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Objectives: The focus of this paper is to compare the main findings regarding work-related problems managed in general practice with those of other data sources in the occupational and public health arenas that provide some information on work-related disorders in Australia, in order to examine the implications for surveillance and prevention., Methods: Data on work-related disorders managed in general practice were obtained from a larger study of general practice activity that involved a cluster random sample of all significantly active general practitioners in Australia from 1998 to 2000. These data were compared with other Australian datasets containing information on work-related disorders., Results: Despite a predominance of musculoskeletal conditions in all the data sources, general practitioner data provided a different picture of work-related disorders in the community to workers' compensation information from the National Data Set of Compensation-based Statistics (NDS) and the limited information on work-related disorders available from other studies of general practice and emergency departments. The mix of conditions was different in many aspects, and diseases were much less common in the NDS., Conclusions: General practitioner data supplement data provided by other sources, particularly the NDS, and make an important contribution to filling some of the gaps in information about work-related diseases and more minor work-related injuries., Implications: General practitioners could prove a useful supplementary source of data on work-related disorders, but the optimal content of, and method for obtaining, these data is not clear.

Objectives: To compare proportions of kindergarten children in Auburn presenting School Immunisation Certificates (SIC) or other school-entry immunisation documentation over time, and to examine the immunisation status of these children., Methods: Immunisation records of kindergarten children enrolled in all primary schools in the Auburn local government area were reviewed in 1994 and 1998., Results: Eight hundred and thirty-three and 737 school entry records of children enrolled in kindergarten were reviewed in 1998 and 1994 respectively. There was no change in the overall proportion of children with immunisation documentation and SICs. Sixty-nine per cent (571/833) of children had SICs in 1998, compared with 72% (531/737) in 1994. Thirteen per cent of children had other immunisation documentation in 1998, compared with 11% in 1994. The proportion of invalid certificates fell from 39.2% in 1994 to 12.6% in 1998 (p<0.001). The 1998 survey indicated that 80.2% of children provided a certificate indicating they were completely immunised compared with 56.7% in 1994 (p<0.001)., Implications: Although SICs play an important role in promoting the importance of immunisation among parents and in the school community, there continues to be a substantial number of children whose immunisation status is unknown. In the event of an outbreak, an effective public health response may need to incorporate the use of additional objective measures, such as the Australian Childhood Immunisation Register or personal health records.

Small area health statistics has assumed increasing importance as the focus of population and public health moves to a more individualised approach of smaller area populations. Small populations and low event occurrence produce difficulties in interpretation and require appropriate statistical methods, including for age adjustment. There are also statistical questions related to multiple comparisons. Privacy and confidentiality issues include the possibility of revealing information on individuals or health care providers by fine cross-tabulations. Interpretation of small area population differences in health status requires consideration of migrant and Indigenous composition, socioeconomic status and rural-urban geography before assessment of the effects of physical environmental exposure and services and interventions. Burden of disease studies produce a single measure for morbidity and mortality--disability adjusted life year (DALY)--which is the sum of the years of life lost (YLL) from premature mortality and the years lived with disability (YLD) for particular diseases (or all conditions). Calculation of YLD requires estimates of disease incidence (and complications) and duration, and weighting by severity. These procedures often mean problematic assumptions, as does future discounting and age weighting of both YLL and YLD. Evaluation of the Victorian small area population disease burden study presents important cross-disciplinary challenges as it relies heavily on synthetic approaches of demography and economics rather than on the empirical methods of epidemiology. Both empirical and synthetic methods are used to compute small area mortality and morbidity, disease burden, and then attribution to risk factors. Readers need to examine the methodology and assumptions carefully before accepting the results.

Objective: To review the epidemiological evidence for the association between passive smoking and lung cancer., Method: Primary studies and meta-analyses examining the relationship between passive smoking and lung cancer were identified through a computerised literature search of Medline and Embase, secondary references, and experts in the field of passive smoking. Primary studies meeting the inclusion criteria were meta-analysed., Results: From 1981 to the end of 1999 there have been 76 primary epidemiological studies of passive smoking and lung cancer, and 20 meta-analyses. There were 43 primary studies that met the inclusion criteria for this meta-analysis; more studies than previous assessments. The pooled relative risk (RR) for never-smoking women exposed to environmental tobacco smoke (ETS) from spouses, compared with unexposed never-smoking women was 1.29 (95% CI 1.17-1.43). Sequential cumulative meta-analysed results for each year from 1981 were calculated: since 1992 the RR has been greater than 1.25. For Western industrialised countries the RR for never-smoking women exposed to ETS compared with unexposed never-smoking women, was 1.21 (95% CI 1.10-1.33). Previously published international spousal meta-analyses have all produced statistically significant RRs greater than 1.17., Conclusions: The abundance of evidence in this paper, and the consistency of findings across domestic and workplace primary studies, dosimetric extrapolations and meta-analyses, clearly indicates that non-smokers exposed to ETS are at increased risk of lung cancer., Implications: The recommended public health policy is for a total ban on smoking in enclosed public places and work sites.

