Mortuary based injury surveillance for low-mid income countries: process evaluation of pilot studies.

OBJECTIVE: Globally, injury is the fourth major cause of death and the third leading contributor to Disability Adjusted Life Years lost due to health conditions, with the greatest burden borne by low-middle income countries (LMICs) where injury data is scarce. In the absence of effective vital registration systems, mortuaries have been shown to provide an alternative source of cause of death information for practitioners and policy makers to establish strategic injury prevention policies and programs. This evaluation sought to assess the feasibility of implementing a standardised fatal injury data collection process to systematically collect relevant fatal injury data from mortuaries. The process evaluation is described. METHODS: A manual including a one page data collection form, coding guide, data dictionary, data entry and analysis program was developed through World Health Organization and Monash University Australia collaboration, with technical advice from an International Advisory Group. The data collection component was piloted in multiple mortuaries, in five LMICs (Egypt, India, Sri-Lanka, Tanzania and Zambia). Process evaluation was based on a questionnaire completed by each country's Principal Investigator. RESULTS: Questionnaires were completed for data collections in urban and rural mortuaries between September 2010 and February 2011. Of the 1795 reported fatal injury cases registered in the participating mortuaries, road traffic injury accounted for the highest proportion of cases, ranging from 22% to 87%. Other causes included burns, poisoning, drowning and falls. Positive system attributes were feasibility, acceptability, usefulness, timeliness, and simplicity and data field completeness. Some limitations included short duration of the pilot studies, limited injury data collector training and apparent underreporting of cases to the medico-legal system or mortuaries. CONCLUSION: The mortuary has been shown to be a potential data source for identifying injury deaths and their circumstances and monitoring injury trends and risk factors in LMICs. However, further piloting is needed, including in rural areas and training of forensic pathologists and data-recorders to overcome some of the difficulties experienced in the pilot countries. The key to attracting ongoing funding and support from governments and donors in LMICs for fatal injury surveillance lies in further demonstrating the usefulness of collected data.

Work-related musculoskeletal injury and suicide: opportunities for intervention and therapeutic jurisprudence.

This article presents evidence for the existence of a common trajectory from work-related musculoskeletal injury to suicide. Specifically, it is argued that the pathway from injury to suicide is typically mediated by three critical events: unsuccessful return to work; the development of chronic pain or disability; and suicidal ideation in the context of chronic pain. The moderating influence of systemic factors is also examined, along with opportunities for intervention at the individual and systemic levels, the latter arising from a therapeutic jurisprudence perspective.

A descriptive analysis of work-related fatal injury in older workers in Australia 2000-2009.

The objective of this study is to describe the extent, nature, age distribution and external causes of older-worker fatalities and to provide baseline data for future studies. The methods included retrospective descriptive cohort study using existing population-based mortality data. The study examined work-related fatalities aged 55 years and older, 2000-2009, in Australia following coronial investigation. Of the 336 fatalities identified, almost all (96.3%) were male. The industry with most deaths was agriculture, forestry and fishing (37.8%), followed by transport, postal and warehousing (19.3%) and construction (16.6%). The most frequent injury mechanism was transport-related (40.4%). With predicted workforce ageing, older-worker deaths will become a significant public health issue. Employers and authorities will need to understand older-workers characteristics and vulnerabilities to enable appropriate injury prevention strategy implementation.

Towards a reassessment of the role of divorce in suicide outcomes: evidence from five Pacific Rim populations.

