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IntroductionDelivering integrated care is an aspiration of health systems around the world. General Practices (GPs) operate between other types of health care and are therefore key to effective integrated care. However, information to understand the patient journey across the health system, such as between primary and acute care, is currently impeded in Australia by lack of interoperable clinical software, privacy concerns, and cross-jurisdictional barriers. This presents a challenge to the formation of an evidence base for the design and implementation of integrated health services. Objectives and ApproachThe Lumos Pilot Project aims to address these challenges. Following ethics approval in February 2016, the pilot was rolled out over five stages to develop a proof of concept for extracting and linking GP data to other health-related data. The objectives were to:I. Build cross-jurisdictional collaborations between primary care and the state health system in New South Wales (NSW), Australia.II. Develop methodologies to address confidentiality requirements.III. Develop technological solutions that will allow for a large scale program. ResultsData were extracted from 102 GPs, covering nearly 1 million patients, and linked to emergency department, hospital and mortality records. GPs were recruited to participate through collaborations with all NSW Primary Health regions. Privacy preserving record linkage was successfully implemented in the fifth stage of the project. This process encoded patient identifiers prior to extraction from the GP and negated the need for identified information during data linkage. Software was developed and tested across all stages of the project so that once enrolled, GP data extraction and transfer were fully automated. Conclusion / ImplicationsThe resultant dataset has provided a new picture of patients’ healthcare journeys while preserving patient privacy. The technological solutions allow for a large scale up of GP recruitment in future.

This paper describes the first stage of a project designed to identify possible strategies to improve the management of fatigue in the long-distance road transport industry in Australia. This stage involved a survey to determine the nature of the pressures on drivers in different sectors of the industry, their impact on fatigue and whether any specific methods for reducing fatigue were being used which could be applied to other groups. The results highlight a number of promising strategies and some that were not working. The second stage will evaluate some of the most successful strategies. Details are given of assessment methods to be used in Stage 2. For the covering abstract see IRRD 876074.

Context Continued exposure to compensation systems has been reported as deleterious to the health of participants. Understanding the associations with time to claim closure could allow for targeted interventions aimed at minimising the time participants are exposed to the compensation system. Study objective To identify the associations of extended time receiving compensation benefits with the aim of developing a prognostic model that predicts time to claim closure. Study design Prospective cohort study in people with whiplash associated disorder. Outcome measures Time to claim closure, in a privately underwritten fault based third party traffic crash insurance scheme in New South Wales, Australia. Method Cox proportional hazard regression modelling. Results Of the 246 participants, 25% remained in the compensation system longer than 24 months with 15% remaining longer than three years. Higher initial disability (Functional Rating Index ≥ 25 at baseline) (HRR: 95% CI, 1.916: 1.324–2.774, p

People with Whiplash Associated Disorder (WAD) often experience pain and disability for extended periods of time. A large proportion of these people will seek treatment through a compensation process. Rarely is data related to people's health collected within the compensation process making it difficult to identify those that are at risk of delayed recovery and appropriately direct interventions.To compare people with WAD who have recovered with those that have not, within 3 months of injury and identify potential predictors of poorer health and non-recovery to inform claim screening processes.Cross-sectional analysis of a cohort study.People who sustained a WAD and claimed compensation within an Australian Motor Accidents Compensation Scheme between November 2007 and June 2009. MEASURE OF RECOVERY: Functional Rating Index (FRI) score (25). HEALTH OUTCOME MEASURES: Short Form 36 (SF36), FRI, and the Pain Catastrophising Scale (PCS).246 people who had lodged a claim for compensation were enrolled in the Whiplash Outcome Study within 3 months of sustaining a WAD injury. Participants were assigned to a recovered or non recovered group and analysed for differences between the two groups. Multiple linear regression models were used to identify potential predictors of poorer health and non-recovery.Overall 23% of the study population had recovered within 3 months of sustaining a WAD, whilst only 9% had finalised their insurance claim. The recovered group had significantly better scores on all health outcome measures; SF36 Physical Component Score, SF36 Mental Component Score and the PCS(p0.001). The significant independent predictors of poorer health and non-recovery were helplessness(p0.001), older age (p0.001) and pre-injury work status being affected (p0.001) (r(2) = .624).Regardless of the health outcome measure used, helplessness was significantly associated with poorer reported health.Including additional information at claim notification, specifically the PCS and information on the effect the injury has on the working population could significantly improve claim screening processes, identifying those with poorer health and risk of non-recovery.

Background Self-reported occupational histories are an important means for collecting historical data in epidemiological studies. An occupational history calendar (OHC) has been developed for use alongside a national occupational hazard surveillance tool. This study presents the systematic development of the OHC and compares work histories collected via this calendar to those collected via a traditional questionnaire. Methods The paper describes the systematic development of an OHC for use in the general working population. A comparison of data quality and recall was undertaken in 51 participants where both tools were administered. Results TheOHCenhanced job recall compared with the traditional questionnaire. Good agreement in the data captured by both tools was observed, with the exception of hazard exposures. Conclusions A calendar approach is suitable for collecting occupational histories from the general working population. Despite enhancing job recall the OHC approach has some shortcomings outweighing this advantage in large-scale population surveillance.

Changes to work and the impact of these changes on worker health and safety have been significant. A core surveillance data set is needed to understand the impact of working conditions and work environments. Yet, there is little harmony amongst international surveys and a critical lack of guidance identifying the best directions for surveillance efforts. This paper describes the establishment of an instrument suitable for use as a hazard surveillance tool for New Zealand workers. An iterative process of critical review was undertaken to create a dimensional framework and select specific measures from existing instruments. Pilot testing to ascertain participant acceptability of the questions was undertaken. The final questionnaire includes measures of socio-demographic characteristics, occupational history, work organisation, physicochemical, ergonomic and psychosocial hazards. Outcome measures were also included. A robust New Zealand hazard surveillance questionnaire comprehensively covering the key measures of work organisation and work environments that impact upon worker health and safety outcomes was developed. Recommended measures of work organisation, work environment and health outcomes that should be captured in work environment surveillance are made.

