Outdoor particulate matter exposure and upper respiratory tract infections in children and adolescents: A systematic review and meta-analysis.

BACKGROUND: While the relationship between outdoor particulate matter (PM) and lower respiratory tract infections in children and adolescents is accepted, we know little about the impacts of outdoor PM on the risk of developing or aggravating upper respiratory tract infections (URTIs). METHODS: We aimed to review the literature examining the relationship between outdoor PM exposure and URTIs in children and adolescents. A systematic search of EMBASE, MEDLINE, PubMed, Scopus, CINAHL and Web of Science databases was undertaken on April 3, 2020 and October 27, 2021. Comparable short-term studies of time-series or case-crossover designs were pooled in meta-analyses using random-effects models, while the remainder of studies were combined in a narrative analysis. Quality, risk of bias and level of evidence for health effects were appraised using a combination of emerging frameworks in environmental health. RESULTS: Out of 1366 articles identified, 34 were included in the systematic review and 16 of these were included in meta-analyses. Both PM2.5 and PM10 levels were associated with hospital presentations for URTIs (PM2.5: RR = 1.010, 95%CI = 1.007-1.014; PM10: RR = 1.016, 95%CI = 1.011-1.021) in the meta-analyses. Narrative analysis found unequivocally that total suspended particulates were associated with URTIs, but mixed results were found for PM2.5 and PM10 in both younger and older children. CONCLUSION: This study found some evidence of associations between PM and URTIs in children and adolescents, the relationship strength increased with PM10. However, the number of studies was limited and heterogeneity was considerable, thus there is a need for further studies, especially studies assessing long-term exposure and comparing sources.

Vegetation and vehicle emissions around primary schools across urban Australia: associations with academic performance.

BACKGROUND: Evolving evidence suggests that vegetation surrounding schools is beneficial to children's academic performance, however vehicle emissions are adversely related. Little is known about concurrent impacts of vegetation and vehicle emissions on academic performance. This study examined associations of vegetation and vehicle emissions near urban Australian primary schools with children's academic performance. METHODS: Vegetation within schoolyards and Euclidean buffers (100, 300 and 1000 m) was assessed using the Normalized Difference Vegetation Index (NDVI). Weighted road density (WRD) was computed for each buffer as a vehicle emissions proxy. Cross-sectional associations and mediating pathways between vegetation and vehicle emissions and standardized average academic scores in Literacy (Reading, Writing, Language Conventions) and Mathematics for Grades 3 and 5 attending 3745 primary schools in urban areas (population ≥10,000) of Australia in 2018 were assessed using generalised linear models adjusted for school socio-educational status. RESULTS: Significant positive associations were found between vegetation and Reading in Grades 3 and 5, Mathematics in Grade 3 (all buffers), Writing in Grade 3 (100 and 300 m), and Language Conventions in Grades 3 and 5 (most buffers). Increased vehicle emissions were negatively associated with Reading and Mathematics in Grades 3 and 5 (most buffers), and Language Conventions in Grade 3 (300 and 1000 m) and Grade 5 (100-1000 m). Within 300 m, vehicle emissions partially mediated associations between vegetation with Mathematics in Grade 3 (proportion mediated, 21%), Reading and Language Conventions in Grade 5 (15%, 37% respectively). CONCLUSIONS: Our findings contribute to growing evidence that vegetation around primary schools is associated with higher achievement in Literacy and Mathematics, with partial mediation by vehicle emissions. Future studies should conduct on-site measurement of vehicle emissions and audit vegetation around schools to confirm findings and inform urban/school planners and school leaders on designing and modifying school environments to support learning.

Differences in psychosocial distress among rural and metropolitan health care workers during the COVID-19 pandemic.