Objective: To document representations of the 1998 introduction of a 30% rebate on private health insurance in the three most-read daily Sydney newspapers., Methods: Thematic frame analysis of 131 newspaper articles., Results: The rebate was opposed through two frames: that it was ineffective and unfair, and that it was politically motivated. Four supportive frames were more complex: the rebate was justified by claims that public health care was collapsing, that responsible citizens should pay for their own health care, and that individuals would benefit financially. There was also a focus on the political battle in the Senate. The newspaper with the readership least likely to benefit from the rebate supported it most strongly., Conclusions: Framing was strongly episodic (two dimensional, decontextualised and case-study based), limiting political accountability, and the anti-rebate case was presented less memorably. Community action around the issue was not encouraged, individual responsibility was emphasised and universal health care was not promoted as fair or necessary. Different readerships received different messages about the rebate., Implications: There is an urgent need to promote the value of the public health care system and make the future of Medicare compelling for news editors and the public.

Background: The effectiveness of individual components (other than exercise) of multifactorial intervention packages aimed to reduce the incidence of falls in older people is uncertain. There have been no randomised trials of home modifications alone for the prevention of falls., Objectives: To estimate the cost-effectiveness of just one component of a multifactorial approach to falls prevention, that is, a home hazard reduction program. The study estimates the size and direction of change in resource use within and between the hospital, home and community sectors., Methods: A randomised trial was conducted to evaluate the effectiveness of home modifications for prevention of falls among older people. An occupational therapist (O/T) with experience in aged care assessed homes for environmental hazards and supervised the necessary home modifications., Subjects: The subjects in this study were people aged 65 years and older and most were recruited during a hospital stay. The cost-effectiveness analysis was based on a randomised trial with a total of 530 subjects., Results: The incremental cost per fall prevented was $4,986. A sensitivity analysis was conducted by removing 12 outlier subjects (6 control and 6 intervention). The incremental cost per fall prevented was $1,921 for all subjects and was cost saving for subjects who had fallen in the 12 months prior to randomisation., Conclusions & Implications: A single factor home hazard reduction program is more likely to be most cost-effective amongst older people who have a history of falls.

Quality is a much used word in health care. It clearly has positive connotations. Yet there is less than clarity in the literature as to what it means. This article suggests that quality has to have something to do with 'goodness' and indeed 'betterment'. It then argues that it follows that quality cannot be defined before we have sorted out 'good' and 'better'. The author appeals for these terms to be defined.

Aims: To demonstrate the use of conjoint analysis (CA) in public health research through a survey of the South Australian community about aspects of their public hospital services., Methods: A series of focus groups determined the most important attributes in choice of hospital services. These were built into a CA survey, using the discrete choice approach. The survey was posted to a representative sample of 700 South Australians. Theoretical validity, internal consistency and non-response bias were all investigated., Results: Some 231 individuals returned the questionnaire. The attribute, 'improvement in complication rates' was positively associated with choice of hospital. Three attributes were found to be negatively associated with such choice: 'waiting times for casualty', 'waiting times for elective surgery' and, anomalously, 'parking and transport facilities'. 'Travel time' and the cost attribute, 'Medicare levy' were not statistically significant. Trade-offs between the significant attributes were estimated, as were satisfaction or utility scores for different ways of providing hospital services. Results concerning internal consistency and internal validity were encouraging, but some potential for non-response bias was detected., Conclusion: A high premium is placed on the quality of hospital care and members of the community are prepared to choose between hospitals largely on the basis of outcomes and length of waiting times for elective surgery and in casualty., Implications: CA can yield potentially policy-relevant information about community preferences for health services.

