 0.901 (95%CI: 0.879-0.923) for the TRISS(NZ) model and 0.890 (95% CI: 0.866-0.913) for TRISS (P<0.001). Insufficient data were available to determine coefficients for penetrating mechanism TRISS(NZ) models. CONCLUSIONS: Both TRISS models accurately predicted survival for blunt mechanism trauma. However, TRISS(NZ) coefficients were statistically superior to TRISS coefficients. A strong case exists for replacing TRISS coefficients in the New Zealand benchmarking software with these updated TRISS(NZ) estimates.

Using Trauma Injury Severity Score (TRISS) variables to predict length of hospital stay following trauma in New Zealand.

AIM: To develop and assess the predictive capabilities of a statistical model that relates routinely collected Trauma Injury Severity Score (TRISS) variables to length of hospital stay (LOS) in survivors of traumatic injury. METHOD: Retrospective cohort study of adults who sustained a serious traumatic injury, and who survived until discharge from Auckland City, Middlemore, Waikato, or North Shore Hospitals between 2002 and 2006. Cubic-root transformed LOS was analysed using two-level mixed-effects regression models. RESULTS: 1498 eligible patients were identified, 1446 (97%) injured from a blunt mechanism and 52 (3%) from a penetrating mechanism. For blunt mechanism trauma, 1096 (76%) were male, average age was 37 years (range: 15-94 years), and LOS and TRISS score information was available for 1362 patients. Spearman's correlation and the median absolute prediction error between LOS and the original TRISS model was p=0.31 and 10.8 days, respectively, and between LOS and the final multivariable two-level mixed-effects regression model was p=0.38 and 6.0 days, respectively. Insufficient data were available for the analysis of penetrating mechanism models. CONCLUSIONS: Neither the original TRISS model nor the refined model has sufficient ability to accurately or reliably predict LOS. Additional predictor variables for LOS and other indicators for morbidity need to be considered.

Implementing the national priorities for injury surveillance.

Injury is a leading cause of disability and death in Australia and is recognised as a national health priority area. The foundation of successful injury prevention is injury surveillance, and national policies and strategies developed over the past 20 years to reduce the burden of injury in Australia have included 22 recommendations on surveillance--only three of which have been completely implemented. Priorities for improving injury surveillance include: improving current injury mortality and morbidity data collection systems; filling the gaps in injury surveillance; maintaining vigilance over data quality; increasing the integration and accessibility of injury data; developing technical expertise in surveillance. Barriers to implementation of the current National Injury Prevention and Safety Promotion Plan include the lack of an implementation plan, performance management structure, appropriate national governance structure and resources--all of which could be overcome with government commitment.

Scald prevention campaigns: do they work?

The aim of this study was to quantify the effectiveness of the Queensland "Hot Water Burns Like Fire" campaign. Cross-section temperature sampling of households' bathroom hot water taps was conducted in Brisbane in 1990 before the intervention (n = 872) and in 2002 to 2003 after the intervention (n = 871). In both surveys, temperature was measured with thermometers held under running water from the bathroom hot tap until the reading stabilized (2 minutes). In 2002 to 2003 the interviewer also recorded whether or not the householder believed a tempering valve was installed in the home. The main injury outcome measure was all scald injury-related admissions at hospitals in Queensland from July 1990 to June 2003. The difference between the mean hot water tap temperature in 1990 and in 2002 to 2003 was determined with independent sample t-tests (P < .05). Rates of hospital admissions were grouped into two categories: scald injuries per year prior to the introduction of the hot water tempering valve legislation (April 1998) and scald injuries per year post-legislation. The difference between the preintervention and postintervention mean rates was determined with t-tests (P < .05). Additionally, the rates were plotted on a scatter plot by year, and a linear regression analysis was used to quantify the relationship with rates of scald-related injuries and year. The temperature in homes where the occupants reported having a tempering valve (mean = 55.5 degrees C) was significantly lower than in homes whose occupants reported not having a tempering valve (mean = 60.1 degrees C) or did not know whether they had a tempering valve (mean = 61.8 degrees C) (P < .01). However, the comparison of the hot water temperature between 1990 and 2002 to 2003 showed a significantly higher mean hot water temperature in 2002 to 2003 (P < .01). There was a significantly higher mean scald injury rate after the introduction of the "Hot Water Burns Like Fire" campaign (170.36/100,000) than before (113.41/100,000; P = .01). The linear regression line of best fit of these data has a slope of 10.43 (P < .01) and an r of 0.79. The results of this study suggest that the Queensland "Hot Water Burns Like Fire" campaign has not led to a significant reduction in hot water temperature or scald injury rates. The lack of effect identified in this study provides further evidence of the strong need to conduct rigorous evaluations of all major health promotion campaigns to add to the evidence base for such activities.

Mental health: a cause or consequence of injury? A population-based matched cohort study.

BACKGROUND: While a number of studies report high prevalence of mental health problems among injured people, the temporal relationship between injury and mental health service use has not been established. This study aimed to quantify this relationship using 10 years of follow-up on a population-based cohort of hospitalised injured adults. METHODS: The Manitoba Injury Outcome Study is a retrospective population-based matched cohort study that utilised linked administrative data from Manitoba, Canada, to identify an inception cohort (1988-1991) of hospitalised injured cases (ICD-9-CM 800-995) aged 18-64 years (n = 21,032), which was matched to a non-injured population-based comparison group (n = 21,032). Pre-injury comorbidity and post-injury mental health data were obtained from hospital and physician claims records. Negative Binomial regression was used to estimate adjusted rate ratios (RRs) to measure associations between injury and mental health service use. RESULTS: Statistically significant differences in the rates of mental health service use were observed between the injured and non-injured, for the pre-injury year and every year of the follow-up period. The injured cohort had 6.56 times the rate of post-injury mental health hospitalisations (95% CI 5.87, 7.34) and 2.65 times the rate of post-injury mental health physician claims (95% CI 2.53, 2.77). Adjusting for comorbidities and pre-existing mental health service use reduced the hospitalisations RR to 3.24 (95% CI 2.92, 3.60) and the physician claims RR to 1.53 (95% CI 1.47, 1.59). CONCLUSION: These findings indicate the presence of pre-existing mental health conditions is a potential confounder when investigating injury as a risk factor for subsequent mental health problems. Collaboration with mental health professionals is important for injury prevention and care, with ongoing mental health support being a clearly indicated service need by injured people and their families. Public health policy relating to injury prevention and control needs to consider mental health strategies at the primary, secondary and tertiary level.