OBJECTIVE: The Australian COVID-19 Frontline Healthcare Workers study examined the prevalence and severity of mental health symptoms during the second wave of the COVID-19 pandemic. This substudy examined the differences in psychological well-being between rural and metropolitan health care workers (HCWs). DESIGN: A nationwide survey conducted between August and October 2020. SETTING AND PARTICIPANTS: Australian HCWs were recruited through multiple strategies. MAIN OUTCOME MEASURES: Demographics, mental health outcomes (anxiety, depression, post-traumatic stress disorder [PTSD] and burnout). RESULTS: Complete responses were included from 7846 participants, with 1473 (18.8%) in regional or remote ('rural') areas and 81.2% in metropolitan areas. Rural participants were older, more likely to work in allied health, nursing or in health administration, and had worked longer in their profession than metropolitan participants. Levels of resilience were similar (p = 0.132), but there was significantly higher prevalence of pre-COVID-19 pandemic mental illness in the rural workforce (p < 0.001). There were high levels of current mental health issues: moderate-severe PTSD (rural 38.0%; metropolitan 41.0% p = 0.031); high depersonalisation (rural 18.1%; metropolitan 20.7% p = 0.047); and high emotional exhaustion (rural 46.5%; metropolitan 43.3% p = 0.002). Among rural participants, mental health symptoms were associated with younger age, worry about being blamed if they contracted COVID-19, fear of transmitting COVID-19 to their family, experiencing worsening relationships and working in primary care or allied health. CONCLUSION: Despite having low COVID-19 case numbers in rural Australian health services compared with metropolitan counterparts over the course of 2020, there were widespread mental health impacts on the workforce. Rural health services need specific and flexible training, education, work policies and practices that support psychological well-being now in preparedness for ongoing or future crises.

Is short-term exposure to grass pollen adversely associated with lung function and airway inflammation in the community?

BACKGROUND: The association between grass pollen exposure and early markers of asthma exacerbations such as lung function changes and increase in airway inflammation is limited. We investigated the associations between short-term grass pollen exposure and lung function and airway inflammation in a community-based sample, and whether any such associations were modified by current asthma, current hay fever, pollen sensitization, age, and other environmental factors. METHODS: Cross-sectional and short-term analyses of data from the Melbourne Atopy Cohort Study (MACS) participants (n = 936). Lung function was assessed using spirometry. Airway inflammation was assessed by fractional exhaled nitric oxide (FeNO) and exhaled breath condensate pH and nitrogen oxides (NOx). Daily pollen counts were collected using a volumetric spore trap. The associations were examined by linear regression. RESULTS: Higher ambient levels of grass pollen 2 days before (lag 2) were associated with lower mid-forced expiratory flow (FEF25%-75% ) and FEV1 /FVC ratio (Coef. [95% CI] = -119 [-226, -11] mL/s and -1.0 [-3.0, -0.03] %, respectively) and also 3 days before (lag 3). Increased levels of grass pollen a day before (lag 1) were associated with increased FeNO (4.35 [-0.1, 8.7] ppb) and also at lag 2. Adverse associations between pollen and multiple outcomes were greater in adults with current asthma, hay fever, and pollen sensitization. CONCLUSION: Grass pollen exposure was associated with eosinophilic airway inflammation 1-2 days after exposure and airway obstruction 2-3 days after exposure. Adults and individuals with asthma, hay fever, and pollen sensitization may be at higher risk.

Associations of traffic-related air pollution and greenery with academic outcomes among primary schoolchildren.