STUDY DESIGN: Interrupted time series. OBJECTIVE: To assess whether a change in legislation improved health status and quality of life for people with whiplash. SUMMARY OF BACKGROUND DATA: Whiplash was the most prevalent injury in a compulsory, fault based, third party motor vehicle insurance scheme in New South Wales, Australia. Legislative change removed financial compensation for "pain and suffering" for whiplash, introduced clinical practice guidelines for its treatment; and changed regulations to permit earlier acceptance of compensation claims, and earlier access to treatment, for all types of injury. METHODS: Three independent groups of people with whiplash were identified from insurance data (before legislative change--the 1999 group and, after legislative change--the 2001 and 2003 groups). Health status was assessed 2 years after injury by a telephone interviewer blinded to the study hypotheses. The main outcome measure was disability, as assessed by the Functional Rating Index (FRI). Pain and health-related quality of life was also assessed. RESULTS: The mean FRI at 2 years after injury was 38.0% (SE, 1.9) for the 1999 group, 31.8% (SE, 2.1) for the 2001 group, and 30.1% (SE, 1.8) for the 2003 group (F = 5.0, P = 0.007). Improvement in secondary outcomes, including pain, also occurred. CONCLUSION: Health status of people with whiplash improved after legislative change. Design of compensation schemes should be undertaken with the understanding that the scheme structure may have substantial effects on the long-term health of injured people. Language: en

Context The detailed course of recovery following compensable whiplash associated disorders (WAD) is not well understood. Some people recover within months and others report symptoms for extended periods. Recent research identified distinct recovery pathways. Identifying recovery pathways for people with this condition in compensable settings could assist clinical and claim management. Study objective This study aimed to identify recovery trajectories based on disability, pain catastrophising and mental health and, secondly, to examine developmental linkages between the trajectories. Study design A cohort of 246 people with compensable WAD were followed for 24 months after a motor vehicle related injury. Outcome measures Functional Rating Index (FRI), Pain Catastrophising Scale (PCS) and the SF36 Mental Component Score (SF 36 MCS). Method Group-based trajectory analytical techniques were used to identify distinct post-injury profiles. Multinominal logistic regression modelling identified factors associated with membership of different trajectories. Results 246 people were enrolled a median of 72 days after injury. Three trajectories were identified for the measures used and their prevalences, respectively, were: for disability (FRI) they were mild (47%), moderate (31%), and severe (22%); for pain catastrophising (PCS) they were non-catastrophisers (55%), moderate-low catastrophisers (32%) and clinically significant catastrophisers (13%); and, for mental health (SF36 MCS) they were good mental health (40%), moderately low mental health (42%) and severely low mental health (18%). All groups showed no further recovery beyond 12 months after injury. The significant baseline predictors of the severe disability trajectory were: lower (that means worse) bodily pain scores (SF 36 BPS) ( p ≤0.01); high pain catastrophising ( p ≤0.01); and, self-reported fair or poor general health ( p =0.03). Conditional probabilities for group membership showed that the three trajectories for both PCS and FRI were linked. Dual membership was high for the mild disability and mild pain catastrophising trajectories and, for the severe disability and clinically significant pain catastrophising trajectories. Conclusions There is a strong and plausible association between severe disability, clinical levels of pain catastrophising and low mental health. Claimants can be identified at claim notification based on three estimated recovery trajectories. Claim and clinical interventions can be targeted to the profile within each recovery trajectory.

Whiplash associated disorders (WAD) were first defined by the Quebec Task Force (QTF) in 1995.1 Health outcomes for WAD have been reported to vary widely in the literature.2,3 Recovery in the short term is reported to vary from between 29%4 to 90%.5 Studies reporting long term follow up show that 76%6 to 97%7 are recovered by 12 months. Differences in health outcomes reported may arise from the difference in cohorts (for example, participants recruited from emergency clinics or insurer databases) and the participant's insurance compensation status (compensation eligible versus ineligible).3 In addition, studies report health outcomes using different measures. Higher recovery rates are reported when outcome measures are based on finalization of the claim,1,8 and lower recovery rates when outcomes are reported in terms of symptoms or disability.9,10 Health outcomes reported according to more comprehensive and consistent outcome measures may allow for a more complete understanding of health outcomes following WAD. Identifying WAD sufferers who are less likely to recover is important, in order to try to address the poor health outcomes of WAD. Factors associated with poor prognosis from WAD have differed over time. In Australia, clinical guidelines were released with poor prognostic indicators identified as sociodemographic, psychosocial, compensation, and symptom related factors.11 This categorization was based on the QTF findings1 and updated by a systematic review of research published since then. Subsequently published systematic reviews conclude that the consistent factor in determining poor recovery is initial symptom intensity, with psychosocial and compensation based factors concluded by these authors not to predict outcome.3,12 However, more recent prospective studies challenge this again, finding psychological factors such as the initial health status using the SF‐3613 and acute post traumatic stress9 to be predictive of poor outcome in WAD. Clearly there is a need for further research to examine all of these potential prognostic indicators in order to determine which are more predictive of poor outcome in WAD. This paper seeks to define the health outcomes of a prospective cohort of people with WAD using a comprehensive set of health outcome measures. In addition, we aim to examine relationships between poor outcome and the identified potential prognostic indicators,11 in order to present a more complete understanding of recovery and therefore assist in the prevention of chronic disability following WAD.

There has been little research into the stressors, psychological distress and musculoskeletal symptoms experienced by dentists. The present study was carried out among a random sample of New Zealand dentists (N=413). The present study aimed to identify the severity of work psychosocial stressors, examine the occurrence of musculoskeletal discomfort and psychological disturbance, and determine relationships between these factors. The average age of the dentists was 43 years, with 74% being male. The annual prevalence of symptoms in both the lower back or neck was 63%, with 49% experiencing symptoms in the shoulders. Older dentists were no more likely to suffer musculoskeletal discomfort than younger dentists. The highest ranking dentistry-specific work-related stressor was ‘patients having a medical emergency’ with 78% scoring this stressor very highly. Dentists scored mental demands as the highest general work-related stressor. One-fifth of the dentists scored highly for psychological disturbance...

