Interventions for preventing injuries in the agricultural industry.

BACKGROUND: Agriculture is more hazardous than most other industries. Many strategies have been introduced to reduce injuries in the field, yet the effectiveness of different interventions on occupational injuries still remains unclear. OBJECTIVES: This review aims to determine the effectiveness of interventions to prevent occupational injuries among workers in the agricultural industry compared to no interventions or to alternative interventions. SEARCH STRATEGY: Cochrane Central Register of Controlled Trials, Cochrane Injuries Group's specialised register, MEDLINE, EMBASE, PsychINFO, OSH-ROM (including NIOSHTIC and HSELINE) databases were searched up to June 2006. Reference lists of selected articles, relevant reviews and additional topic related databases and web sites were also searched. The searches were not restricted by language or publication status. SELECTION CRITERIA: Randomised controlled trials, cluster-randomised controlled trials, prospective cohort studies with a concurrent control group, and interrupted time series studies assessing any type of intervention aiming to prevent fatal or non-fatal injuries among workers in agriculture. DATA COLLECTION AND ANALYSIS: Two reviewers conducted data extraction and study quality assessment independently. Rate ratios of randomised controlled trials were calculated and the effect sizes were combined in a meta-analysis. Interrupted time series studies were reanalysed and each of them studied for having an immediate and a progressive effect. MAIN RESULTS: Five randomised controlled trials (RCTs) with 11,565 participants and three interrupted time series studies (ITSs) with 26.3 data points on average met the criteria. For educational interventions aiming at reducing injury rates among adults the pooled rate ratio after recalculation from effect sizes in three RCTs was 1.02 (95% CI 0.87 to 1.20). For educational interventions aiming at children the pooled rate ratio for injury rates in two RCTs was 1.27 (95% CI 0.51 to 3.16). One ITS that evaluated the effect of an intervention that included financial incentives decreased the injury level immediately after the intervention with an effect size of -2.68 (95% CI -3.80 to -1.56) but did not have a significant effect on the injury trend over time with an effect size of -0.22 (95% CI -0.47 to 0.03). One ITS study that evaluated the effect of legislation to ban Endosulfan pesticide on fatal pesticide poisonings increased the level of poisonings immediately after the introduction with an effect size of 2.20 (95% CI 0.97 to 3.43) but led to decrease in the trend of poisonings over time with an effect size of -2.15 (95% CI -2.64 to -1.66). One ITS study documented four different regulations aiming to increase the use of rollover protective structures (ROPS) on tractors and their effect on injuries and fatal injuries. The introduction of two different pieces of legislation requiring ROPS on new tractors sold after a certain date was associated with a decrease of fatal injuries over the long term (effect size -0.93 95% CI -1.02 to -0.03) but they were also associated with an increase of injuries in general (fatal and non-fatal injuries combined). Introduction of legislation requiring ROPS on all tractors, old tractors included, was not associated with a decrease but with an increase of injuries and fatal injuries over the long term. AUTHORS' CONCLUSIONS: The selected studies provided no evidence that educational interventions are effective in decreasing injury rates among agricultural workers. Financial incentives could reduce injury rates. Legislation to ban pesticides could be effective. Legislation expanding the use of safety devices (ROPS) on new tractors was associated with a decrease in fatal injuries.

Evaluation of the Latrobe Valley Better Health Injury Prevention Program.

OBJECTIVE: To evaluate the Latrobe Valley Better Health Injury Prevention Program, a regional community based intervention in south east Victoria, Australia. METHOD: The evaluation design was quasiexperimental including pre-intervention and post-intervention observations in a predominately town dwelling population of approximately 76,000. There was no comparison community. Process measures included key informant interviews. Impact evaluation utilised self reported changes in injury risk and protective factors, gathered by a random household telephone survey. Outcome evaluation was based on five years of emergency department injury surveillance data for the Latrobe Valley. RESULTS: The program built strategic partnerships, increasing the emphasis on local safety. Activities were implemented in the targeted areas of home, sport, and playground injuries. Some 47,000 educational contacts were made with the community and at least 6,000 resource items distributed. There were significant increases in home safety knowledge. Some changes in the areas of playground and sport safety were achieved after partnership development with relevant agencies. Poisson regression models showed significant decreases in the presentation rate for all home injury and for the more severe home injuries. CONCLUSION: This study clearly demonstrates the difficulty of conducting robust evaluation in the absence of readily available and reliable data and adequate budgets. The Latrobe Valley Better Health Program activities contributed to structural, environmental, and organisational changes that have the potential to reduce injury. The extent of this contribution beyond that made by the statewide injury prevention strategy is not able to be determined.