BACKGROUND: There is preliminary evidence that greenery/greenspace around schools may be positively associated with children's cognitive development and academic outcomes, whereas traffic-related air pollution (TRAP) may have a detrimental effect. Few studies have examined pathways between both exposures and academic outcomes. This study aimed to assess associations between greenery, road traffic density (a proxy for TRAP) surrounding primary (elementary) schools, and academic achievement of primary schoolchildren in Melbourne, Australia. METHODS: This cross-sectional study examined mean academic scores in Years 3 and 5 for primary schools (n = 851) in Greater Melbourne. Scores were from the 2018 'National Assessment Program - Literacy and Numeracy' (NAPLAN) in five domains: 'Reading'; 'Writing'; 'Spelling'; 'Grammar & Punctuation' and 'Numeracy'. Greenery was measured within school boundaries and surrounding Euclidean buffers (100, 300, 1000 and 2000 m) using the Normalized Difference Vegetation Index (NDVI). Measured TRAP proxies were weighted road density (WRD) within the buffers and distance to a major road. Generalised Linear Models were used to examine associations of greenery and TRAP with academic scores (adjusted for school socio-educational status), and to identify mediating pathways. RESULTS: Greenery was positively associated with Reading scores in Year 3 (all buffers except 2000 m) and in Year 5 (all buffers), with Numeracy in Years 3 and 5 (all buffers) and with Grammar & Punctuation in Year 5 (all buffers). WRD was inversely associated with Reading scores in Year 5 (all buffers), with Numeracy in Year 3 (all buffers) and Year 5 (300 and 1000 m buffers), and with Grammar & Punctuation in Year 3 (100 and 300 m buffers) and Year 5 (all buffers). Distance to a major road was not associated with any score. TRAP partially mediated associations of greenery within 300 m with Numeracy in Year 3 and Grammar & Punctuation in Year 5, and within 2000 m for Reading in Year 5. CONCLUSIONS: Preliminary evidence indicated that greenery around primary schools was positively associated with Reading, Numeracy and Grammar & Punctuation scores, with TRAP mediating some associations. Further research is required to improve TRAP exposure assessment around schools to verify these findings and inform town/school planners and educators regarding optimal school locations and environments for promoting learning.

From urban neighbourhood environments to cognitive health: a cross-sectional analysis of the role of physical activity and sedentary behaviours.

BACKGROUND: There is a dearth of studies on the effects of the neighbourhood environment on adults' cognitive function. We examined how interrelated aspects of the built and natural neighbourhood environment, including air pollution, correlate with adults' cognitive function, and the roles of physical activity and sedentary behaviours in these associations. METHODS: We used data from 4,141 adult urban dwellers who participated in the Australian Diabetes, Obesity and Lifestyle 3 study on socio-demographic characteristics, neighbourhood self-selection, physical activity and sedentary behaviours, and cognitive function. Neighbourhood environmental characteristics included population density, intersection density, non-commercial land use mix, and percentages of commercial land, parkland and blue space, all within 1 km residential buffers. We also calculated annual mean concentrations of NO2 and PM2.5. Generalised additive mixed models informed by directed acyclic graphs were used to estimate the total, direct and indirect effects of environmental attributes on cognitive functions and the joint-significance test was used to examine indirect effects via behaviours. RESULTS: In the total effects models, population density and percentage of parkland were positively associated with cognitive function. A positive association of PM2.5 with memory was also observed. All neighbourhood environmental attributes were directly and/or indirectly related to cognitive functions via other environmental attributes and/or physical activity but not sedentary behaviours. Engagement in transportation walking and gardening frequency partially mediated the positive effects of the neighbourhood environment on cognitive function, while frequency of transportation walking mediated the negative effects. CONCLUSIONS: In the context of a low-density country like Australia, denser urban environments with access to parkland may benefit residents' cognitive health by providing opportunities for participation in a diversity of activities. A more fine-grained characterisation of the neighbourhood environment may be necessary to tease out the negative and positive impacts of inter-related characteristics of urban neighbourhood environments on cognitive function.

Association between fire smoke fine particulate matter and asthma-related outcomes: Systematic review and meta-analysis.

BACKGROUND: Asthma-related outcomes are regularly used by studies to investigate the association between human exposure to landscape fire smoke and health. Robust summary effect estimates are required to inform health protection policy for fire smoke exposure. OBJECTIVE: To conduct a systematic review and meta-analysis to estimate the association between short-term exposure to landscape fire smoke (LFS) fine particulate matter (PM2.5) and asthma-related outcomes. METHODS: We conducted a systematic review and meta-analysis following PRISMA guidelines. Four databases (PubMed, Medline, EMBASE and Scopus) and reference lists of recent fire smoke and health reviews were searched. The Newcastle-Ottawa Scale was used to evaluate the quality of case-crossover studies, and a previously validated quality assessment framework was used for observational studies lacking control groups. Publication bias was assessed using funnel plots and Egger's Test. The trim and fill method was used when there was evidence of publication bias. Sensitivity and influence analyses were conducted on all endpoints to test the robustness of estimates. Summary estimates were obtained for hospitalisations and emergency department (ED) visits. A descriptive analysis was conducted for physician visits, medication use, and salbutamol dispensations. RESULTS: From an initial 181 articles (after duplicate removal), 20 studies were included for quantitative assessment and descriptive synthesis. LFS PM2.5 levels were positively associated with asthma hospitalisations (RR = 1.06, 95% CI: 1.02-1.09) and emergency department visits (RR = 1.07, 95% CI: 1.04-1.09). Subgroup analyses found that females were more susceptible than males for ED visits, and that there was an increasing association by age groups for hospital admissions and ED visits. High heterogeneity between studies was observed, but results were robust to sensitivity analysis. CONCLUSIONS: Females and all adults aged over 65 years appear to be the population groups most sensitive to asthma-related outcomes when exposed to LFS PM2.5. Overall, results were higher than those obtained for a typical PM2.5 mixture.