Objective: To assess the reliability and validity of self-reported attendance for mammographic screening., Methods: To assess reliability of recall of attendance for a screening mammogram, 100 women selected at random were interviewed twice (approximately one week apart). To assess validity, 127 women who reported having a mammogram within the national breast screening program (BreastScreen Australia) consented to having their reports verified by the national program., Results: Test-retest reliability for the question "Have you ever had a mammogram?" was perfect (agreement 100%, kappa 1). Validity was also high. About one-quarter of women (24.4%) recalled the exact date of their last mammogram and a further third (39.4%) correctly reported the month in which the mammogram was done. Almost all (91.3%) women reported the mammogram date accurately to within 12 months of the recorded date., Conclusions: These data suggest that Australian women provide reliable and valid information in relation to mammographic screening attendance., Implications: Self-reported data about attendance for mammographic screening are likely to provide reliable and valid estimates for research and health services evaluation purposes.

Objective: To examine the validity of self-reported height and weight data reported over the telephone in the 1997 NSW Health Survey, and to determine its accuracy to monitor overweight and obesity in population surveys., Method: Self-reported and measured heights and weights were collected from 227 people living in Western Sydney, who had participated in the NSW Health Survey 1997., Results: Self-reported (SR) weights and heights led to misclassification of relative weight status. BMI, based on measured weights and heights, classified 62% of males and 47% of females as overweight or obese, compared with 39% and 32%, respectively, from self-report., Conclusions: Caution should be used when interpreting SR height and weight data from surveys, because BMI derived from these is likely to underestimate the true prevalence of overweight and obesity., Implications: SR data have a place in nutrition monitoring because they are relatively inexpensive and easy to collect. However, classifying people into weight categories on the basis of accepted cut-points, using SR heights and weights, yields inaccurate prevalence estimates. Periodic sub-studies of the validity of SR heights and weights are needed to indicate the extent to which the validity of SR is changing.

Objective: To describe the measured dietary intakes and anthropometry of a large, free-living population of middle-aged and older Australians who participated in the Australian Blue Mountains Eye Study (BMES), and to identify the socio-demographic characteristics associated with attainment or non-attainment of dietary goals., Method: Anthropometry and dietary intakes were compared with current population dietary goals and Recommended Dietary Intakes for 2,873 people (79% of eligible residents) aged > or = 49 years who participated in the BMES. Nutrient intakes were measured by a validated food frequency questionnaire., Results: Nutrients for which mean intakes deviated most from nutrition goals included: percentages of energy from total and saturated fat, carbohydrate and alcohol (men), as well as absolute intakes of calcium, zinc and fibre. More than half the men (60%) and women (54%) were overweight or obese. Several micro-nutrient goals were more likely to be met in households where the respondents and/or their spouses were independent. Married men were more likely to meet goals for fibre and iron, but less likely to meet the goal for cholesterol. Several goals were more likely to be met by men and women who had qualifications after leaving school, those with higher job status and non-pensioners, suggesting an socio-economic status dimension., Conclusions and Implications: These results indicate that over- rather than under-nutrition is more prevalent among community-dwelling older people, although under-nutrition should not be overlooked. Particular sub-groups that are less likely to meet some dietary goals may require targeting in community nutrition interventions.

Objective: To estimate the prevalence of smoking, stage-of-change and GP advice to quit in the Sydney Lebanese community and whether these findings varied by survey method., Method: Three methods--telephone interviews using sampling from the electronic White Pages, personal interviews of a household member selected using cluster sampling and a mailed survey using an electoral roll sample--were used in separate surveys of persons born in Lebanon living in three postcode areas of Sydney in 1997., Results: Smoking prevalence was consistent across the three methods, with male smoking averaging 49% and female smoking averaging 29%. About two-thirds of smoking respondents across each of the survey methods had no plans for quitting., Conclusions: As smoking prevalence did not vary across the three sampling and survey methods used here, the simplest and most inexpensive method (the electronic White Pages and telephone surveying of identifiable ethnic surnames) should be preferred., Implications: Smoking prevalence in the Sydney Lebanese community is determined consistently using a variety of survey methods.