The connection between divorce and suicide risk in Asia is unclear. To understand the contribution of cultural transitions to suicide among the divorced, we compare age- and sex-specific suicide rates among divorced men and women from five Pacific Rim populations: Hong Kong, Taiwan, Japan, South Korea and the state of Victoria in Australia. On a cultural spectrum, we consider Hong Kong and Taiwan to lie between the more individualistic Australian culture and the more collectivistic Japanese and Korean cultures. Coefficients of aggravation (COA) are also compared. Suicide rates were found to be higher among the divorced than among other marital status groups in all five populations, but this difference was small in Victoria. The effect of divorce was significantly greater for men than for women only in Japan and South Korea. In the other populations, divorced men and women were at equal risk. Age trends in suicide rates for the divorced groups differed across populations. The COAs for the divorced group aged 40 or younger in the East Asian populations were higher than the COAs for older divorced groups, though this was not the case in the Victorian population. Suicide patterns among the divorced in the East Asian populations can be understood in terms of the legacy of Confucian traditions. Gender differences in Japan and South Korea may reflect either gender inequality (male dominance in formal interactions and emotional dependence in domestic life within a deteriorating Confucian family support system) or unique socio-cultural factors among married women. Divorced East Asian groups aged 40 or younger may be at a higher risk of suicide due to individual-level cultural ambivalence combined with a desire for systemic-level emotional interdependence. Social welfare regimes in the four East Asian populations need to fill the vacancy left by retreating traditional family systems. Research implications are discussed.

Work-related suicide in Victoria, Australia: a broad perspective.

While unintentional work-related injury is increasingly recognised as important and preventable, population studies of the full range of work related suicides have received less attention. The objective of this study is to investigate the epidemiology of work-related suicide in Victoria, July 2000-December 2007. The study draws on a database of all work-related deaths reported to the Victorian Coroner, inclusive of broadly defined work-relatedness. Inclusion criteria for work-related suicide were at least one of: suicide means was work related, work stressors were identified in police reports to the Coroners or the Coroner's finding, the suicide method involved another person's work (e.g. rail suicide, heavy vehicle) or the suicide location was a workplace. Cases still open for investigation were excluded. Of 642 work-related suicides, 55% had an association with work stressors; 32% jumped or lay in front of a train or heavy vehicle; 7% involved a work location and 6% involved work agents. Work stressor cases identified included business difficulties, recent or previous work injury, unemployment/redundancy or conflict with supervisors/colleagues (including workplace bullying). Work-related suicide is a substantial problem, for which few detailed population wide studies are available. Further research is required to understand the contribution of work stressors and effective interventions.

Focus on seat belt use in China.

OBJECTIVE: To explain low seat belt use prevalence results of observation and interview surveys in Nanjing, Jiangsu Province, and Zhoushan, Zhejiang Province, and to extend knowledge on associated seat belt use determinants. METHOD: Ten focus groups comprising professional, owner, and taxi drivers; passengers; van drivers (Nanjing); or police (Zhoushan) were conducted to capture a range of experiences, attitudes, and opinions. RESULTS: There was common agreement in all focus groups on the need to use seat belts on highways in the front seat but not to use in the rear seat regardless of road type. Participants generally agreed with the apparent practice of fines for drivers and warnings for front seat passengers, especially on highways. Lack of seat belt comfort was elaborated on. Professional and taxi drivers were inconvenienced by the effort involved for short trips to put on seat belts and discomfort was greater for those who did not have or could not afford to operate air conditioning. There was lack of agreement on the need to use seat belts in the city areas. Crash video clips on the nonuse of seat belts were judged by participants as potentially effective for promotion of seat belt use, especially if scenarios were associated with relatively low speeds. CONCLUSIONS: The benefits of seat belt use for all seating positions and at low and medium speeds and awareness of passenger seat belt responsibility need to be promoted. Enforcement should be applied more consistently.

Taxi driver seat belt wearing in Nanjing, China.

