Ultrafine Particles from Traffic Emissions and Children’s Health (UPTECH) in Brisbane, Queensland (Australia): Study design and implementation

Ultrafine particles are particles that are less than 0.1 micrometres (µm) in diameter. Due to their very small size they can penetrate deep into the lungs, and potentially cause more damage than larger particles. The Ultrafine Particles from Traffic Emissions and Children’s Health (UPTECH) study is the first Australian epidemiological study to assess the health effects of ultrafine particles on children’s health in general and peripheral airways in particular. The study is being conducted in Brisbane, Australia. Continuous indoor and outdoor air pollution monitoring was conducted within each of the twenty five participating school campuses to measure particulate matter, including in the ultrafine size range, and gases. Respiratory health effects were evaluated by conducting the following tests on participating children at each school: spirometry, forced oscillation technique (FOT) and multiple breath nitrogen washout test (MBNW) (to assess airway function), fraction of exhaled nitric oxide (FeNO, to assess airway inflammation), blood cotinine levels (to assess exposure to second-hand tobacco smoke), and serum C-reactive protein (CRP) levels (to measure systemic inflammation). A pilot study was conducted prior to commencing the main study to assess the feasibility and reliably of measurement of some of the clinical tests that have been proposed for the main study. Air pollutant exposure measurements were not included in the pilot study.

Past, present and the evolving future of public health and health promotion: Reflections on dismantling in Queensland Australia

Objective For more than ten years the public health and health promotion workforce in the Australian state of Queensland grew dramatically. This growth was most pronounced in the disciplines of Health Promotion and in Public Health Nutrition, both regionally and corporately. In 2012 political change led to an abrupt dismantling of its public and preventive health services across the state. Individual responsibility was declared. Method This presentation provides a qualitative narrative description of past achievements and activities, the current situation and provides a perspective towards the future. Findings Government reports over several years described the growing burden of chronic disease arising from conditions such as obesity, physical inactivity, and poor nutrition in Queensland. By 2008, obesity had overtaken smoking as the single greatest risk factor to the health of Queenslanders. In 2010, the Chief Health Officer called for an increased focus on prevention to address the continuing need for more beds in hospitals. However, with political change in 2012 resulted in the dismantling and dismissal of preventive health services across the state. The following year, despite outcry, sexual health services were also axed. At present, outbreaks of vaccine preventable diseases such as measles are occurring. The epidemics of chronic disease, obesity and physical inactivity continue to grow. Conclusion The evolution of public health is not necessarily progressive, but cyclic. Challenges include political change, health practice and the interplay of health policy. A lack of an embedded emphasis on systematic review translation is one potential contributor. Perhaps the warning of Lang & Rayner should be heeded: “public health proponents have allowed themselves to be corralled into the narrow language of individualism and choice”.

Text mining for screening efficiency? Testing within a Cochrane public health review

Background The requirement for dual screening of titles and abstracts to select papers to examine in full text can create a huge workload, not least when the topic is complex and a broad search strategy is required, resulting in a large number of results. An automated system to reduce this burden, while still assuring high accuracy, has the potential to provide huge efficiency savings within the review process. Objectives To undertake a direct comparison of manual screening with a semi‐automated process (priority screening) using a machine classifier. The research is being carried out as part of the current update of a population‐level public health review. Methods Authors have hand selected studies for the review update, in duplicate, using the standard Cochrane Handbook methodology. A retrospective analysis, simulating a quasi‐‘active learning’ process (whereby a classifier is repeatedly trained based on ‘manually’ labelled data) will be completed, using different starting parameters. Tests will be carried out to see how far different training sets, and the size of the training set, affect the classification performance; i.e. what percentage of papers would need to be manually screened to locate 100% of those papers included as a result of the traditional manual method. Results From a search retrieval set of 9555 papers, authors excluded 9494 papers at title/abstract and 52 at full text, leaving 9 papers for inclusion in the review update. The ability of the machine classifier to reduce the percentage of papers that need to be manually screened to identify all the included studies, under different training conditions, will be reported. Conclusions The findings of this study will be presented along with an estimate of any efficiency gains for the author team if the screening process can be semi‐automated using text mining methodology, along with a discussion of the implications for text mining in screening papers within complex health reviews.