Objective: To review the principal sub-texts contained in all press coverage and references to the tobacco industry in a major Sydney newspaper over five years., Method and Sample: After excluding value-neutral financial page reports, thematic analysis of all value-laden references to the tobacco industry in the Sydney Morning Herald, January 1993 to December 1997., Results: Some 155 articles containing 221 separate references to the tobacco industry were identified. Eight sub-texts (callous merchants of death; conspiracy/cover-up; blood money; toxic pied pipers; corporate leviathans; beleaguered/legitimate industry; index case of unethical or corrupt practice; and bumbling fools) accounted for all 221 references. Eighty-nine per cent of references to the industry framed it negatively. Journalists or regular newspaper columnists authored 56% of the references. Only 5% of comments were attributed to tobacco company sources., Conclusions: In press reports, the tobacco industry is routinely framed as a corporate pariah by journalists, the public, government spokespeople and tobacco control advocates., Implications: Routine negative publicity about the tobacco industry is likely to significantly reduce its public credibility and political influence.

Objective: This study examines the variation in coronary heart disease (CHD) mortality and acute myocardial infarction (AMI) by socio-economic status (SES), country of birth (COB) and geography (urban/rural) in the total population of New South Wales (Australia) in 1991-95., Method: CHD deaths and AMI are from complete enumerations of deaths and hospital admissions, respectively; and population denominators are from census information. Data are examined separately by sex, and comparisons of SES groups (based on municipalities), COB and region are analysed using Poisson regression, after adjustment for age., Results: The study identified higher risk for AMI admissions and CHD mortality in lower SES populations with significant linear trends, for both sexes, adjusted for age, region and COB. According to the population attributable fractions (PAF), 23-41% of the risk of CHD occurrence is due to SES lower than the highest quartile. The higher age-adjusted risk for CHD occurrence in rural and remote populations for both sexes, compared with urban communities, was lessened by adjustment for COB, and all but abolished when also adjusted for SES.COB analysis indicated significantly lower age-adjusted AMI admissions and CHD mortality compared with the Australian-born., Conclusions: Higher risks for CHD in rural populations compared with the capital city (Sydney) are due, in part, to lower SES, lesser migrant composition., Implications: Strategies for reducing CHD differentials should consider demographic factors and the fundamental need to reduce socio-economic inequalities, as well as targeting appropriate prevention measures.

Hysterectomy fractions by age group for particular periods are of interest for: estimating proper population denominators for calculation of disease and procedure rates affecting the cervix and uterus; estimating the target population for Pap test programs, and response rates; and as a way of displaying the cumulative consequences of hysterectomies in a population. Hysterectomy fractions for populations can be determined by direct inquiry via a representative sample survey, or, as in this study, from prior hysterectomy rates of the cohorts of women which compose each age bracket. Hysterectomy data 1979-93 were obtained from the hospital In-patients Statistics Collection (ISC) which covers both public and private hospitals in NSW. Annual population denominators of women were obtained from Census data. Data were modelled by Poisson regression, using five-year age group (15- > or = 85 years), annual period, and five-year birth cohort (APC model). Forward- and back-projection of the period effects were undertaken. The resultant NSW hysterectomy fractions by age and period are consistent with fractions obtained from modelled hysterectomy rates for Western Australia (1980-84), and fractions from national representative sample surveys (1989/90 and 1995) for younger women, but not for women aged > or = 70 years in 1995, which revealed higher hysterectomy fractions than modelled hysterectomy data would suggest. Hysterectomy fractions for NSW women by five-year age group for quinquennia centred on 1971 to 2006 are provided.

Starting in 1989, an attempt was made to change the aim of methadone treatment in NSW from abstinence to harm-minimisation. A study was undertaken to measure change in attitudes among staff working in public methadone programs in Sydney. Using scales developed in a 1989 survey, we found a statistically significant and meaningful reduction in support for abstinence-oriented policies had occurred by 1992. There was no change in staff's support for the punishment of illicit drug use or their knowledge of the risks and benefits of methadone maintenance. This suggests problems with staff attitudes and, indirectly, the effectiveness of public health interventions, can be addressed using educational campaigns.

