Efficacy of infant simulator programmes to prevent teenage pregnancy: a school-based cluster randomised controlled trial in Western Australia.

BACKGROUND: Infant simulator-based programmes, which aim to prevent teenage pregnancy, are used in high-income as well as low-income and middle-income countries but, despite growing popularity, no published evidence exists of their long-term effect. The aim of this trial was to investigate the effect of such a programme, the Virtual Infant Parenting (VIP) programme, on pregnancy outcomes of birth and induced abortion in Australia. METHODS: In this school-based pragmatic cluster randomised controlled trial, eligible schools in Perth, Western Australia, were enrolled and randomised 1:1 to the intervention and control groups. Randomisation using a table of random numbers without blocking, stratification, or matching was done by a researcher who was masked to the identity of the schools. Between 2003 and 2006, the VIP programme was administered to girls aged 13-15 years in the intervention schools, while girls of the same age in the control schools received the standard health education curriculum. Participants were followed until they reached 20 years of age via data linkage to hospital medical and abortion clinic records. The primary endpoint was the occurrence of pregnancy during the teenage years. Binomial and Cox proportional hazards regression was used to test for differences in pregnancy rates between study groups. This study is registered as an international randomised controlled trial, number ISRCTN24952438. FINDINGS: 57 (86%) of 66 eligible schools were enrolled into the trial and randomly assigned 1:1 to the intervention (28 schools) or the control group (29 schools). Then, between Feb 1, 2003, and May 31, 2006, 1267 girls in the intervention schools received the VIP programme while 1567 girls in the control schools received the standard health education curriculum. Compared with girls in the control group, a higher proportion of girls in the intervention group recorded at least one birth (97 [8%] of 1267 in the intervention group vs 67 [4%] of 1567 in the control group) or at least one abortion as the first pregnancy event (113 [9%] vs 101 [6%]). After adjustment for potential confounders, the intervention group had a higher overall pregnancy risk than the control group (relative risk 1·36 [95% CI 1·10-1·67], p=0·003). Similar results were obtained with the use of proportional hazard models (hazard ratio 1·35 [95% CI 1·10-1·67], p=0·016). INTERPRETATION: The infant simulator-based VIP programme did not achieve its aim of reducing teenage pregnancy. Girls in the intervention group were more likely to experience a birth or an induced abortion than those in the control group before they reached 20 years of age. FUNDING: Western Australian Health Promotion Foundation (Healthway), Lotteries WA, the Western Australian Department of Education and Training, and the Western Australian Department of Health.

Burden of stroke in indigenous Western Australians: a study using data linkage.

BACKGROUND AND PURPOSE: Despite the disproportionate burden of cardiovascular disease among indigenous Australians, information on stroke is sparse. This article documents the incidence and burden of stroke (in disability-adjusted life years) in indigenous and non-indigenous people in Western Australia (1997-2002), a state resident to 15% of indigenous Australians comprising 3.4% of the population of Western Australia. METHODS: Indigenous and non-indigenous stroke incidence and excess mortality rates were estimated from linked hospital and mortality data, with adjustment for nonadmitted events. Nonfatal burden was calculated from nonfatal incidence, duration (modeled from incidence, excess mortality, and remission), and disability weights. Stroke death counts formed the basis of fatal burden. Nonfatal and fatal burden were summed to obtain disability-adjusted life years, by indigenous status. RESULTS: The total burden was 55 099 and 2134 disability-adjusted life years in non-indigenous and indigenous Western Australians, respectively. The indigenous to non-indigenous age-standardized stroke incidence rate ratio (≥15 years) was 2.6 in males (95% CI, 2.3-3.0) and 3.0 (95% CI, 2.6-3.5) in females, with similar rate ratios of disability-adjusted life years. The burden profile differed substantially between populations, with rate ratios being highest at younger ages. CONCLUSIONS: The differential between indigenous and non-indigenous stroke burden is considerable, highlighting the need for comprehensive intersectoral interventions to reduce indigenous stroke incidence and improve outcomes. Programs to reduce risk factors and increase access to culturally appropriate stroke services are required. The results here provide the quantitative basis for policy development and monitoring of stroke outcomes.

Excess mortality rates for estimating the non-fatal burden of stroke in Western Australia: a data linkage study.

BACKGROUND: Non-fatal stroke burden measured in Years Lived with Disability (YLD) requires valid estimates of stroke case fatality to allow modelling of disease duration. In the model, case fatality can be calculated from the absolute risk of mortality in cases in excess of that in the non-diseased. AIMS: Our purpose was to estimate excess mortality rates in 28-day survivors of stroke in Western Australia and to evaluate differentials in survival by stroke type, age and time since the first stroke event. METHOD: Excess mortality among prevalent (first-ever plus existing) survivors was estimated from linked hospital and mortality data. Changes in excess mortality over time were calculated over a 6-year period. RESULTS: Excess mortality increased with age for both males (21 per 1,000 in the 15- to 54-year to 109 per 1,000 in the > or =85-year age group) and females (16 and 122 per 1,000 for the 15- to 54-year and > or =85-year groups, respectively). Survival by stroke sub-types differed at ages <55 years but not >55 years. During the first year excess mortality was markedly higher, after which it was relatively constant for each age group. The assumption of constant rather than changing excess mortality in 28-day survivors of stroke had minimal effect on estimates of duration. CONCLUSION: Measures of excess mortality in prevalent survivors have not previously been available for estimating YLD for stroke. An analysis of all stroke types combined is not likely to substantially bias estimates of non-fatal stroke burden nor is an assumption of constant excess mortality for survivors.