Outdoor fungal spores and acute respiratory effects in vulnerable individuals.

BACKGROUND: Many outdoor fungal spores are ubiquitous, respirable and possibly allergenic. They may contribute to asthma symptoms; however, little is known about their effects on respiratory function. OBJECTIVE: To investigate if outdoor fungal spore levels were associated with lung function or airway inflammation, and whether fungal sensitization or current asthma modified any associations. METHODS: Cross-sectional associations between same day (Lag0) and cumulative 3-day lagged (Lag0-3) counts of 12 outdoor fungal spore taxa and pre-bronchodilator spirometry (FEV1, FVC, FEF25%-75%), bronchodilator response (BDR) and airway inflammation (fractional exhaled nitric oxide (FeNO) and exhaled breath condensate (EBC) nitrogen oxides (NOx) and pH were investigated in 936 Melbourne Atopy Cohort Study participants during September 2009 to December 2011. Generalized linear models were used to quantify associations with lung function, FeNO and EBC pH; generalized estimating equations for BDR; and ordinal logistic regression for EBC NOx. Models were adjusted for age, sex, height, temperature, relative humidity, grass pollen and sample storage time. Potential effect modification by fungal sensitization and current asthma were examined using interaction terms. RESULTS: Mixed associations were found. Higher levels of Ustilago/smuts were associated with lower lung function at Lag0 (FEV1: 21ml [95%CI -36, -7]; FEF25%-75%: 39ml [-65, -13]) and Lag0-3 (FEV1: 9ml [-14, -4]; FEF25%-75% -18ml [-27, -9]). Positive BDR was associated with Ustilago/smuts (Lag0 OR = 1.1 [1.04, 1.2]; Lag0-3 OR = 1.04 [1.02, 1.07]), Alternaria (Lag0 OR = 1.3 [1.0, 1.6]) and Drechslera (Lag0 OR = 1.1 [1.03, 1.2]). Higher EBC NOx was associated with Cladosporium (Lag0-3 OR = 1.1 [1.0, 1.2]), Alternaria (Lag0-3 OR = 1.1 [1.0, 1.3]). No associations were found with higher FeNO. In those with fungal sensitization, Ustilago/smuts and Drechslera were associated with lower FEV1 and FVC; Cladosporium was associated with increased FEV1, FVC and FEF25%-75% but also with higher FeNO and lower EBC pH. In those with current asthma, Alternaria, Ustilago/smuts and Drechslera were associated with lower FEV1, FVC, FEF25-75% and EBC pH. CONCLUSION: Exposure to outdoor fungal spores may be associated with lower lung function and increased airway inflammation, particularly in those with fungal sensitization and/or current asthma.

High ambient levels of grass, weed and other pollen are associated with asthma admissions in children and adolescents: A large 5-year case-crossover study.