This review describes the Australian decline in all-cause mortality, 1788-1990, and compares this with declines in Europe and North America. The period until the 1870s shows characteristic 'crisis mortality', attributable to epidemics of infectious disease. A decline in overall mortality is evident from 1880. A precipitous fall occurs in infant mortality from 1900, similar to that in European countries. Infant mortality continues downward during this century (except during the 1930s), with periods of accelerated decline during the 1940s (antibiotics) and early 1970s. Maternal mortality remains high until a precipitous fall in 1937 coinciding with the arrival of sulphonamide. Excess mortality due to the 1919 influenza epidemic is evident. Artefactual falls in mortality occur in 1930, and for men during the war of 1939-1945. Stagnation in overall mortality decline during the 1930s and 1945-1970 is evident for adult males, and during 1960-1970 for adult females. A decline in mortality is registered in both sexes from 1970, particularly in middle and older age groups, with narrowing of the sex differential. The mortality decline in Australia is broadly similar to those of the United Kingdom and several European countries, although an Australian advantage during last century and the first part of this century may have been due to less industrialisation, lower population density and better nutrition. Australia shows no war-related interruptions in the mortality decline. Australian mortality patterns from 1970 are also similar to those observed in North America and European countries (including the United Kingdom, but excluding Eastern Europe.

In this study, we compared the likely cost-effectiveness of alternative strategies for controlling a school-based measles outbreak. The analysis involved assessing the expected costs and number of cases in a school-based outbreak of measles, with no intervention and with each of six control strategies. The marginal cost per case prevented ranged from $32.90 when only previously unvaccinated school children were offered vaccination to $6795 when vaccination was extended to the siblings of school children aged 6 to 12 months. This study provided further evidence of the cost-effectiveness of vaccination in outbreak control, and yielded useful information to inform control strategies in the event of a school-based outbreak. Decisions about which groups of children to aim at and whether to conduct school-based clinics will be influenced by local circumstances, particularly the baseline measles vaccination rate and the measles attack rate among infants.

There is some evidence that low childhood immunisation rates in Australia may be attributed partly to parental antipathy toward immunisation. The anti-immunisation movement is becoming more organised in its efforts to lobby against childhood immunisation, while the lessening of the public's exposure to the effects of vaccine-preventable disease has provided a climate ripe for such a lobby to have a disproportionate influence on parents. Forty months of Australian print media coverage of immunisation were reviewed for anti-immunisation arguments and their underlying ideological subtexts. Of 2440 articles about childhood immunisation, 115 (4.7 per cent) contained statements opposing immunisation. Eight subtexts that referenced wider discourses about medicine, the state and the body dominated anti-immunisation discourse (cover-up; excavation of the facts; unholy alliance for profit; towards totalitarianism; us and them; vaccines as poisonous chemical cocktails; vaccines as cause of idiopathic ills; and back to nature). Attempts to redress claims made against immunisation must not only address specific claims about vaccine efficacy and safety but be grounded in a reframing of the ideological appeals that currently frame the contents of anti-immunisation discourse.

This review describes the changes in composition of mortality by major attributed cause during the Australian mortality decline this century. The principal categories employed were: infectious diseases, nonrheumatic cardiovascular disease, external causes, cancer, 'other' causes and ill-defined conditions. The data were age-adjusted. Besides registration problems (which also affect all-cause mortality) artefacts due to changes in diagnostic designation and coding are evident. The most obvious trends over the period are the decline in infectious disease mortality (half the decline 1907-1990 occurs before 1949), and the epidemic of circulatory disease mortality which appears to commence around 1930, peaks during the 1950s and 1960s, and declines from 1970 to 1990 (to a rate half that at the peak). Mortality for cancer remains static for females after 1907, but increases steadily for males, reaching a plateau in the mid-1980s (owing to trends in lung cancer); trends in cancers of individual sites are diverse. External cause mortality declines after 1970. The decline in total mortality to 1930 is associated with decline in infection and 'other' causes. Stagnation of mortality decline in 1930-1940 and 1946-1970 for males is a consequence of contemporaneous movements in opposite directions of infection mortality (decrease) and circulatory disease and cancer mortality (increase). In females, declines in infections and 'other' causes of death exceed the increase in circulatory disease mortality until 1960, then stability in all major causes of death to 1970. The overall mortality decline since 1970 is a consequence of a reduction in circulatory disease, 'other' cause, external cause and infection mortality, despite the increase in cancer mortality (for males).

Australia has the world's second highest per capita use of mobile phones. To meet rapid expansion in use, transmission towers are being erected hastily, backed by federal government exemptions from normal local government planning procedures. In a case study of media reportage of a successful resident protest about the placement of transmitters adjacent to a kindergarten, uncertain risks to health were the ostensible concerns voiced by the protesters. Eleven of the 12 primary components and six out of eight secondary components of Sandman's model of community risk perception were consistent with both the protesters' expressed concerns about the transmission towers and the way in which the issues involved were framed by the media.