OBJECTIVE: To determine and validate patterns of seat belt use and attitudes of taxi drivers on wearing a seat belt following national and provincial seat belt legislation in 2004-2005. DESIGN: Roadside daylight seat belt observation and interview survey methods were used, as well as observations from inside taxis during routine trips and a taxi driver focus group. The setting was Nanjing, Jiangsu Province, PR China in April of 2006 and 2007. MAIN OUTCOME MEASURES: Prevalence of seat belt use and attitudes to wearing a seat belt were determined, as were vehicle and driver characteristics, and comparisons with other motor-vehicle driver's seat belt use and attitudes. RESULTS: Taxi drivers interviewed were predominantly male and aged 30-39 years. They spent more hours per week in their vehicles and had more driving experience than other drivers. Over half (56.2%) of taxi drivers interviewed reported that they always wore seat belts, while observation of taxi drivers showed lower wearing rates (i.e., roadside observation was 43.8%, and observation from inside taxis was 36.2%). Belt tampering was a practice of 12-15% of taxi drivers. "Fine avoidance, safety, high speed and long trips" were given as important reasons for wearing and "feeling trapped and uncomfortable" for not wearing. Seat belt reminder signs in taxis were common (82.6% of taxis), but did not appear to impact on driver seat belt use. CONCLUSION: The four research methods found taxi drivers to have consistently low "correct wearing" rates. IMPACT ON INDUSTRY: As in several other countries, taxi drivers are particularly resistant to seat belt use. Innovative strategies, including occupational health and safety approaches, may be required to achieve increased levels of seat belt use.

[Study on the situation of seat belt wearing among drivers and front-seat passengers of vehicles in Nanjing in 2005-2007].

OBJECTIVE: To find out the situation of seat belt wearing among drivers and passengers in Nanjing after the National Road Traffic Safety Law and its Ordinance had been issued for 3 years, in Jiangsu province. METHODS: Situation on seat belt wearing among drivers and front passengers on four types of vehicles including taxi, cars (below 8 seats), vans and pickups was studied during different time blocks at 4 sites in the city. RESULTS: A total number of 35 256 vehicles, their drivers and another 15 772 passengers sitting in the front, were observed. The prevalence rates of seat belt wearing, not wearing and pretend wearing among drivers were 49.9%, 44.1%, and 4.6% respectively while among front-seat passengers were 9.1% and 90.9% respectively. There were significantly declining trends in seat belt wearing among both drivers and front-seat passengers during the 3-years of observation, after adjustment by sex, types of vehicles and other factors (P < 0.01). Risk of not wearing among front seat passengers was higher for those 'not-wearing' drivers (OR = 8.10, P < 0.01). CONCLUSION: Neither the current law nor ordinance in Jiangsu province gives detailed regulations on seat belt wearing, which hampers the effective enforcement.

Attitudes to seat belt wearing and related safety features in two cities in China.

The study aimed to establish characteristics of vehicles, occupants, seat belt and vehicle safety features for the Chinese cities of Nanjing and Zhoushan in order to interpret previously observed low seat belt wearing rates, particularly of passengers. Convenience interview surveys, stratified by vehicle and occupant type, of 2280 motor vehicle users were conducted in 2006 and 2007. Most participants (74.4%) were male, particularly drivers. Over half the occupants surveyed were aged 30-39 years. Drivers had relatively new vehicles and less driving experience compared with more motorised countries. Seat belts in most front seating positions and in half of the rear seats were fitted and functional. Where fitted, reasons for 'never wearing' were mostly 'feeling trapped and uncomfortable'; inconsistent wearers were influenced by 'habit development, trip length, speed, comfort and enforcement'. Public awareness of the safety benefits of seat belts, strong enforcement and retrofitting are necessary to overcome these barriers as achieved by past and present best practice.

Study on the situation of seat belt wearing among drivers and front-seat passengers of vehicles in Nanjing in 2005 - 2007 / 中华流行病学杂志

Objective To find out the situation of seat belt wearing among drivers and passengers in Nanjing after the National Road Traffic Safety Law and its Ordinance had been issued for 3 years, in Jiangsu province. Methods Situation on seat belt wearing among drivers and front passengers on four types of vehicles including taxi, cars (below 8 seats), vans and pickups was studied during different time blocks at 4 sites in the city. Results A total number of 35 256 vehicles, their drivers and another 15 772 passengers sitting in the front, were observed. The prevalence rates of seat belt wearing, not wearing and pretend wearing among drivers were 49.9%, 44.1%, and 4.6% respectively while among front-seat passengers were 9.1% and 90.9% respectively. There were significantly declining trends in seat belt wearing among both drivers and front-seat passengers during the 3-years of observation, after adjustment by sex, types of vehicles and other factors (P<0.01). Risk of not wearing among front seat passengers was higher for those 'not-wearing' drivers (OR=8.10, P<0.01). Conclusion Neither the current law nor ordinance in Jiangsu province gives detailed regulations on seat belt wearing, which hampers the effective enforcement.