BACKGROUND: Pollen is an important aeroallergen that triggers asthma exacerbations in children, but we know little about the impact of different pollen types in cities with varying climatic conditions and pollen seasons. OBJECTIVES: We aimed to assess the role of ambient level of different types of pollen on a large time series of child and adolescent asthma hospitalizations in Sydney, Australia. METHODS: Childhood asthma hospitalization and the daily ambient pollen concentrations of different species were collected in South-West Sydney. With a bidirectional case-crossover design, we fitted conditional logistic regression models to measure the associations between instantaneous and up to 3 days lagged effects of pollen concentrations on asthma hospitalizations after controlling for potential confounders and testing for interactions. RESULTS: A total of 2098 children, more boys (59.7%) and 2-5 years old (62.6%), were hospitalized due to asthma. The geometric mean concentration of Cupressus, 7.88 [5.02] grains/m3 , was the highest during the study period. The increase from 75th to 90th percentile of grass (OR = 1.037, 95% CI 1.005-1.070), weed other than Plantago species (OR = 1.053, 95% CI 1.009-1.098) and unclassified pollen (OR = 1.034, 95% CI 1.010-1.058) were significantly associated with the odds of asthma hospitalizations. Boys were at greater risk of asthma exacerbations associated with grass (OR = 1.046, 95% CI 1.003-1.090) and unclassified pollen (OR = 1.041, 95% CI 1.010-1.073). There was evidence of effect modification by age groups for Cupressus, conifer, total tree and total pollen. CONCLUSIONS: Although boys are more vulnerable to grass pollen, weed, and other pollen are also important triggers of asthma exacerbations in all children and adolescents. These findings are important for urban green space planning and the development of pollen monitoring systems for families with children at risk of asthma exacerbations during peak pollen seasons.

Associations between outdoor fungal spores and childhood and adolescent asthma hospitalizations.

BACKGROUND: Childhood asthma is a significant public health problem and severe exacerbations can result in diminished quality of life and hospitalization. OBJECTIVE: We sought to examine the contribution of outdoor fungi to childhood and adolescent asthma hospitalizations. METHODS: The Melbourne Air Pollen Children and Adolescent study is a case-crossover study of 644 children and adolescents (aged 2-17 years) hospitalized for asthma. The Melbourne Air Pollen Children and Adolescent study collected individual data on human rhinovirus infection and sensitization to Alternaria and Cladosporium and daily counts of ambient concentrations of fungal spores, pollen, and air pollutants. Conditional logistic regression models were used to assess associations with increases in spore counts while controlling for potential confounding and testing interactions. RESULTS: Exposure to Alternaria (adjusted odds ratio [aOR], 1.07; 95% CI, 1.03-1.11), Leptosphaeria (aOR, 1.05; 95% CI, 1.02-1.07), Coprinus (aOR, 1.04; 95% CI, 1.01-1.07), Drechslera (aOR, 1.03; 95% CI, 1.00-1.05), and total spores (aOR, 1.05; 95% CI, 1.01-1.09) was significantly associated with child asthma hospitalizations independent of human rhinovirus infection. There were significant lagged effects up to 3 days with Alternaria, Leptosphaeria, Cladosporium, Sporormiella, Coprinus, and Drechslera. Some of these associations were significantly greater in participants with Cladosporium sensitization. CONCLUSIONS: Exposures to several outdoor fungal spore taxa, including some not reported in previous research, are associated with the risk of child and adolescent asthma hospitalization, particularly in individuals sensitized to Cladosporium. We need further studies to examine cross-reactivity causing asthma exacerbations. Identifying sensitization to multiple fungal allergens in children with asthma could support the design and implementation of more effective strategies to prevent asthma exacerbations.

The role of outdoor fungi on asthma hospital admissions in children and adolescents: A 5-year time stratified case-crossover analysis.

BACKGROUND: Some fungal spores can trigger asthma exacerbation but knowledge of which outdoor fungal spores contribute to asthma hospitalisation is limited. OBJECTIVES: To examine the role of outdoor fungal spores in child and adolescent asthma hospitalisations. METHODS: We conducted a bi-directional time-stratified case-crossover study of child and adolescent asthma hospitalisations over 5 years. Conditional logistic regression assessed the role of 20 fungi taxa (Same day [L0] and lagged [L1-3]) adjusted for maximum temperature, humidity and grass pollen. Strata specific effects were explored if there was evidence of effect modification by age, sex, air pollutants or grass pollen. Non-linear effects examined with Generalized Additive Models. RESULTS: Of 2098 children hospitalised for asthma, 60% were boys; mean age was 5.5±3.7 years. Fungal spore counts peaked during warm months. Regression models found weak associations with Coprinus [L0,L1: OR=1.03, 1.01-1.06], Periconia [L0: OR=1.03, 1.001-1.07] and Chaetomium [L2: OR=1.08, 1.0-1.2]. Sex appeared to act as an effect modifier with girls having stronger associations with Cladosporium, Coprinus and total fungi. Older adolescent (14-18 years) hospitalisation was significantly associated with Coprinus and Ustilago/smuts. Air pollutants and grass pollen did not appear to act as effect modifiers. Non-linearity was not detected. CONCLUSION: There may be associations between some outdoor fungal spores and asthma hospitalisations. Further research needed to explore whether these findings can be replicated; and examine whether fungal sensitisation and/or human rhinovirus infections are associated with stronger effects. If findings are replicated, then the need to develop predictive models for fungal spore distribution and levels may become more important.