This study of breast cancer survival is based on analysis of five-year relative survival of 38,362 cases of invasive breast cancer in New South Wales (NSW) women, incident between 1972 and 1991, with follow-up to 1992, using data from the population-based NSW Central Cancer Registry. Survival was ascertained by matching the registry file of breast cancers against NSW death certificates from 1972 to 1992, mainly by automated probabilistic linkage. Absolute survival of cases was compared with expected survival of age- and period-matched NSW women. Proportional hazard regression analysis was used for examination of the effects on excess mortality of age, period of diagnosis and degree of spread at diagnosis. Relative survival at five years increased from 70 per cent in 1972-1976 to 77 per cent in 1987-1991. Survival improved during the 1970s and in the late 1980s. Regression analysis suggested that part of the improved survival in the late 1980s was due to lesser degree of spread at diagnosis, whereas the improved survival during the 1970s may have been due to treatment. Survival was better for those aged 40-49 years (RR = 0.86) and worse for those aged > or = 70 years (RR = 1.22) compared with the referent group (60-69 years). Excess mortality was much less for those with invasive localised disease than those with regional spread (RR = 3.1) or metastatic cancer (RR = 15.5) at diagnosis. For the most recent period (1987-1991), relative five-year survival was 90, 70 and 18 per cent, respectively, for the three degree-of-spread categories.

Social surveys have established dose-response relationships between aircraft noise and annoyance, with a number of psychological symptoms being positively related to annoyance. Evidence that exposure to aircraft noise is associated with higher psychiatric hospital admission rates is mixed. Some evidence exists of an association between aircraft noise exposure and use of psychotropic medications. People with a pre-existing psychological or psychiatric condition may be more susceptible to the effects or exposure to aircraft noise. Aircraft noise can produce effects on electroencephalogram sleep patterns and cause wakefulness and difficult in sleeping. Attendances at general practitioners, self-reported health problems and use of medications, have been associated with exposure to aircraft noise, but some findings are inconsistent. Some association between aircraft noise exposure and elevated mean blood pressure has been observed in cross-sectional studies of schoolchildren, but with little confirmation from cohort studies. There is no convincing evidence to suggest that all-cause or cause-specific mortality is increased by exposure to aircraft noise. There is no strong evidence that aircraft noise has significant perinatal effects. Using the World Health Organization definition of health, which includes positive mental and social wellbeing, aircraft noise is responsible for considerable ill-health. However, population-based studies have not found strong evidence that people living near or under aircraft flight paths suffer higher rates of clinical morbidity or mortality as a consequence of exposure to aircraft noise. A dearth of high quality studies in this area precludes drawing substantive conclusions.

This study describes the health risks and health behaviour of a sample of 283 out-of-school 16-year-olds in New South Wales. We sampled study participants through the Commonwealth Employment Service offices in 1994 using a multistage sampling procedure. Of those surveyed, 129 responded to a letter inviting them to participate and 154 were recruited opportunistically. This paper describes the study methods and results for self-reported binge drinking, weekly use of tobacco and marijuana, sexual abuse, physical abuse, drink-driving, violence, and use of health services, by sex and method of recruitment. High rates of substance use were observed. Reported substance use in the out-of-school group was consistently higher than for 16-year-olds in school, except for binge drinking for girls recruited by letter. Of the out-of-school group, 34 per cent reported weekly use of tobacco, marijuana and also binge drinking. Boys were more likely to report drink-driving than girls (28 per cent and 13 per cent respectively). Having been in trouble with police ranged from 32 per cent for girls recruited by letter to 75 per cent for boys recruited opportunistically. A high proportion of girls reported sexual abuse (34 per cent of the 'letter' group and 41 per cent of the 'opportunistic' group). Overall, 87 per cent of respondents had used health services in the previous year. The results indicate that this is a disadvantaged group of young people who are an important target for health service provision and interventions.

Schools represent a very attractive setting for health promotion. Most children and young people attend school, professional educators are in place, and most school communities are microcosms of the larger community, providing opportunities for children to develop and practice the skills necessary to support a healthy life-style. In response to this opportunity, the precepts of contemporary health promotion have been synthesised into the 'health-promoting school' model, which is guided by a holistic view of health and by the principles of equity and empowerment. Although there are different conceptions of the model, the key components are: the formal curriculum; school ethos (the social climate); the physical environment; the policies and practices of the school; school health services; and the school-home-community interaction. The health-promoting school model offers a comprehensive, systematic approach to health promotion in the school setting, which is widely accepted internationally. There have been few studies in Australia that have attempted to determine the prevalence of activities related to the model or to evaluate interventions. Unfortunately, conceptual and practical advances have far outstripped the development of research and evaluation instruments. There is an urgent need to create valid research tools to support the development and implementation of this potentially fruitful health promotion model.