An impact evaluation of a falls prevention program among older people.

The aim of this evaluation study was to assess the impact of peer-presented education sessions on the falls-related attitude, knowledge and behaviour of older people. The evaluation was undertaken on the Bellarine Peninsula in Victoria, Australia, and adopted a non-randomised pre-test post-test design. Baseline, 3 and 12 months follow-up data were collected for 107 individuals who attended the education sessions and 116 controls, matched by age range and sex. The groups were not strictly equivalent at baseline, with the intervention group having a greater knowledge about falls and falls prevention. Analyses which controlled for baseline differences showed that those who attended the education sessions maintained a greater knowledge of factors that can prevent falls at 12 months follow-up. The intervention group also made more changes in and around their home to prevent falls by 3 and 12 months follow-up. Younger participants who reported a previous history of falls and having taken action to prevent falls were most likely to take additional action. The results can help target this type of education program and suggest that their major benefit may lie in providing those who voluntarily attend with the impetus to take the most effective preventative action.

Unintentional poisoning hospitalisations among young children in Victoria.

OBJECTIVES: To describe the epidemiology of unintentional childhood poisoning hospitalisation in Victoria, Australia, in order to monitor trends and identify areas for research and prevention. METHODS: For children under 5 years, all Victorian public hospital admissions, July 1987 to June 1995, due to unintentional poisoning by drugs, medicines, and other substances were analysed. Similar cases were also extracted from the database of the Royal Children's Hospital intensive care unit, Melbourne for the years 1979-91. Log linear regression modelling was used for trend analyses. RESULTS: The annual average childhood unintentional poisoning rate was 210.7 per 100,000. Annual rates for males consistently exceeded those for females. The most common agents were those acting on the respiratory system and on smooth and skeletal muscles (muscle relaxants, cough and cold medicines, antiasthmatics), aromatic analgesics (paracetamol), and systemic agents (including antihistamines). Further investigation is justified for cardiac agents, some respiratory agents, and asthma medications. CONCLUSIONS: Childhood poisoning hospitalisation rates have not decreased in Victoria over recent years. A focused, agent specific approach, as well as a series of generic measures for the prevention of poisoning to children under 5 is advocated. The ongoing surveillance, collection and analysis of data, in addition to research on specific poisoning agents are essential components of any prevention strategy.

Farm work related fatalities among adults in Victoria, Australia: the human cost of agriculture.

The purpose of this study was to review the patterns of, and trends in, farm work related fatalities among adults in one Australian state for the period 1985-1996. Fatality data was provided by the Victorian Workcover Authority Health and Safety Division. Trends were determined using regression techniques assuming a Poisson error structure for annual fatality rates. Results showed an annual average of eight deaths. Males, and those 60 years and over, were over-represented, compared to persons employed. Tractor incidents were the most common type of fatality (72%), with tractor roll overs accounting for 61% of all tractor incidents. Non tractor fatalities included being hit by a falling object and transport incidents. Statistical trend analyses revealed a non significant decrease in the tractor roll over fatality rate, and significant increases in the all farm (P = 0.004) and non tractor fatality rates (P = 0.036). The 3 year moving average rate for non tractor farm fatalities has increased to the point where it exceeds that for tractor roll over fatalities, and is approaching that for all tractor fatalities. Changes within the agricultural industry, coupled with the ageing of the farm workforce, appear to placing Victorian farmers at increased risk of farm work related death.

Rediscovering method II as a reimbursement option.

Recent discussions within the renal community confirm the following: we are in an evolving health care environment that obliges us to review reimbursement opportunities that promote patient care, contain costs, and maximize revenues. This article will look at a sometimes overlooked option--Method II reimbursement for home dialysis patients--as a way for dialysis facilities to work within the established rules to both benefit patients and the overall dialysis program.