Informing methods for preparing public health overviews of reviews: a comparison of public health overviews with Cochrane Overviews published between 1999 and 2014

Background: Overviews of systematic reviews (SRs) are useful for public health policy; however there is an absence of Cochrane Overviews covering public health (PH) topics. Objectives: We sought to analyze the methodological approaches used in existing Cochrane Overviews and Protocols for overviews (primarily clinical in nature), and compare these to the methods and approaches used in PH overviews (non-Cochrane). The intent was to identify issues that would be relevant for undertaking Cochrane overviews. Methods: We conducted a descriptive analysis of overviews published between 1999 and 2014. We searched the Cochrane Database of Systematic Reviews for Cochrane Protocols for overviews and Cochrane Overviews, and the HealthEvidence.org for PH overviews. The primary characteristics of the overviews and elements of the methodology were extracted and compared. Results: A total of 61 overviews of SRs were included in our analysis; specifically, this included 21 Cochrane Protocols for overviews, 15 Cochrane Overviews, and 27 non-Cochrane PH overviews. Amongst the overviews, the most significant differences are that PH overviews (non-Cochrane) tend to: include earlier and more reviews, greater number of participants, allow lower levels of evidence, use assessment tools other than AMSTAR (A Measurement Tool to Assess Systematic Reviews, i.e. a tool for assessing quality of SRs), not assess quality of evidence in reviews, search more databases overall, specify search limits including English-only reviews, and not consider recent primary studies for inclusion. Some of these differences clearly related to quality, however many relate to the nuances of PH interventions. Conclusions: The methodology in Cochrane overviews and PH overviews varies widely. Future PH overviews may benefit from the Cochrane methodology but the Cochrane approach requires modification to accommodate PH research methodology. Additionally, the use of databases that pre-screen and quality assess relevant PH systematic reviews may help expedite the search process.

A call for better care: the impact of postnatal contact services on women’s parenting confidence and experiences of postpartum care in Queensland, Australia

Background Universal postnatal contact services are provided in several Australian states, but their impact on women’s postnatal care experience has not been evaluated. Furthermore, there is lack of evidence or consensus about the optimal type and amount of postpartum care after hospital discharge for maternal outcomes. This study aimed to assess the impact of providing Universal Postnatal Contact Service (UPNCS) funding to public birthing facilities in Queensland, Australia on women’s postnatal care experiences, and associations between amount and type (telephone or home visits) of contact on parenting confidence, and perceived sufficiency and quality of postnatal care. Methods Data collected via retrospective survey of postnatal women (N = 3,724) were used to compare women who birthed in UPNCS-funded and non-UPNCS-funded facilities on parenting confidence, sufficiency of postnatal care, and perceived quality of postnatal care. Associations between receiving telephone and home visits and the same outcomes, regardless of UPNCS funding, were also assessed. Results Women who birthed in an UPNCS-funded facility were more likely to receive postnatal contact, but UPNCS funding was not associated with parenting confidence, or perceived sufficiency or perceived quality of care. Telephone contact was not associated with parenting confidence but had a positive dose–response association with perceived sufficiency and quality. Home visits were negatively associated with parenting confidence when 3 or more were received, had a positive dose–response association with perceived sufficiency and were positively associated with perceived quality when at least 6 were received. Conclusions Funding for UPNCS is unlikely to improve population levels of maternal parenting confidence, perceived sufficiency or quality of postpartum care. Where only minimal contact can be provided, telephone may be more effective than home visits for improving women’s perceived sufficiency and quality of care. Additional service initiatives may be needed to improve women’s parenting confidence.

Sharing of clinical data in a maternity setting: How do paper hand-held records and electronic health records compare for completeness?