The purpose of this study was to describe the rate of permanent placement in aged care institutions (nursing homes and hostels) after hip fracture and to assess whether or not hip fracture is an independent risk factor for institutionalisation. It was a cohort study with median follow-up time of 14 months. Subjects were 291 people living in the community in western Sydney: 13] with hip fractures and 160 controls. Permanent admission to an aged care institution and/or death during follow-up was assessed by telephone interview with study subjects of carers. Data on potential confounders were collected with an interviewer-administered questionnaire at the time of recruitment into the study. During follow-up, 27 per cent of hip fracture cases and 5 per cent of controls were admitted to an aged care institution. The age- and sex-adjusted hazard ratio for hip fracture and institutionalisation was 5.1 (95 per cent confidence interval (CI) 2.2 to 11.9). Adjusting for multiple health-related factors reduced the strength of association but the hazard ratio remained high at 4.0 (CI 1.7 to 9.5). The risk of institutionalisation after hip fracture is high; this is only partly explained by the poor pre-fracture health status of many people who fracture their hips.

Area-based needs-assessment methods tend to reinforce the status quo in service or program delivery rather than challenge it. Data collection easily becomes routine and self-justifying. To rid ourselves of ritualistic methods of data collection, we must turn attention to the process of change that should result from it. That is, we must think in advance of the types of decisions that must made about service delivery and the nature of the change process itself. There are two routes to this end, depending on how change is conceptualised. If one adopts a conflict model of change, then felt need or, more crudely, what consumers or groups and communities want becomes the primary focus. This would place consumers in the chief role within an action-oriented advocacy process. Alternatively, if a more functionalist model of change is adopted, then the focus of activity is on the information needs of managers and the type of data they require to justify a resource shift. Typically these data are not about "needs' but marginal health gains and costs. In either event, the data collection procedures should be far more specific and directed than the existing broad-brush procedures that presently serve only a limited purpose and effectively dilute or detract from both agendas for change. There are several possible pathways to resolve some of these issues, in particular, using hypothetical results to foresee if or how change could result from any proposed data collection activity.

Two genes associated with a high breast cancer risk (BRCA1 and BRCA2) have been discovered recently from study of large breast-cancer-dense kindreds. It is problematic to make inferences from these atypical families to the general population. Nevertheless, it appears that about 1 to 2 per cent of all breast cancer may be due to rare deleterious mutations in BRCA1 or BRCA2. The majority of breast cancer families with fewer than four cases are likely to have cancers not attributable to these genes. There may be more common mutations in other genes (such as ATM, HRAS1) that confer a moderate risk of breast cancer, and may account for 5 to 15 per cent of cases. At this early stage of cancer genetics, the risks associated with particular mutations are not known, there are no proven and acceptable strategies for women with an inherited susceptibility to ameliorate risk or improve prognosis, and risk estimates appropriate for Australian women with a family history of breast cancer are not established, although data from the United States may overestimate risk. Information is needed from population-based studies, such as the Australian Breast Cancer Family Study (Hopper et al. Breast 1994; 3: 79-86), but 100 per cent mutation detection in large cancer genes is difficult and expensive. Development of a systematic, research-oriented, evidence-based approach to genetic testing in Australia is recommended. Australia could lead the world in having common protocols used in breast cancer clinics across the country, linked to a national research consortium and database.