Eucalyptus oil poisoning among young children: mechanisms of access and the potential for prevention.

We studied unintentional paediatric eucalyptus oil poisoning to identify potential intervention strategies. The epidemiology of paediatric eucalyptus oil poisoning in Victoria was determined by analysis of four databases. The sequence of events preceding ingestion was examined by a telephone survey involving 109 parents or guardians of children under five years involved in an actual or suspected ingestion of eucalyptus oil. Such children were identified prospectively from all callers during a nine-month period to the Victorian Poisons Information Centre and those presenting to the emergency departments of the participating hospitals of the Victorian Injury Surveillance System. Eucalyptus oil was a leading agent associated with hospitalisation for poisoning among Victorian children aged under five years. In the telephone survey, 90 incidents were found to involve vaporiser solutions, 15 eucalyptus oil preparations, and the remainder other eucalyptus-oil-containing products of a medicinal nature. Regardless of the type of product, 74 per cent gained access via a home vaporiser unit, most frequently placed at ground level. Although amounts ingested are usually small, the reported range of toxic doses is wide, necessitating at least a medical assessment following ingestion. Potential countermeasures identified in a consultative workshop included: discontinuing the use of eucalyptus oil as a therapeutic agent; confirmation that vaporiser-well residues are nontoxic; removal of barriers to product reregistration following safety-related modifications; improved child-resistant closures; discouraging vaporiser use for respiratory infections among young children; and development and dissemination of protocols for treatment of suspected ingestion.

A cost analysis of family planning in Bangladesh.

This article presents a step-down cost analysis using secondary data sources from 26 Bangladesh non-government organizations (NGOs) providing family planning services under a US Agency for International Development-funded umbrella organization. The unit costs of the NGOs' Maternal-Child Health (MCH) clinics and community-based distribution (CBD) systems were calculated and found to be minimally different. Several simulations were conducted to investigate the impact of alternative cost-reduction measures. The more general financial analysis proved more insightful than the unit cost analysis in terms of identifying means by which to improve the efficiency of the family planning operations of these NGOs. The analysis revealed that 56 per cent of total expenditures in the two-tiered umbrella's organizational structure are incurred in management operations and overheads. Of the remaining 44 per cent of project expenditures, 39 per cent is spent on the CBD program and 5 per cent on the MCH clinics. Within the CBD program, most resources are spent providing 4 million contacts (two-thirds of the annual total) which do not involve contraceptive re-supply. The clinics devote more resources to providing MCH services than to providing family planning services. The findings suggest that significant savings could be generated by containing administrative costs, improving operational efficiency, and reducing unnecessary or redundant fieldworker contacts. The magnitude of the potential savings raises a fundamental question about the continued viability and sustainability of this supply-driven CBD strategy.

PIP: A successful supply-side approach has governed the delivery of family planning in Bangladesh for the past 20 years. The heart of the current system is an extensive community-based distribution (CBD) system which provides free door-to-door services and visits almost every eligible couple in the country 6 times per year. However, considerable program overlap and duplication waste resources. The current system is also inefficient because of its reliance upon relatively more expensive re-supply methods and its failure to consider contraceptive demand. With US Agency for International Development (USAID) funding likely to be reduced in the coming years, an impending need exists to improve system efficiency. Findings are presented from a step-down cost analysis using secondary data sources from 26 Bangladeshi nongovernmental organizations (NGOs) which provide family planning services through a USAID-funded umbrella organization. 56% of total expenditures in this 2-tiered umbrella's organizational structure are incurred in management operations and overhead expenses. 88% of the remaining program funds are spent upon the CBD program and 12% are spent upon maternal-child health (MCH) clinic activities. Most CBD program resources are spent providing 4 million contacts which do not involve contraceptive re-supply, with the clinics devoting more resources to providing MCH services than to providing family planning services. Significant savings could be generated through containing administrative costs, improving operational efficiency, and reducing unnecessary or redundant field worker contacts.

Rodenticide poisoning among children.