Background Historically, the paper hand-held record (PHR) has been used for sharing information between hospital clinicians, general practitioners and pregnant women in a maternity shared-care environment. Recently in alignment with a National e-health agenda, an electronic health record (EHR) was introduced at an Australian tertiary maternity service to replace the PHR for collection and transfer of data. The aim of this study was to examine and compare the completeness of clinical data collected in a PHR and an EHR. Methods We undertook a comparative cohort design study to determine differences in completeness between data collected from maternity records in two phases. Phase 1 data were collected from the PHR and Phase 2 data from the EHR. Records were compared for completeness of best practice variables collected The primary outcome was the presence of best practice variables and the secondary outcomes were the differences in individual variables between the records. Results Ninety-four percent of paper medical charts were available in Phase 1 and 100% of records from an obstetric database in Phase 2. No PHR or EHR had a complete dataset of best practice variables. The variables with significant improvement in completeness of data documented in the EHR, compared with the PHR, were urine culture, glucose tolerance test, nuchal screening, morphology scans, folic acid advice, tobacco smoking, illicit drug assessment and domestic violence assessment (p = 0.001). Additionally the documentation of immunisations (pertussis, hepatitis B, varicella, fluvax) were markedly improved in the EHR (p = 0.001). The variables of blood pressure, proteinuria, blood group, antibody, rubella and syphilis status, showed no significant differences in completeness of recording. Conclusion This is the first paper to report on the comparison of clinical data collected on a PHR and EHR in a maternity shared-care setting. The use of an EHR demonstrated significant improvements to the collection of best practice variables. Additionally, the data in an EHR were more available to relevant clinical staff with the appropriate log-in and more easily retrieved than from the PHR. This study contributes to an under-researched area of determining data quality collected in patient records.

"It broke our hearts": Understanding parents' lived experiences of their child's admission to an acute mental health care facility

This article reports the evaluative findings of an Early Psychosis Education Program (EPEP) designed to support parents caring for their child who was recently admitted to the psychiatric intensive care unit of an inpatient mental health care facility in Australia. The EPEP offered education on mental illness, treatment options, and medication, as well as information on the recovery model of care. The EPEP was facilitated by two RNs and was evaluated for educational effectiveness using a simple pre- and postevaluation questionnaire. The evaluation revealed two themes expressed by parents: "We didn't see it coming," and "Hopelessness and helplessness." The themes highlighted the parents' lack of mental health care knowledge prior to the EPEP, which had a significant impact on the parents' experiences and well-being. The evaluative findings highlighted a need for a nurse-led EPEP within the community. A community EPEP has the potential to strengthen the partnership between parents, families, and mental health service providers and to help with the provision of a recovery framework of care.

What do most Americans think of cost-effectiveness research in health care?

My impression is that explicit data on the cost-effectiveness of different health care services are not valued highly by US policy makers. An example is a recent decision to approve ipilimumab for the treatment of metastatic melanoma. The extra health benefit over standard treatment is 2.1 months in previously untreated patients and the cost is $120,000 for 4 doses. This is poor value for money. Had $120,000 been allocated to an intensive lifestyle modification programme for diabetes risk (Diabet Med. 2004 Nov;21(11):1229-36) then 67 years of life or 800 months could have been returned. A massive increase in health benefits for the same costs.

Estimating the burden of disease attributable to childhood and maternal undernutrition in South Africa in 2000

OBJECTIVES To estimate the disease burden attributable to being underweight as an indicator of undernutrition in children under 5 years of age and in pregnant women for the year 2000. DESIGN World Health Organization comparative risk assessment (CRA) methodology was followed. The 1999 National Food Consumption Survey prevalence of underweight classified in three low weight-for-age categories was compared with standard growth charts to estimate population-attributable fractions for mortality and morbidity outcomes, based on increased risk for each category and applied to revised burden of disease estimates for South Africa in 2000. Maternal underweight, leading to an increased risk of intra-uterine growth retardation and further risk of low birth weight (LBW), was also assessed using the approach adopted by the global assessment. Monte Carlo simulation-modeling techniques were used for the uncertainty analysis. SETTING South Africa. SUBJECTS Children under 5 years of age and pregnant women. OUTCOME MEASURES Mortality and disability-adjusted life years (DALYs) from protein- energy malnutrition and a fraction of those from diarrhoeal disease, pneumonia, malaria, other non- HIV/AIDS infectious and parasitic conditions in children aged 0 - 4 years, and LBW. RESULTS Among children under 5 years, 11.8% were underweight. In the same age group, 11,808 deaths (95% uncertainty interval 11,100 - 12,642) or 12.3% (95% uncertainty interval 11.5 - 13.1%) were attributable to being underweight. Protein-energy malnutrition contributed 44.7% and diarrhoeal disease 29.6% of the total attributable burden. Childhood and maternal underweight accounted for 2.7% (95% uncertainty interval 2.6 - 2.9%) of all DALYs in South Africa in 2000 and 10.8% (95% uncertainty interval 10.2 - 11.5%) of DALYs in children under 5. CONCLUSIONS The study shows that reduction of the occurrence of underweight would have a substantial impact on child mortality, and also highlights the need to monitor this important indicator of child health.