We analysed five-year relative survival of 6992 cases of cervical cancer incident between 1972 and 1991 in New South Wales (NSW) women, using data from the population-based state Cancer Registry. Follow-up was to 1992. Survival was determined by record linkage to death certificates. Relative survival was derived from absolute survival of cases with expected survival of age- and period-matched NSW women. Proportional hazard regression analysis was used for multivariate analysis. Relative survival at five years improved from 64 per cent in 1972-1976 to 72 per cent in 1987-1991, although the only significant increase occurred between 1972-1976 and 1977-1981 (64 to 70 per cent). Survival was better for the age groups 0-39 years (RR 0.51) and 40-49 years (RR 0.63) and worse for the elderly (> or = 65 years) (RR 1.47) than for the referent group (50-64 years). Excess mortality was much less for those with localised disease (referent group), than for those with regional spread (RR 3.47) or metastatic cancer (RR 10.5) at diagnosis. For the most recent period (1987-1991), relative five-year survival for localised disease was 82 per cent, for regional spread at diagnosis it was 49 per cent, and for metastatic cancer 21 per cent. When adjusted for confounding, excess mortality was significantly higher for adenocarcinoma (RR 1.16) than for squamous cell carcinoma. Five-year relative survival for cervical cancer in NSW women for the most recent period is similar to that in South Australia, and both compare favourably with international statistics. The lack of improvement of five-year survival for cervical cancer over 15 years since 1977-1981 reinforces the importance of prevention through regular screening by cytology.

The Australian health care system consists of mixed public and private financing underpinned by Medicare, a universal government-run insurance scheme paid through taxation (and levy) on income. Australia has improved its ranking for life expectancy (at birth) since 1960, and in 1990 ranked ninth and seventh of 24 countries for females and males respectively; this is ahead of the United States and United Kingdom, and approximately equal to Canada. Australian hospital bed supply and utilisation are average, after deletion of day-only cases. The proportion of gross domestic product (GDP) spent on health, in relation to GDP per capita (adjusted for purchasing power), in Australia in 1990 was average, and the prices for health care from 1975 to 1990 did not increase when adjusted for inflation. Although 68 per cent of health expenditure emanates from public sources in Australia, this is lower than in the majority of European countries and Canada. Some countries are doing poorly (such as the United States, with lower than average life expectancy and higher than predicted health expenditure) and some countries are doing well (with higher than average life expectancy and lower than predicted health expenditure; for example, Japan). Australia has higher than average life expectancy and only slightly higher than predicted health expenditure per capita. Although the Australian system could be improved, there are no indications that radical changes are required. The relatively high life expectancy in Australia can be attributed to favourable social and economic conditions, successful public health programs, and the availability of universal quality health care.

The incremental costs and effects of annual faecal occult blood test screening in Australia were modelled for a hypothetical cohort of 1000 persons offered screening or not offered screening. Incremental costs and effects were estimated as the differences in direct health care costs (Australian costs) and years of life remaining between the annual-screen group and the control (no screen) group, based on the published results of the Minnesota randomised controlled trial. The cost per life year saved was $24,660. The greatest source of variability in the cost-effectiveness ratio is the effectiveness of screening. The 95 percent confidence interval for cumulative mortality in the annual-screen group is 3.86 to 7.9 per 1000, assuming the control rate is fixed at 8.83 per 1000. With this confidence interval, the cost per life year saved ranges from $12,695 to $67,848. The cost-effectiveness ratio increases to $48,000 if no mortality benefit is assumed beyond the end of the trial follow-up period, 13 years. The results are sensitive to the cost of colonoscopy (at $400 per colonoscopy, the cost per life year saved is $12,319) and the false-positive rate. The cost-effectiveness of colorectal cancer screening is comparable with that of other screening programs but further evidence is needed on the efficacy of screening. Whether the benefits of colorectal cancer screening outweigh the harm and costs needs to be more certain before more resources are committed to mass screening. Health policy planners should initiate planning for Australian pilot projects in the event that the efficacy of screening is confirmed by two current studies.

The proportion of the Australian population from non-English-speaking backgrounds is increasing (particularly among the elderly, who are more likely to be disabled), but their use of health care services and institutions is proportionately lower than that for other Australians, and many care for a family member with a disability or illness at home. The study objective was to document the experiences of such carers in using health and other support services in order to understand the reasons for underutilisation. This study differs from most other carer studies in concentrating on carers with little or no English, and by using a semistructured interview that enabled carers to describe their experiences and attitudes more openly. Forty women carers were interviewed, with bilingual interviewers or interpreters being used where necessary. Interviews were tape-recorded and content-analysed. The services used, sources of information and referral, and the reasons for not using a service were identified. Some of the difficulties experienced in using services were common to many carers, irrespective of background, whereas others related specifically to English language deficits and cultural differences. Carers were reluctant to institutionalise a family member, despite their own health problems, emphasising the need for greater support from existing and expanded services to enable the relative to be cared for at home.