Objective: To compare the extent and characteristics of motor vehicle traffic incidents on public roads resulting in fatal occupational injuries in Australia, New Zealand (NZ), and the United States (US). Design and setting: Information came from separate data sources in Australia (1989–92), NZ (1985–98), and the US (1989–92). Methods: Using data systems based on vital records, distributions and rates of fatal injuries resulting from motor vehicle traffic incidents were compared for the three countries. Common inclusion criteria and occupation and industry classifications were used to maximize comparability. Results: Motor vehicle traffic incident related deaths accounted for 16% (NZ), 22% (US), and 31% (Australia) of all work related deaths during the years covered by the studies. Australia had a considerably higher crude rate (1.69 deaths/100 000 person years; 95% confidence interval (95% CI) 1.54 to 1.83) compared with both NZ (0.99; 95% CI 0.85 to 1.12) and the US (0.92; 95% CI 0.89 to 0.94). Industry distribution differences accounted for only a small proportion of this variation in rates. Case selection issues may have accounted for some of the remainder, particularly in NZ. In all three countries, male workers, older workers, and truck drivers were at higher risk. Conclusions: Motor vehicle traffic incidents are an important cause of work related death of workers in Australia, NZ, and the US. The absolute rates appear to differ between the three countries, but most of the incident characteristics were similar. Lack of detailed data and inconsistencies between the data sets limit the extent to which more in-depth comparisons could be made.

Background The New South Wales Health (NSW Health) Chronic Disease Management Program (CDMP) delivers interventions to adults at risk of hospitalisation for five target chronic conditions that respond well to ambulatory care: diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease. The intervention consists of two main components: (1) care coordination across sectors (acute, ambulatory, and community care from both public and private sectors) and clinical specialties, facilitated by program care coordinators, and (2) health coaching including management of lifestyle risk factors and medications and self-management. These components were broadly prescribed by the head office of NSW Health, which funded the program, and were implemented by regional health services (local health districts) in ways that best suited their own history, environment, workforce, and patient need. We used a propensity-matched cohort study to evaluate health service utilisation after enrolment in the CDMP. Methods and Findings The evaluation cohort included 41,303 CDMP participants enrolled between 1 January 2011 and 31 December 2013 who experienced at least one hospital admission or emergency department (ED) presentation for a target condition in the 12 mo preceding enrolment. Potential controls were selected from patients not enrolled in the CDMP but experiencing at least one hospital admission or ED presentation over the same period. Each CDMP patient in the evaluation cohort was matched to one control using 1:1 propensity score matching. The primary outcome was avoidable hospitalisations. Secondary outcomes included avoidable readmissions, avoidable bed days, unplanned hospitalisations, unplanned readmissions, unplanned bed days, ED presentations, and all-cause death. The primary analysis consisted of 30,057 CDMP participants and 30,057 matched controls with a median follow-up of 15 mo. Of those, 25,638 (85.3%) and 25,597 (85.2%) were alive by the end of follow-up in the CDMP and control groups, respectively. Baseline characteristics (including history of health service utilisation) were well balanced between the matched groups. In both groups, utilisation peaked just before the time of enrolment/matching, declined sharply immediately following enrolment, and then continued to decrease more gradually; however, after enrolment, avoidable and unplanned health service utilisation remained higher for CDMP participants compared to controls. The adjusted yearly rate of avoidable hospital admissions was 0.57 (95% CI 0.52 to 0.62) in the CDMP group versus 0.33 (95% CI 0.31 to 0.37) in the control group (adjusted rate ratio 1.70, 95% CI 1.62 to 1.79, p < 0.001). Significant increases in service utilisation were also observed for unplanned hospitalisations (1.42, 95% CI 1.37 to 1.47, p < 0.001) and ED presentations (1.37, 95% CI 1.32 to 1.42, p < 0.001) as well as avoidable (2.00, 95% CI 1.80 to 2.22, p < 0.001) and unplanned (1.51, 95% CI 1.40 to 1.62, p < 0.001) readmissions and avoidable (1.70, 95% CI 1.59 to 1.82, p < 0.001) and unplanned (1.43, 95% CI 1.36 to 1.49, p < 0.001) bed days. No evidence of a difference was seen for all-cause death (adjusted risk ratio 0.96, 95% CI 0.96 to 1.01, p = 0.10) or non-avoidable hospitalisations (all hospitalisations minus avoidable hospitalisations; adjusted rate ratio 1.03, 95% CI 0.97 to 1.10, p = 0.26). Despite the robustness of these results to sensitivity analyses, in the absence of a randomised control group, one cannot exclude the possibility of residual or unmeasured confounding that was not controlled for by the matching process and multivariable analyses. Conclusions Participation in the CDMP was associated with an increase in avoidable hospital admissions compared to matched controls but no difference in the rate of other types of hospitalisation or death. A possible explanation is that the program identified conditions that required participants to be hospitalised. Service utilisation decreased sharply following its peak for both groups. This finding reflects the natural tendency for high-risk patients to show reductions in use following intense phases of service utilisation and highlights that, despite the additional complexity, a carefully selected control group is essential when assessing the effectiveness of interventions on hospital use., In this propensity-matched cohort study, Laurent Billot and colleagues evaluate health service utilization among patients enrolled in the New South Wales Health Chronic Disease Management Program., Author Summary Why Was This Study Done? There is an increasing number of people living with chronic disease and whose chronic conditions lead to increased hospitalisations and expenditures for health systems. There is evidence to support the effectiveness of a variety of interventions, including self-management support and care coordination. New South Wales Health implemented the Chronic Disease Management Program to help people with chronic disease better manage their conditions in the community and commissioned an independent evaluation to assess the effect of the program on future hospitalisations, especially so-called avoidable, or “potentially preventable”, hospitalisations. What Did the Researchers Do and Find? We compared hospitalisation patterns in 30,057 individuals enrolled in the Chronic Disease Management Program to those in 30,057 similar individuals who were not part of the program and who were matched using a propensity score. We found, over an average follow-up of 15 mo, that avoidable hospitalisations appeared more frequent in those enrolled in the program (adjusted rate ratio 1.70, 95% CI 1.62 to 1.79, p < 0.001), with most of the excess related to the conditions targeted by the program such as chronic respiratory and cardiovascular diseases. Excesses were also observed for other secondary outcomes such as unplanned hospital admissions, readmissions, length of hospital stay, and emergency department presentations, but no difference was seen in mortality or non-avoidable hospitalisations. What Do These Findings Mean? The Chronic Disease Management Program may have uncovered unaddressed needs that led to increased hospitalisations related to the conditions targeted by the program. The results were consistent across outcomes and robust in sensitivity analyses; however, due to the non-randomised nature of the evaluation, one cannot exclude the possibility of unmeasured confounding that could not be accounted for by propensity matching and multivariable analyses. Other health indicators, such as data collected by general practices, might provide additional insight for the early identification of individuals who might benefit from similar programs, and might provide more sensitive measures of program effectiveness.