Estimating the burden of disease attributable to diabetes in South Africa in 2000

OBJECTIVES To estimate the burden of disease attributable to diabetes by sex and age group in South Africa in 2000. DESIGN The framework adopted for the most recent World Health Organization comparative risk assessment (CRA) methodology was followed. Small community studies used to derive the prevalence of diabetes by population group were weighted proportionately for a national estimate. Population-attributable fractions were calculated and applied to revised burden of disease estimates. Monte Carlo simulation-modelling techniques were used for uncertainty analysis. SETTING South Africa. SUBJECTS Adults 30 years and older. OUTCOME MEASURES Mortality and disability-adjusted life years (DALYs) for ischaemic heart disease (IHD), stroke, hypertensive disease and renal failure. RESULTS Of South Africans aged >or= 30 years, 5.5% had diabetes which increased with age. Overall, about 14% of IHD, 10% of stroke, 12% of hypertensive disease and 12% of renal disease burden in adult males and females (30+ years) were attributable to diabetes. Diabetes was estimated to have caused 22,412 (95% uncertainty interval 20,755 - 24,872) or 4.3% (95% uncertainty interval 4.0 - 4.8%) of all deaths in South Africa in 2000. Since most of these occurred in middle or old age, the loss of healthy life years comprises a smaller proportion of the total 258,028 DALYs (95% uncertainty interval 236,856 - 290,849) in South Africa in 2000, accounting for 1.6% (95% uncertainty interval 1.5 - 1.8%) of the total burden. CONCLUSIONS Diabetes is an important direct and indirect cause of burden in South Africa. Primary prevention of the disease through multi-level interventions and improved management at primary health care level are needed.

Estimating the burden of disease attributable to iron deficiency anaemia in South Africa in 2000

OBJECTIVES To estimate the extent of iron deficiency anaemia (IDA) among children aged 0 - 4 years and pregnant women aged 15 - 49 years, and the burden of disease attributed to IDA in South Africa in 2000. DESIGN The comparative risk assessment (CRA) methodology of the World Health Organization (WHO) was followed using local prevalence and burden estimates. IDA prevalence came from re-analysis of the South African Vitamin A Consultative Group study in the case of the children, and from a pooled estimate from several studies in the case of the pregnant women (haemoglobin level < 11 g/dl and ferritin level < 12 microg/l). Monte Carlo simulation-modelling was used for the uncertainty analysis. SETTING South Africa. SUBJECTS Children under 5 years and pregnant women 15 - 49 years. OUTCOME MEASURES Direct sequelae of IDA, maternal and perinatal deaths and disability-adjusted life years (DALYs) from mild mental disability related to IDA. Results. It is estimated that 5.1% of children and 9 - 12% of pregnant women had IDA and that about 7.3% of perinatal deaths and 4.9% of maternal deaths were attributed to IDA in 2000. Overall, about 174,976 (95% uncertainty interval 150,344 - 203,961) healthy years of life lost (YLLs), or between 0.9% and 1.3% of all DALYs in South Africa in 2000, were attributable to IDA. CONCLUSIONS This first study in South Africa to quantify the burden from IDA suggests that it is a less serious public health problem in South Africa than in many other developing countries. Nevertheless, this burden is preventable, and the study highlights the need to disseminate the food-based dietary guidelines formulated by the National Department of Health to people who need them and to monitor the impact of the food fortification programme.

Beyond survivorship? A discursive analysis of how people with pancreatic cancer negotiate identity transitions in their health

We explored how people negotiate, and respond to, identity transitions following a diagnosis of pancreatic cancer. Interviews with 19 people with pancreatic cancer were analysed using thematic discourse analysis. While discursively negotiating two transitions, “moving from healthy to ill” and “moving from active treatment to end-of-life care”, participants positioned themselves as “in control”, “optimistic” and managing their health and illness. In the absence of other discourses or “models” of life post-cancer, many people draw on the promise of survival. Moving away from “survivorship” may assist people with advanced cancer to make sense of their lives in a short timeframe.

How an urban Aboriginal and Torres Strait Islander primary health care service improved access to mental health care

Aboriginal and Torres Strait Islander people experience higher levels of psychological distress and mental ill health than their non-Indigenous counterparts, but underuse mental health services. Interventions are required to address the structural and functional access barriers that cause this underuse. In 2012, the Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care employed a psychologist and a social worker to integrate mental health care into its primary health care services. This research study examines the impact of this innovation.