Effect of season of birth on cord blood IgE and IgE at birth: A systematic review and meta-analysis.

BACKGROUND: Elevated cord blood IgE is important on the pathway to allergic disease. The association between season of birth and infant cord blood IgE is not well-established. Study findings differ on which birth season is associated with higher cord blood IgE risk and its magnitude. We conducted a systematic review and meta-analysis of studies on season of birth and cord blood IgE. METHODS: We searched Medline, Web of Science, Scopus and ProQuest Health databases, and reviewed reference lists of articles that met the inclusion criteria. All included studies measured IgE as a binary variable using various cut-off values. We performed multivariate-random-effects meta-analysis to handle an exposure with multiple categories of Season of Birth. RESULTS: Our search identified 275 records and 10 had sufficient data to be included in a meta-analysis. Relative to summer, winter birth had the greatest odds of high IgE (≥ 0.1IU/ml), meta-analysis OR = 1.24 (95%CI: 1.01-1.52). A similar OR, was found for IgE ≥ 0.5 IU/ml, OR = 1.30 (95%CI: 0.99-1.71). CONCLUSIONS: A winter season of birth was associated with statistically significant higher odds of elevated cord blood IgE at cut-off ≥ 0.1IU/ml but borderline at cut-off ≥ 0.5IU/ml. This winter effect is likely to be a marker for a range of other environmental exposures during specific stages of pregnancy, such as aeroallergen exposures, maternal infections and vitamin D levels. Further research is required to support our finding and to identify the exact mechanisms that lead to the winter season of birth effect on circulating IgE levels, as this may have implications for allergic disease prevention.

Oral health-related knowledge, attitudes and self-efficacy of Australian rural older adults.

OBJECTIVE: A cross-sectional study was conducted involving older adults from social clubs within a regional local government area in the state of Victoria, Australia, to identify factors associated with knowledge, and attitudes about oral health, as well as perceived self-efficacy. METHODS: Participants underwent an oral health interview, followed by a comprehensive oral clinical examination. RESULTS: A total of 225 older adults participated in this study. The mean age was 70.7 (range: 55-96) years. The majority was females (62.0%) and had incomplete secondary education or less (56.1%); 34.2% were fully edentulous. The mean oral health knowledge score was 24.7 (SD 3.8). None of the socio-demographic and oral health variables yielded a significant effect on the knowledge score. The attitude score had a mean of 5.0 (SD 1.6). Four variables remained significant in the multivariate analysis [p < 0.0001]. A dentate female, with tertiary education, had better oral health attitudes. Higher oral health knowledge scores were associated with a better attitude. The overall self-efficacy mean value was 83.1% (SD 10.6). Dental visits and oral health knowledge remained significant in the attitudes multivariate analysis [p < 0.01]. CONCLUSION: Findings indicate that there were some misconceptions in oral health among this group of older adults. These are important influences on the success/failure of an oral health programme. Oral health education is needed to increase older adults' oral health knowledge, in particular of oral cancer, and to some extent periodontal disease, and improves attitudes and oral health self-efficacy. Oral health knowledge, attitudes and self-efficacy were minimally explained by socio-demographic and clinical variables.

The quality of cardiovascular disease prevention in rural primary care.