Problem: A number of structural and organizational changes have occurred recently within the New Zealand Forestry Industry, with concerns being raised about the impact of these changes on the forestry worker in terms of fatigue, sleepiness, and compromised safety. This study explored the relationship of fatigue, and some of its key determinants, with accidents and injuries in a group of forestry industry workers in New Zealand. Method: A total of 367 forestry workers responded to a self-administered questionnaire. Results: Fatigue was found to be commonly experienced at work in the forest, with 78% of workers reporting that they experienced fatigue at least “sometimes.” This study found that certain groups of workers reported long working hours, reduced sleep, compromised recovery time, and intensely paced work. The results of logistic regression analysis showed that recent sleep, number of breaks taken during the workday, and specific job/tasks were independently associated with reporting of high fatigue levels at work. Near-miss injury events were significantly more common among those reporting a high level of fatigue at work. Accidents and lost-time injury were associated with length of time at work, ethnicity, and having had near-miss injury events. Discussion: Together, these results suggest that fatigue and aspects of work organization, which are likely to be fatiguing, may be associated with compromised safety for forest workers. Impact on Industry: With an already slim margin of error present in forest operations, an impairment due to increased fatigue may constitute a significant risk factor for accidents and injuries in this workforce. The results indicate the need for further examination of shift and workload management among forestry workers, as well as a role for improving industry awareness about the causes and consequences of fatigue.

Context Many people with Whiplash Associated Disorder (WAD) seek treatment though a compensation system where factors such as legal involvement have been reported as having a negative impact on recovery outcomes. Objective To compare those with and without legal involvement in their compensation claim, and identify associations with legal involvement at 12 months post injury; and longer term disability. Study design Inception cohort study. Participants 246 people with WAD compensation claim. Outcome measures Legal involvement and Functional Rating Index at 12 months post injury. Methods Participants were recruited from an insurance database. Baseline health (Functional Rating Index, Pain Catastrophising Scale and SF-36), socio-economic, work capacity, and claims data were collected within three months of injury and 12 months. Logistic regression models were used to identify associations with legal involvement at 12 months; and disability (FRI) at 12 months. Results At baseline 246 participants were enrolled into the study in a median 72 days post injury. At 12 months post injury 52 (25%) had engaged a lawyer. The significant independent associations with legal involvement at 12 months were higher levels of initial disability, work disability, speaking a language other than English at home and lower levels of mental health. Specifically, the odds of lawyer involvement at 12 months post injury was 4.9 times greater for those with work disability; 2.3 times greater for those who spoke a language other than English at home. In terms of health, they had poorer mental health and for every 10 unit increase in the baseline FRI score the odds of having lawyer involvement increased by 38%. Disability at 12 months (FRI) was significantly independently associated with, PCS-helplessness (p Conclusion This study suggests the people with lawyer involvement in their claim 12 months after injury have socio-economic disadvantage, have had a prior claim and a worse baseline health profile compared to those without a lawyer. Understanding this profile could allow for improved claims processes and targeted interventions to assist this group through any perceived complexities in the system and address the underlying reasons for lawyer participation within compensation schemes.

Objectives—To investigate the utility of narrative analysis of text information for describing the mechanism of injury and to compare the patterns of the mechanism of injury for work related fatalities in three countries. Methods—Three national collections of data on work related fatalities were used in this study including those for New Zealand, 1985‐94 (n=723), for Australia, 1989‐92 (n=1220), and for the United States, 1989‐92 (16 383). The New Zealand and Australian collections used the type of occurrence standard code for the mechanism of injury, however the United States collection did not. All three databases included a text description of the circumstances of the fatality so a text based analysis was developed to enable a comparison of the mechanisms of injury in each of the three countries. A test set of 200 cases from each country dataset was used to develop the narrative analysis and to allow comparison of the narrative and standard approaches to mechanism coding. Results—The narrative coding was more useful for some types of injury than others. DiVerences in coding the narrative codes compared with the standard code were mainly due to lack of sensitivity in detecting cases for all three datasets, although specificity was always high. The pattern of causes was very similar between the two coding methods and between the countries. Hit by moving objects, falls, and rollovers were among the five most common mechanisms of workplace fatalities for all countries. More common mechanisms that distinguished the three countries were electrocutions for Australia, drowning for New Zealand, and gunshot for the United States. Conclusion—Narrative analysis shows some promise as an alternative approach for investigating the causes of fatalities. (Injury Prevention 2001;7(Suppl I):i15‐20)

OBJECTIVES—To describe work related fatal injuries to agricultural workers in New Zealand to identify priority areas for further research and injury control measures. METHODS—Injury deaths in New Zealanders aged 15-84 inclusive for the period 1985-94 were identified and the coroner's files for these obtained. These files were then reviewed to determine whether the death arose as a result of work activities. Those deaths considered to be work related were coded for information relating to decedent demographics and the circumstances of the fatal injury. Work related deaths from injury occurring in the agricultural production and services to agriculture sectors were analysed. RESULTS—The rate of fatal injuries to male agricultural workers over the study period was 21.2/100 000, with injury deaths in the agricultural sectors accounting for nearly a quarter of all work related fatal injuries in New Zealand in that time. There was no significant decline in fatal injuries to agricultural workers in the study decade. Workers in the 65-84 age bracket were at substantially higher risk of fatal injury than other age groups. Machinery and motor vehicles were commonly associated with fatal injury, with overturns on or next to embankments and slopes being the most frequent scenario. CONCLUSIONS—The results of this study highlight fatal injuries in older workers and machinery incidents (particularly tractors overturning) as priority areas for further research into contributing factors and injury control measures. Keywords: agriculture; fatal injury