China belting up or down? Seat belt wearing trends in Nanjing and Zhoushan.

National seat belt wearing legislation became effective in China May 2004 and associated provincial and city regulations followed. Despite rapid motorisation seat belt studies in China have been scarce. Patterns and trends in urban seat belt wearing were observed for all driver, front and rear seating positions over the years 2005-2007 in two eastern cities Nanjing (Jiangsu Province) and Zhoushan (Zhejiang Province). There were 35,256 vehicles observed in Nanjing, 20,939 in Zhoushan and 95,933 occupants overall. Males dominated all seating positions, especially drivers. Seat belt wearing overall was significantly higher for drivers (49.9% Nanjing, 47.4% Zhoushan) than for front seat passengers (9.1% Nanjing, 1.0% Zhoushan) and virtually nonexistent for rear passengers (0.5% Nanjing, 0.2% Zhoushan). Generally levels declined significantly from year to year (drivers Nanjing 66.7%, 47.7%, 38.6%; Zhoushan 57.4%, 57.9%, 30.6%; front passengers Nanjing 19.2%, 6.6%, 3.2%). Zhoushan wearing did not initially decline, 2006 observations coinciding with anticipation of provincial regulations (July 2006). Observations revealed an absence of child restraints. Pretend wearing/belt tampering was observed almost exclusively in taxi drivers (14.2% of Nanjing taxi drivers, 11.3% of Zhoushan's). Awareness of and attitudes to urban seat belt laws should be investigated, appropriate countermeasures developed and enforcement reassessed.

Motor Vehicle Exhaust Gas Suicide.

In many motorized countries, inhalation of carbon monoxide from motor vehicle exhaust gas (MVEG) has been one of the leading methods of suicide. In some countries it remains so (e.g., Australia 16.0% of suicides in 2005). Relative to other methods it is a planned method and one often used by middle-aged males. The study provides a review of countermeasures aimed at restricting this method of suicide. The prevention measures identified were catalytic converters (introduced to reduce carbon monoxide for environmental reasons); in-cabin sensors; exhaust pipe modification; automatic idling stops; and helpline signage at suicide "hotspots." Catalytic converters are now in 90% of new vehicles worldwide and literature supports them being associated with a reduction in exhaust-gassing suicides. There remain, however, accounts of exhaust-gas fatalities in modern vehicles, whether accidentally or by suicide. These deaths and also crashes from fatigue could potentially be prevented by in-cabin multi-gas sensors, these having been developed to the prototype stage. Helpline signage at an exhaust-gassing suicide "hotspot" had some success in reducing suicides. The evidence on method substitution and whether a reduction in MVEG suicides causes a reduction in total suicides is inconsistent.

Motor vehicle exhaust gas suicide in Victoria, Australia 1998-2002.

Motor vehicle exhaust gas suicide (MVEGS) is the second most frequent method of suicide in Victoria, Australia. It is a highly lethal method of suicide with 1.5 deaths for every hospital admission. Australian regulations require all vehicles manufactured since 1998 to have a maximum carbon monoxide exhaust emission level of 2.1 g/km, reduced from the previous level of 9.6 g/km. Information surrounding all Victorian MVEGS between 1998-2002 was analyzed to determine whether suicides occurred in vehicles with the lower emission levels. Between 1998-2002, 607 suicides by this means were recorded while just 393 hospital admissions were recorded for the same period. Mean carboxyhaemoglobin levels were significantly lower in fatalities using vehicles manufactured from 1998, however suicide still occurred in these vehicles (n = 25). The extent to which the new regulations contributed to the relatively low rate of suicide in vehicles less than 5 years old compared to their frequency in the fleet remains unknown. Based on international experience and the age of the Victorian vehicle fleet, it may take well over a decade until substantial decreases in MVEGS are observed in the absence of active preventive measures.