OBJECTIVE: To measure the differences in the recording of risk factors and lifestyle advice between those at high risk of cardiovascular disease and those diagnosed with cardiovascular disease, and to identify the practice characteristics associated with such recording in rural primary care. DESIGN: A cross-sectional observation study of 14 general practices. Medical records were audited to measure recording of risk factors and lifestyle advice for those at high risk of and those diagnosed with cardiovascular disease. Practice characteristics were collected, with logistic regression used to test for an association with the recording of risk factors. SETTING: General practices in rural Australia. PARTICIPANTS: Each practice was asked to identify 20 patients; 10 at high risk and 10 diagnosed with cardiovascular disease. MAIN OUTCOME MEASURES: The recording of risk factors and lifestyle advice in patient records and practice characteristics. RESULTS: 282 records were audited with 142 being high risk and 140 diagnosed with cardiovascular disease.Measures recorded significantly less in the high-risk group were: blood pressure (94% versus 99%; P = 0.019); physical activity (24% versus 56%; P = 0.000); dietary advice (32% versus 51%; P = 0.001); and physical activity advice (34% versus 56%; P = 0.000). Recording of risk factors was positively associated with practice involvement in quality improvement (P < 0.001), continuing education (P < 0.001), and greater percentage of general practitioners (P < 0.05) and practice nurses (P < 0.001). CONCLUSIONS: There is substantial room for enhanced cardiovascular disease prevention through rural primary care in Australia, particularly for high-risk patients. This study has demonstrated an association between practice factors (including targeted education, quality improvement activities and appropriate workforce) and improved preventive activities.

Prevention of cardiovascular disease in rural Australian primary care: an exploratory study of the perspectives of clinicians and high-risk men.

Rural primary care services have the potential to play a major role in reducing the gap in cardiovascular disease (CVD) outcomes between rural and metropolitan Australians, particularly in men at high risk of CVD. The aim of this study was to explore the self-reported behaviours and satisfaction with their general practice/practitioner of men at high risk of CVD, and attitudes of rural primary care clinicians regarding the role of primary care in CVD prevention. This observational research was addressed through survey questionnaires with rural men at high risk of CVD and semi-structured interviews with rural primary care clinicians. Fourteen rural primary care practices from towns with populations less than 25000 participated. One hundred and fifty-eight high-risk men completed the questionnaire. Their responses demonstrated poorly controlled risk factors despite a willingness to change. Alternatively, rural primary care clinicians (n=20) reported that patients were unlikely to change and that illness-based funding models inhibited cardiovascular preventive activities. Australians living in rural areas have worse CVD outcomes. In addition, there is a disparity in the assumptions of health providers and male patients at high risk of CVD in rural areas. This necessitates innovative rural primary care models that include a blended payment system that incentivises or funds preventive care alongside an emphasis on lifestyle advice, as well as an explicit strategy to influence clinician and patient behaviour to help address the disparity.

Outdoor fungi and child asthma health service attendances.

Asthma is a significant global public health issue. Severe asthma exacerbations can be triggered by environmental factors and require medical care from health services. Although it is known that fungal exposure may lead to allergic sensitization, little is understood about its impact on asthma exacerbations. This review aims to examine whether outdoor fungi play a significant role in child asthma exacerbations. Systematic search of seven electronic databases and hand searching for peer-reviewed studies published in English, up to 31 August 2013. Inclusion criteria were study population aged <18 yr, diagnosis of asthma, attended a health service; outdoor fungi exposure was reported. Quality and risk of bias assessments were conducted. Due to significant heterogeneity, meta-analysis was not conducted. Of the 1896 articles found, 15 were eligible. Findings were not consistent, possibly due to methodological variations in exposure classifications, statistical methods and inclusion of confounders. Cross-sectional studies found no or weak associations. All but one time series studies indicated an association that varied between fungal species. Increasing evidence indicates that asthmatic children are susceptible to asthma exacerbations when exposed to outdoor fungal spores. There is limited understanding of the contributions of different fungal species. Research is needed to investigate interactions of outdoor fungi with pollen, air pollutants and respiratory viruses.

Staff perceptions of primary healthcare service change: influences on staff satisfaction.