To compare the extent, distribution, and nature of fatal occupational injury in New Zealand, Australia, and the United States.Workplaces in New Zealand, Australia, and the United States.Data collections based on vital records were used to compare overall rates and distribution of fatal injuries covering the period 1989-92 in Australia and the United States, and 1985-94 in New Zealand. Household labour force data (Australia and the United States) and census data (New Zealand) provided denominator data for calculation of rates. Case definition, case inclusion criteria, and classification of occupation and industry were harmonised across the three datasets.New Zealand had the highest average annual rate (4.9/100,000), Australia an intermediate rate (3.8/100,000), and the United States the lowest rate (3.2/ 100,000) of fatal occupational injury. Much of the difference between countries was accounted for by differences in industry distribution. In each country, male workers, older workers, and those working in agriculture, forestry and fishing, in mining and in construction, were consistently at higher risk. Intentional fatal injury was more common in the United States, being rare in both Australia and New Zealand. This difference is likely to be reflected in the more common incidence of work related fatal injuries for sales workers in the United States compared with Australia and New Zealand.The present results contrasted with those obtained by a recent study that used published omnibus statistics, both in terms of absolute rates and relative ranking of the three countries. Such differences underscore the importance of using like datasets for international comparisons. The consistency of high risk areas across comparable data from comparable nations provides clear targets for further attention. At this stage, however, it is unclear whether the same specific occupations and/or hazards are contributing to the aggregated industry and occupation group rates reported here.

Successful accident prevention relies to a large extent on knowledge about the causes of accidents. The Australian Work-Related Fatalities Study provided the opportunity to gain a better understanding of the causes of fatal accidents at work by summarizing the circumstances of all fatal accidents occurring in Australia over a three-year period. This paper reports on a further analysis of the immediate and wider circumstances of work-related deaths due to electricity. This analysis looked at two groups of cases: first, where the direct cause of death was contact with electricity (electrocution); and second, where deaths occurred in occupations with high exposure to electricity (electrical and related trades) but where the cause of death was not necessarily electrocution. The accident patterns for these two groups were compared to accident patterns for all fatalities. As for all fatalities, behavior was most likely to be involved in electricity-related deaths and be a prime cause; but unlike all fatalities, behavioral involvement occurred earlier in the accident sequence. The event just before the fatality was most likely to be environmental, involving the worker coming into contact with electricity, but this was very rarely a prime cause of the fatality. Overall behavior took similar forms in electricity-related fatalities as for fatalities in general, with a few notable differences. First, in electricity-related fatalities omission errors were much more common than commission errors. Second, electricity-related fatalities had different patterns of contributing factors. Electrocutions were much more likely to have involved poor upkeep of equipment and task errors at an earlier time compared to electrical trades fatalities and fatalities in general. By revealing the particular details of the causes of fatalities involving electricity, and consequently the most effective targets for prevention, better safety solutions can be designed.

Drivers and companies operating in the heavy road transport industry were surveyed about drivers' hours of work and perceptions of the causes and magnitude of fatigue as an industry problem. These drivers were operating in a state which, at the time of the survey, did not restrict driving hours for heavy haulage drivers. On the day of the interview, estimates based on retrospective and prospective reports, suggest that in a 24 hour period about 38% of drivers exceed 14 hours of driving, and 51% exceed 14 hours of driving plus other non-driving work. About 12% of drivers reported less than 4 hours of sleep on one or more working days in the week preceding the interview. These drivers are likely to be operating their vehicles while having a significant sleep debt. About 20% of drivers reported less than 6 hours sleep before starting their current journey, but nearly 40% of dangerous events that occurred on the journey were reported by these drivers (p < 0.05). Many drivers and company representatives reported fatigue to be a problem for other drivers, but considered themselves or their companies' drivers to be relatively unaffected by fatigue. There were differences between drivers' and companies' perceptions about causes of fatigue, and strategies that should be used to manage it. The results obtained from these drivers in an unregulated state were compared with earlier findings from drivers in states where driving hours restrictions are in place.

The information surrounding the occurrence of all traumatic work-related fatalities in Australia over the years 1982 to 1984 was analyzed. Previous analysis of patterns of accident causation revealed that pre-existing poor work practices were the most common precursors of human errors precipitating fatalities, and that, overall, this combination of causal factors was the most common one leading to fatalities. The present paper examined further the nature of work practices involved in these fatalities and their relationship to subsequent behavioural events in the accident sequence. The most common work practices were those associated with procedures, either originating from management or individual practices. Examination of the association of particular work practices with the occurrence of subsequent human errors revealed that the origin of the unsafe practice varied for different error types. Individual worker practices, safety equipment and personal protective equipment practices were all associated with later skill-based errors. In contrast, management practices were associated with knowledge-based errors, while general equipment practices were associated with rule-based errors. These findings provide evidence for the view that aspects of work organization provide the circumstances in which later events may precipitate the accident. Moreover, the data suggest that being able to identify the precursors of critical events, and, in particular, those events that are difficult to directly target, can provide a specific focus for prevention. Knowledge-based errors can be directly targeted for prevention, whereas for skill-based errors the only avenue for prevention lies in targeting the surrounding circumstances.