We aimed to determine the nature, extent and sequence of events of accidental childhood poisoning with rodenticides and identify potential intervention strategies. Subjects were identified prospectively from callers to the Victorian Poisons Information Centre and those presenting to the Emergency Departments of hospitals participating in the Victorian Injury Surveillance System from 1 April to 31 December 1993. The events preceding rodenticide ingestion were examined via telephone questionnaire involving 128 parents or guardians of children under five years exposed to rodenticides. Rodenticides are not leading agents for severe poisoning but are a frequent and increasing cause of less severe poisoning. Most children (90 per cent) had obtained the rodenticide from the site at which it had been laid, usually by the caregiver (67 per cent), in the kitchen, lounge room or laundry, inside cupboards or-wardrobes. In 69 per cent of these cases, respondents thought the site would not normally allow access to children. Only 13 per cent of children were admitted to hospital, although 41 per cent sought medical attention. Most caregivers (90 per cent) were aware of some dangers associated with rodenticides. Children usually ingest insufficient amounts of rodenticide to cause serious effects. However, medical assessment and monitoring of prothrombin times is often indicated, with a consequent cost to the healthcare system. Potential countermeasures, focusing on packaging and positioning of rodenticide baits, product reformulation, and the distribution of management guidelines for health workers, were identified. Implementation of the identified countermeasures was initiated by a workshop involving stakeholders from industry, research and health professions.

What are the options for nephrologists under capitation?

Nephrologists will play a pivotal role in changing tomorrow's renal delivery system. Nephrologists still control patients and drive the health care delivered to patients suffering from ESRD. As a result, practice management companies, independent consulting firms, renal societies, hospitals, dialysis providers, insurance companies, managed care plans, government agencies, and, yes, even independent practice groups are exploring business strategies that will unite nephrologists under a common goal--that of an integrated renal delivery network. Nephrologists face what is probably their professional career's most important business decision: Partner with such organizations as hospitals, dialysis providers, or practice management companies, or form an independent nephrologist owned IPA and contract with an MSO. As nephrologists evaluate the options, they should seek partners that will at a minimum provide the following: a business plan that spells out the relationships of all the players; practice evaluations that can improved efficiencies; skilled day-to-day practice management; model legal documents; human resource management; expert, pro-physician reimbursement negotiation, coupled with a system to track contract profitability; case management, critical paths, practice guidelines; and renal industry expertise. Above all, nephrologists should seek partners in the formation of an integrated delivery system that offer an attitude dedicated to physician empowerment in the interest of good patient care.

Injury mortality in adults 25-64 years of age: implications for prevention.

The aim of this retrospective study was to identify major categories of death from injury in the age range 25 to 64 years and their potential for prevention. We analysed the Victorian Coroner's database of deaths from injury for the three years from 1989-90 to 1991-92. The major causes of death were suicide (39.9 per cent) and transport-related injury (30.2 per cent). Males accounted for 75.4 per cent of injury deaths. The highest mortality rate was in the youngest age group, 25 to 29 years. Deaths from injury in the study age range accounted for slightly more than half of all deaths from injury in Victoria, although this age group had a lower mortality rate than other age groups. Specific issues for prevention programs include reduction of access to carbon monoxide car emissions and prevention of transport-related injury to motor vehicle occupants. Data reliability issues identified in this study have implications for refinements of the Victorian Coroner's database and hence for the National Coronial Information System currently under development.

Injury morbidity in Victoria among adults 25 to 64 years of age: implications for prevention.

The aim of this retrospective study was to complete the baseline descriptive epidemiology of hospital-treated injury for all ages in Victoria, by focusing on the age group, 25 to 64 years, to identify major categories of injury and the potential for prevention. We analysed injury databases for hospital admissions and emergency department presentations for major variables influencing injury frequency and rates. We found that nearly 40 per cent (158 537) of all hospitalisations for injury occurred in the study age range. The major causes of injury were health-care related causes (32 per cent), falls (15 per cent), transport (14 per cent), and intentional causes (10 per cent). The leading reason for emergency department presentation (excluding admission) was unintentional cutting or piercing injury. The home was the major location of injury. Vehicles, man-made and natural surfaces, knives, and floors and flooring materials were among the leading five factors potentially associated with both admissions and presentations. Injury prevention in this age range will be largely addressed by the injury-prevention strategy being implemented in Victoria. However, specific additional issues were identified, including falls from ladders and scaffolds, pedestrian and female passenger injury, and injury associated with power tools, chain saws, and knives.