Mortality in a cohort of opiate and amphetamine users in Perth, Western Australia.

AIMS: This study compares the hazard of death among opiate and amphetamine using clients who accessed drug treatment with individuals who had no specialist treatment contact between 1985 and 1998. DESIGN, SETTING, PARTICIPANTS: This was a retrospective cohort study of 4280 drug-using individuals (2887 opiate users, 1393 amphetamine users) admitted to Perth metropolitan hospitals or Perth psychiatric institutions between 1985 and 1998. Of these, 1469 attended Next Step Specialist Drug and Alcohol Services (928 received methadone and 541 attended counselling or support groups) and 2811 had no contact with this service. METHODS: Data from two drug treatment programmes were linked with hospital morbidity, psychiatric services and the mortality database using record linkage. FINDINGS: The results show that people who were currently in drug treatment had a lower hazard of death compared with non-clients and those who had ceased treatment. Those who had ceased treatment more than 6 months ago had 7.0 times the hazard of all-cause death and 8.4 times the hazard of drug-cause death. Opiate users were at 1.4 times the hazard of all-cause death and 2.4 times the hazard of drug-cause death compared with amphetamine users. Males were at 1.79 times the hazard of all-cause death and, unexpectedly, were found to be at 2.69 times the hazard of drug-cause death compared with females. CONCLUSIONS: Treatment protected clients from premature death compared with people who did not receive treatment and also those who ceased treatment. While amphetamine users had a lower risk of mortality compared with opiate users, the full extent of the relationship between amphetamine use and mortality needs to be examined further.

Disability burden due to stroke in Western Australia: new insights from linked data sources.

BACKGROUND: The disability-adjusted life year index is used extensively to compare disease burden among diseases and locations, but difficulties remain in accurately estimating the nonfatal stroke burden in years lived with disability. AIMS: To improve stroke-related years lived with disability estimates in Western Australia for 2000, by improving the accuracy of component inputs: nonfatal (28-day survivor) incidence, disease duration and disability (severity) weights. METHODS: Nonfatal stroke incidence and the mortality difference between prevalent cases and the general population were estimated from linked hospital and mortality data using the Western Australian Data Linkage System. dismod software used these inputs to model disease duration. Disability weights were estimated from population-based stroke survey data, using indirect health valuation methods and adjusting for prestroke disability. Years lived with disability were calculated from the three components. RESULTS: The annual age-standardised nonfatal incidence (n=1985) was higher in males (121/100,000) than females (96/100,000). The duration varied between 35.8 (females 15-24 years) and 3.4 years (males 85+ years). The mean pre-stroke-adjusted disability weight was higher at 4-months (0.38) than at 12-months (0.31). The age-standardised rate of nonfatal burden in males (302/100,000; 95% CI 290-314) was significantly higher than that in females (250/100,000; 95% CI 240-260). The nonfatal proportion of stroke burden (males 45%; females 37%) was higher than estimated in previous studies. CONCLUSION: This study illustrates that previous reports most likely underestimated disability burden as a contributor to the total stroke burden in Australia. Methodological refinements will contribute to burden of disease studies elsewhere.

Study protocol for the evaluation of an Infant Simulator based program delivered in schools: a pragmatic cluster randomised controlled trial.

BACKGROUND: This paper presents the study protocol for a pragmatic randomised controlled trial to evaluate the impact of a school based program developed to prevent teenage pregnancy. The program includes students taking care of an Infant Simulator; despite growing popularity and an increasing global presence of such programs, there is no published evidence of their long-term impact. The aim of this trial is to evaluate the Virtual Infant Parenting (VIP) program by investigating pre-conceptual health and risk behaviours, teen pregnancy and the resultant birth outcomes, early child health and maternal health. METHODS AND DESIGN: Fifty-seven schools (86% of 66 eligible secondary schools) in Perth, Australia were recruited to the clustered (by school) randomised trial, with even randomisation to the intervention and control arms. Between 2003 and 2006, the VIP program was administered to 1,267 participants in the intervention schools, while 1,567 participants in the non-intervention schools received standard curriculum. Participants were all female and aged between 13-15 years upon recruitment. Pre and post-intervention questionnaires measured short-term impact and participants are now being followed through their teenage years via data linkage to hospital medical records, abortion clinics and education records. Participants who have a live birth are interviewed by face-to-face interview. Kaplan-Meier survival analysis and proportional hazards regression will test for differences in pregnancy, birth and abortion rates during the teenage years between the study arms. DISCUSSION: This protocol paper provides a detailed overview of the trial design as well as initial results in the form of participant flow. The authors describe the intervention and its delivery within the natural school setting and discuss the practical issues in the conduct of the trial, including recruitment. The trial is pragmatic and will directly inform those who provide Infant Simulator based programs in school settings. TRIAL REGISTRATION: ISRCTN24952438.