In understanding the safety climate or culture of a workplace, the perceptions and attitudes of the workforce are important factors in assessing safety needs. Safety solutions may fail if they do not take into account these prevailing attitudes and perceptions. Also, changes in attitudes and perceptions about safety are often likely outcomes of safety interventions. The aim of this study was to develop a measure of perception and attitudes about safety as an indicator of safety culture for use with working populations. After reviewing the structure and content of a number of older, related measures of safety attitudes, a 67-item questionnaire was developed. The questionnaire was distributed in a self-administered form to 1560 workers in a wide variety of types of jobs and 660 questionnaires were returned from 7 workplaces with a response rate of 42%. Items were evaluated by Cronbach alpha which showed that the item set shared considerable common variance. Scale development was approached in two ways. First items which were highly skewed were removed, resulting in removal of around half of the items, with very little loss in alpha. The remaining items were then subjected to factor analysis which revealed five factors; personal motivation for safe behaviour, positive safety practice, risk justification, fatalism and optimism. This factor structure showed acceptable psychometric properties. Second, in an effort to produce a unidimensional scale with a small, but representative set of items, additional items were removed which had high correlation with other items. This resulted in loss of around half of the remaining items. The short scale contained 17 items with again overall acceptable psychometric properties. The most striking finding in the development of this questionnaire was that there was little variation between respondents on a very large proportion of the questions originally selected. Clearly there are well-known beliefs about safety in the working community which need to be understood in order to progress the concept of safety culture.

Occupational fatalities are thought to have similar origins across different types of work. In this study all occupational fatalities occurring in Australia over a three year period were coded and classified using a method designed to describe the comprehensive causes of accidents. The aim of the study was to determine whether there are general causation patterns for fatalities at work across all industry. One thousand and twenty occupational fatalities were coded for the analysis. Correspondence analysis and cluster analysis were used to describe the patterns and relationships between occupational groups and nature of the accident precursor sequence. The results of the final cluster analysis showed that fatalities occurred in a similar manner for most occupational groups. The major exceptions were timbergetters and electrical trades workers. Two main factors seemed to be important, however, in distinguishing the nature of accident precursors of the occupational groups — the gross nature of the accident sequence with respect to the involvement of behavioural or environmental factors and the presence or absence of unsafe work practices as contributors to the sequences. There was some interaction between these two factors.

The relationship between accidents and the time of day is not entirely clear. Although there is considerable evidence that performance is poorest in the early morning hours compared to at all other times, the degree to which this is translated into accidents is not understood. In this study work-related fatal accidents were analysed to determine whether the causes of these accidents vary with time. The analysis used a classification and coding system devised to describe the wider circumstances of the causes of fatalities. In terms of absolute numbers, fatalities were most common in the late morning or early afternoon. When these results were expressed in terms of the estimated number of workers at work, the proportion of fatal accidents occurring at night was more than double that occurring during the day. Behavioural factors were the most common cause of fatalities at all times, but most common in the early hours of the morning. Further analysis of the nature of the behavioural involvement showe...

To date management of fatigue in professional drivers has largely focused on strategies that limit the amount of time spent on the job. These approaches have, however, not taken into account the well-documented effect of time of day. Consequently, the likely impact of the pattern and timing of work and rest has received little attention. The results revealed that the group of drivers who did the shortest trips and worked the shortest weekly hours were the lowest reporters of fatigue, although longer hours were not always associated with the highest reporting of fatigue. In contrast, the shortest working hours were associated with earliest onset of fatigue. For all drivers, the influence of circadian rhythms was evident in the occurrence of fatigue, with better management of the problem evident among drivers who were able to arrange the timing of rest to more closely coincide with periods of fatigue. Thus, time of day appeared to be a more important influence in determining effective rest than did...

The present study is the second part of a large project designed to identify possible strategies to better manage driver fatigue in the long distance road transport industry. The first study in the project, reported elsewhere, investigated driver fatigue among truck drivers. The present study examined driver fatigue in the passenger sector. The questionnaire was designed for the first study and was adapted for the passenger sector. The questionnaire obtained information about the drivers' experience of fatigue, working conditions, type of driving operation as well as details of their last trip and last working week. The results revealed that the experience of drivers in the passenger sector only partially overlapped that for the truck sector. The ways in which fatigue occurred and some of the contributors to fatigue showed remarkable consistency across sectors. There was major divergence, however, in the ways drivers reported managing fatique.

The experience of low-back pain and its psychosocial associates were directly compared among sufferers drawn from three populations, a blue-collar working group, a white-collar working group, and a patient group. Sufferers drawn from the patient population revealed the expected psychological disturbance. There was no evidence of such involvement for sufferers still at work. Disability resulting from low-back pain was positively linearly related to severity of pain for sufferers drawn from working groups, irrespective of psychological disturbance. For patients, on the other hand, the presence of psychological disturbance modified the relationship between severity and disability such that no simple linear relationship existed between the two variables. Work dissatisfaction was not found to be related to the presence of, and did not account for disability resulting from, low-back pain in working subjects.

A Questionnaire was used to obtain information from 960 long distance truck drivers about the drivers” experience, type of employment and their working conditions, type of driving operation, as well as details of their last trip and their last working week. Operations specifically designed to combat driver fatigue by provision of a relief driver in a team operation did not appear to achieve their intended outcome. The potential benefits of such operations appeared to be outweighed by the greater distances and lack of flexibility that characterised these trips.

The circumstances of all work-related fatalities occurring in Australia over a three year period were analysed to determine how they differed between occupational groups. Correspondence analysis was used to examine the relationship between the sequence of events immediately preceding the accident, the involvement of unsafe work practices and type of work being performed. There were clear differences in the causes of deaths at work between occupational groups which provide information about the most likely targets for accident prevention.

A comprehensive classification system was applied to the analysis of the information surrounding the occurrence of all traumatic work-related fatalities in Australia over the years 1982–1984. The information coded included factors immediately antecedent to the accident as well as factors removed in time which contributed to the occurrence of the accident. The results indicated that the relationships between human and other factors, among human factors, and between factors immediately preceding the accident and those removed in time from the accident all provide important insights about the causes of occupational accidents and their prevention.

Williamson, A. and Feyer, A.-M., 1990. Behavioural epidemiology as a tool for accident research. Journal of Occupational Accidents , 12: 207–222. In this study the incidence and nature of behavioural events preceding work-related fatalities were investigated. All occupational facilities were examined for the years 1982 to 1984. The events preceding the fatality and any pre-existing factors that contributed to the fatality were coded. The coding focussed on such aspects as the environment, equipment design and upkeep, as well as human factors like work practice, supervision, training, medical precursors and task errors. The primary events and contributory factors were ranked and weighted in order to establish the casual relationships between them. Multivariate analysis was used to determine the nature of these relationships across all fatalities. As this study covers so many types of accidents in such a wide variety of occupational groups, the results provide more specific information about human behavioural epidemiological method to evaluate the impact of different aspects of human error on accident causation. This method will allow highlighting of the most suitable strategies for accident prevention.