Strong primary healthcare (PHC) services are efficient, cost-effective and associated with better population health outcomes. However, little is known about the role and perspectives of PHC staff in creating a sustainable service. Staff from a single-point-of-entry primary health care service in Elmore, a small rural community in north-west Victoria, were surveyed. Qualitative methods were used to collect data to show how the key factors associated with the evolution of a once-struggling medical service into a successful and sustainable PHC service have influenced staff satisfaction. The success of the service was linked to visionary leadership, teamwork and community involvement while service sustainability was described in terms of inter-professional linkages and the role of the service in contributing to the broader community. These factors were reported to have a positive impact on staff satisfaction. The contribution of service delivery change and ongoing service sustainability to staff satisfaction in this rural setting has implications for planning service change in other primary health care settings. WHAT IS KNOWN ABOUT THIS TOPIC?: Integrated PHC services have an important role to play in achieving equitable population health outcomes. Many rural communities struggle to maintain viable PHC services. Innovative PHC models are needed to ensure equitable access to care and reduce the health differential between rural and metropolitan people. WHAT DOES THIS PAPER ADD?: Multidisciplinary teams, visionary leadership, strong community engagement combined with service partnerships are important factors in the building of a rural PHC service that substantially contributes to enhanced staff satisfaction and service sustainability. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Understanding and engaging local community members is a key driver in the success of service delivery changes in rural PHC services.

Oral healthcare issues in rural residential aged care services in Victoria, Australia.

OBJECTIVES: To identify major issues in providing and accessing oral health care in Victorian rural residential aged care services from the perspectives of dentists, aged care staff and residents. METHODS: Structured interviews were conducted with five dentists, nine aged care staff and six residents. Three focus groups were conducted with aged care staff. These data were thematically analysed independently by two researchers. RESULTS: The challenges reported by dentists included complexity of care, infrastructure needs and need for skill development. Aged care staff reported lack of skills and confidence in providing oral hygiene care, especially in residents with natural teeth, and an increasing burden on their daily workload. Residents reported concern and shame regarding their declining oral health status and increased challenges accessing appropriate oral health care. CONCLUSION: These findings indicate the need to build and sustain aged care 'oral health teams' who are able to provide daily oral hygiene care for residents and mentor other staff. Rural dentists need access to gerodontic training, portable equipment and appropriate workspaces in aged care services. Aged care and oral health services need to establish clear referral and communication pathways.

Improving traffic-related air pollution estimates by modelling minor road traffic volumes.

Accurately estimating annual average daily traffic (AADT) on minor roads is essential for assessing traffic-related air pollution (TRAP) exposure, particularly in areas where most people live. Our study assessed the direct and indirect external validity of three methods used to estimate AADT on minor roads in Melbourne, Australia. We estimated the minor road AADT using a fixed-value approach (assuming 600 vehicles/day) and linear and negative binomial (NB) models. The models were generated using road type, road importance index, AADT and distance of the nearest major road, population density, workplace density, and weighted road density. External measurements of traffic counts, as well as black carbon (BC) and ultrafine particles (UFP), were conducted at 201 sites for direct and indirect validation, respectively. Statistical tests included Akaike information criterion (AIC) to compare models' performance, the concordance correlation coefficient (CCC) for direct validation, and Spearman's correlation coefficient for indirect validation. Results show that 88.5% of the roads in Melbourne are minor, yet only 18.9% have AADT. The performance assessment of minor road models indicated comparable performance for both models (AIC of 1,023,686 vs. 1,058,502). In the direct validation with external traffic measurements, there was no difference between the three methods for overall minor roads. However, for minor roads within residential areas, CCC (95% confidence interval [CI]) values were -0.001 (-0.17; 0.18), 0.47 (0.32; 0.60), and 0.29 (0.18; 0.39) for the fixed-value approach, the linear model, and the NB model, respectively. In the indirect validation, we found differences only on UFP where the Spearman's correlation (95% CI) for both models and fixed-value approach were 0.50 (0.37; 0.62) and 0.34 (0.19; 0.48), respectively. In conclusion, our linear model outperformed the fixed-value approach when compared against traffic and TRAP measurements. The methodology followed in this study is relevant to locations with incomplete minor road AADT data.