To estimate the extent of bystander work-related traffic fatal injury for New Zealand as well as the contribution of all bystander events to the total burden of work-related fatal traffic injury and work-related fatal injury in general.Potential cases were identified from national administrative databases. The circumstances of the deaths in each incident were reviewed directly from coronial files to determine work-relatedness.For 1985-1998 we identified 1447 people whose death was associated with another person's work activity on a public road and who were not working at the time. This compares with 241 "working" and 192 "commuting" deaths on a public road for the same period. Bystanders thus represented approximately 75% of the work-related fatal traffic crash injury problem. We estimate that (on average) approximately 115 bystanders were killed each year and this represents approximately 52% of the total work-related fatality problem.Work-related bystander deaths are a major contributor to work-related injury in New Zealand, the majority occurring in the context of road traffic crashes. These deaths deserve more attention than they have received to date.

To compare the effectiveness of interviewer-led and postal surveys in gathering adequate health data for occupational health programmes among farmers.Two cross-sectional studies of farmers from southern New Zealand were conducted. Farms were randomly selected from the public land valuation roll and all farmers and farm workers invited to participate in the farmers' health study. First, 477 farms were invited to participate in an interviewer administered questionnaire and health check; and second, a further 432 farms were selected and invited to participate in a self-administered postal survey. Both groups completed the same questionnaire.The response for the interviewer-led and postal surveys was 65.4 % and 51.6 % respectively. The 2 groups differed demographically, with fewer young farm workers in the postal survey, but were similar in all areas of health information collected, except that men in the interviewer-led survey were significantly more likely to have a psychological disturbance than men in the postal survey (chi ( 2 ) =5.06, df=1, p=0.024).Despite the interviewer-led survey having a higher response rate, the postal survey produced similar health data, which is adequate for planning occupational health programmes for farmers. Extra effort should be made to recruit younger farm workers in future research.

To identify and describe all work-related traffic fatalities in New Zealand between 1985 and 1998 inclusive.Potential cases were identified from databases held by three national agencies. The circumstances of the deaths in each fatal incident were reviewed directly from coronial files to determine work-relatedness.The rate of work-related fatal injury involving vehicles on a public road was 2.01 per 100,000 workers per year. The rate for worker deaths was 1.11 and that for commuting deaths was 0.89 per 100,000 workers per year.There is a substantial number of work-related crash fatalities each year and these represent a sizeable portion of the total burden of work-related fatalities.

To estimate the numbers and rates of work-related fatal injury for children under the age of 15 years.Potential cases of work-related injury deaths of persons aged15 years of age were identified from the national electronic mortality data-files for the period 1985-1998 inclusive. The circumstances of the death in each fatality incident were reviewed directly from coronial files to determine work-relatedness.A total of 87 workplace work-related fatalities were identified. The vast majority of children identified were fatally injured while a bystander to another person's work. Workplace bystander involvement was found to vary by age, with the majority of workers identified aged 10-14 years old. With a third of all fatalities, the agricultural industry was the most common industry for workplace work-related fatalities in children. In the period 1985-94, children15 years of age were found to account for 46% of New Zealand's total workplace bystander deaths.Children contribute significantly to the overall burden of work-related fatal injury in New Zealand, especially as bystanders to other people's work. The high contribution to bystander deaths by children aged15 years suggests that hazard control in certain work settings is lacking.

As part of a larger study comparing work-related fatal injury of workers in Australia, New Zealand and the United States, an assessment was made of the similarities and differences between the three countries in identifying fatal incidents as work-related or not. The researchers in each country independently classified 333 brief scenarios, describing a variety of fatal incidents, into one of nine categories related to work: worker, bystander, commuter, volunteer, student, suicide, other, unknown and none of the above. Complete agreement with the classification was moderate (62%), but agreement when classifying scenarios as working, not working or unknown was much higher (full agreement for 80% of scenarios; Kappa = 0.71). Only 5% of scenarios were classified differently by all three countries. Other main findings of the study were that there is variation between countries in the interpretation of what is and what is not work-related, and variation in the amount or type of information required to make a definitive classification. Common circumstances described in the scenarios for which there was some disagreement in classification included domestic violence incidents at work, volunteer workers, business trips, social functions connected to work, hobby farmers and some possible bystander incidents that occurred on farms or on the road. The results suggest that, even without the use of standard definitions, comparisons between the datasets of the countries involved in this study can be made with reasonable confidence. However, they also emphasise the importance of minimising ambiguity in the definitions used, and of understanding the manner in which the definitions are applied, when comparing results between studies.

The purpose of this workplace evaluation was to assess the effects on performance, alertness and subsequent sleep of strategic napping on 12-h overnight shifts. In a counterbalanced crossover design, 24 male aircraft maintenance engineers working in a forward rotating 12-h shift pattern volunteered to take part in the study for two work weeks. During the experimental week, each subject was given the opportunity to take a 20-min nap at work between 01:00 and 03:00 h on each of their two overnight shifts. On the control week no naps were taken on the night shifts. A computerized neurobehavioural test battery was employed to assess performance and subjective levels of fatigue at the beginning and end of each night shift, and pre- and postnap. Subjects were also asked to rate how near they had come to falling asleep while driving to and from work. The results revealed that taking a single 20-min nap during the first night shift significantly improved speed of response on a vigilance task measured at the end of the shift compared with the control condition. On the second night shift there was no effect of the nap on performance. Taking a short nap during either night shift had no significant effect on subjective ratings of fatigue, the level of sleepiness reported while driving to and from work, or subsequent sleep duration and sleep quality. Overall the results suggest some promise for a short duration nap taken in the workplace to counteract performance deficits associated with the first night shift.

A number of structural and organizational changes have occurred recently within the New Zealand Forestry Industry, with concerns being raised about the impact of these changes on the forestry worker in terms of fatigue, sleepiness, and compromised safety. This study explored the relationship of fatigue, and some of its key determinants, with accidents and injuries in a group of forestry industry workers in New Zealand.A total of 367 forestry workers responded to a self-administered questionnaire.Fatigue was found to be commonly experienced at work in the forest, with 78% of workers reporting that they experienced fatigue at least "sometimes." This study found that certain groups of workers reported long working hours, reduced sleep, compromised recovery time, and intensely paced work. The results of logistic regression analysis showed that recent sleep, number of breaks taken during the workday, and specific job/tasks were independently associated with reporting of high fatigue levels at work. Near-miss injury events were significantly more common among those reporting a high level of fatigue at work. Accidents and lost-time injury were associated with length of time at work, ethnicity, and having had near-miss injury events.Together, these results suggest that fatigue and aspects of work organization, which are likely to be fatiguing, may be associated with compromised safety for forest workers.With an already slim margin of error present in forest operations, an impairment due to increased fatigue may constitute a significant risk factor for accidents and injuries in this workforce. The results indicate the need for further examination of shift and workload management among forestry workers, as well as a role for improving industry awareness about the causes and consequences of fatigue.

The effects of 28 h of sleep deprivation were compared with varying doses of alcohol up to 0.1% blood alcohol concentration (BAC) in the same subjects. The study was conducted in the laboratory. Twenty long-haul truck drivers and 19 people not employed as professional drivers acted as subjects. Tests were selected that were likely to be affected by fatigue, including simple reaction time, unstable tracking, dual task, Mackworth clock vigilance test, symbol digit coding, visual search, sequential spatial memory and logical reasoning. While performance effects were seen due to alcohol for all tests, sleep deprivation affected performance on most tests, but had no effect on performance on the visual search and logical reasoning tests. Some tests showed evidence of a circadian rhythm effect on performance, in particular, simple reaction time, dual task, Mackworth clock vigilance, and symbol digit coding, but only for response speed and not response accuracy. Drivers were slower but more accurate than controls on the symbol digit test, suggesting that they took a more conservative approach to performance of this test. This study demonstrated which tests are most sensitive to sleep deprivation and fatigue. The study therefore has established a set of tests that can be used in evaluations of fatigue and fatigue countermeasures.

OBJECTIVES—To compare the relative effects on performance of sleep deprivation and alcohol. METHODS—Performance effects were studied in the same subjects over a period of 28 hours of sleep deprivation and after measured doses of alcohol up to about 0.1% blood alcohol concentration (BAC). There were 39 subjects, 30 employees from the transport industry and nine from the army. RESULTS—After 17-19 hours without sleep, corresponding to 2230 and 0100, performance on some tests was equivalent or worse than that at a BAC of 0.05%. Response speeds were up to 50% slower for some tests and accuracy measures were significantly poorer than at this level of alcohol. After longer periods without sleep, performance reached levels equivalent to the maximum alcohol dose given to subjects (BAC of 0.1%). CONCLUSIONS—These findings reinforce the evidence that the fatigue of sleep deprivation is an important factor likely to compromise performance of speed and accuracy of the kind needed for safety on the road and in other industrial settings. Keywords: sleep deprivation; performance; alcohol

OBJECTIVE—To examine risk factors for onset of low back pain (LBP) in healthcare workers. METHODS—Nursing students, during their 3 year training period, and 1 year after training were studied in a prospective cohort study, with repeated self reported measurements of determinants of LBP at 6 monthly intervals for 3 years during training, and after a 12 month interval there was an additional final follow up. RESULTS—During training, increased risk of new episodes of LBP was associated with having had LBP at baseline, with part time work, and with a high score on the general health questionnaire (GHQ). A high GHQ score preceded the onset of LBP, in such a way that a high score at the immediately previous follow up increased risk of LBP at the next follow up. 12 Months after training, a history of recurring LBP during training increased the risk of a new episode as did having obtained work as a nurse. A high GHQ score at this follow up was also associated with a concurrently increased risk. Pre-existing GHQ score, either at the end of training or at baseline, had no effect on risk of LBP 12 months after training. CONCLUSIONS—Other than a history of LBP, pre-existing psychological distress was the only factor found to have a pre-existing influence on new episodes of LBP. Increased levels of psychological distress (as measured by the GHQ) preceded the occurrence of new episodes of pain by only short intervening periods, implying a role for acute distress in the onset of the disorder. This finding suggests that management of the onset of occupational LBP may be improved by management of psychological distress. Keywords: low back pain; nurses; psychological factors

Twenty seven professional truck drivers completed a 12 hour, 900 km trip under each of three driving regimes-a relay (staged) trip, a working hours regulated one-way (single) trip, and a one-way (flexible) trip with no working hours constraints. The results indicated that none of the driving regimes prevented fatigue and that the pattern of fatigue experienced during the trips appeared to be related to pretrip fatigue levels.

Papers p 829 Being awake at times that are biologically programmed for sleep, prolonged wakefulness, and having had restricted sleep over a period of time result in fatigue and sleepiness. These conditions undoubtedly adversely affect human performance. This week's issue includes another reminder of the dangers of sleepiness while driving,1 yet we continue to fail to treat fatigue with the seriousness it deserves. The impact of sleep loss on performance is well documented by laboratory research.2 Even modest amounts of sleep loss over short periods (about two hours a night over one week) accumulate and manifest themselves as an irresistible tendency to fall asleep during inappropriate or dangerous situations, like driving.3 The vulnerability of performance to circadian rhythm in alertness and sleepiness, even in well rested individuals, is similarly well documented.2 Data on accidents from a variety of sources worldwide confirm the impact of time of day on the occurrence of accidents.4 Working at night, and working hours that restrict sleep opportunity, have long been implicated in compromised safety at work.5 The size of the problem is significant. A survey of car drivers in the United Kingdom found …

One problem of test battery design in occupational health and safety has been the absence of a unifying theoretical framework for the selection of tests. Consequently, systematic interpretation of observed deficits has been impeded. A computer aided battery of tests based on a model of human information processing was designed. Together, the tests provide a comprehensive and integrated evaluation of sensory, motor and cognitive performance. The tests, their relationship to the model on which they are based and the purpose-specific hardware and software designed to run the tests are detailed.