2009 vol. 33 no. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 195© 2009 The Authors. Journal Compilation © 2009 Public Health Association of Australia

in Sarikei), we are finally able to secure the understanding of

the relevant local council and peoples’ elected representatives

to adopt the same measures, and are confident that the situation

will soon improve.

We are fully aware the ecology and the check and balance of the

natural environment, and we are also appreciative of the fact that

the birds play an important role in insect (and therefore disease)

control. However, we are most concerned about the public health

situation and the general aesthetic appearance/hygiene of our living

and working environment, especially in the central business district

where many activities including tourism are important components

of Sibu life. We cannot allow the bird droppings to accumulate,

and must be pro active to maintain a healthy, green and pleasant

environment, to live and to work in.

We have taken as a model, the Australian Government issuing

of licenses to cull kangaroos (a protected species) if their numbers

and activities become a nuisance, such as causing extensive

economic damages to farms. We have also suggested frequent

clearing of bird nests under the roofs of the shop houses, and we

support the state government’s rulings that bird rearing should

not be carried out in the top floors of shop houses in the central

business district, and that relevant authorities issue licenses to

enable culling of some of the birds, as too many bird droppings

affected our daily lives and threaten our health. We are also looking

into other control options (such as inexpensive ‘bird scarers’, radar,

ultrasonic, radiofrequency methods). We hope all these will find

cost beneficial applications in our daily lives, in terms living in

harmony with nature.

My public health training at Sydney University continues to be

useful in my daily clinic work as well as in my capacity as a leader

in public health issues in our community.

Refererences1. Histoplasmosis. In: Zoonoses and communicable diseases sommon to man

and animals. Volume 1. Bacterioses and Mycoses, 339-345.Third edition. Pan Americal Publci Health Association, Washington, USA. 2003.

2. Histoplasmosis. In: Control of Communicable Diseases Manual, 18th edition. 273-275, 2004. Ed: David L. Heyman. APHA and WHO, Washington.

Correspondence to:Dr Robert Hu, Hu’s Specialist Clinic, 1B Brooke Drive, Sibu , Sarawak, Malaysia, Fax: 6 084 313939; e-mail: chhu@streamyx.com

Bird droppings on a windowsill of a shophouse.

Letters

doi: 10.1111/j.1753-6405.2009.00371.x

Authors’ response to letter regarding a public health approach to child abuse and neglectMelissa O’Donnell

Telethon Institute for Child Health Research, Centre for Child Health Research, The University of Western Australia

Dorothy ScottAustralian Centre for Child Protection, University of South Australia

Fiona StanleyTelethon Institute for Child Health Research, Centre for Child Health Research, The University of Western Australia

We thank Lillian De Bortoli for her comments1 on our article,

‘Child abuse and neglect – is it time for a public health approach?2

We strongly agree that the valuing of children in a culture is at

the core of preventing child abuse and neglect and that there

indeed are complex tensions between societal valuing of family

privacy and the use of the State’s powers to protect children. We

also acknowledge as Ms De Bortoli has pointed out that there are

significant deficits in knowledge which need to be addressed in

the areas of child abuse prevention and intervention.

While we appreciate that De Bortoli agrees that public health

principles are essential components of prevention we feel that the

comments on the limitations of a public health approach stem from

a failure to understand what this approach fully encompasses. The

comment that ‘child abuse cannot be equated to heart disease or

obesity in adults’ and that ‘children are not actors in their own

abuse’ implies that we would only be tackling child abuse through

a health promotion strategy and that children are not able to

implement these health messages. We argue that a public health

approach is much more than a health promotion strategy aimed

at individual behaviour change. Some of the many population

based strategies which are likely to reduce child abuse and neglect

include increasing breastfeeding (there is some very recent research

on this as a protective factor),3 reducing close spacing between

births,4 home visiting programs for at-risk families.5 reducing the

availability of child pornography,6 improving respite for families

with children who have physical/behavioural disabilities and

conditions,7 reducing the level of adult alcohol misuse by a range

of whole community interventions,8 etc. None of these require the

child to be the health service user who takes on a message.

De Bortoli also commented on the focus on hospital admission

rates as measures of incidence and prevalence. We will never

get complete data on child abuse and neglect; therefore as we

argued in the paper, it is necessary to broaden our surveillance

approaches to other datasets, besides Child Protection Agency

196 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2009 vol. 33 no. 2© 2009 The Authors. Journal Compilation © 2009 Public Health Association of Australia

doi: 10.1111/j.1753-6405.2009.00372.x

Essentials of Biostatistics in Public Health & Essentials of Biostatistics Workbook: Statistical Computing Using Excel

By Lisa M. Sullivan. Published by Jones and Bartlett Publishers, Sudbury, Massachusetts, US 2008, Paperback 203 & 135 pages. ISBN 9780763756208 and 9780763754778. RRP AUS$99.00 each.

Reviewed by Lyndsey WatsonMother and Child Health Research, La Trobe University, Victoria

The textbook and its accompanying workbook provide clear

and useful guidance for elementary statistical procedures such

as descriptive statistics, confidence intervals, hypothesis testing,

power and sample size determination and regression analysis. The

descriptions and formulae enable students to know and calculate

the relevant statistics. These will go some way to overcome the

tendency for those with little mathematical background to rely on

the ‘black-box’ use of statistical packages. They cover essential

skills for Public Health researchers.

The books are part of an introductory series Essential Public

Health which include Environmental Health, Health Policy and

Law, Health Behaviour, Global Health, Infectious Disease, Health

Economics and Epidemiology. They are well laid out with clear

and useful figures and boxes summarising issues and formulae.

The author is the Chair of the Department of Biostatistics at

the Boston University School of Public health and clearly has had

much experience assisting those new to data analysis on the road

to competence. She has been involved with the Framington Heart

Study and uses data from that study for the worked examples.

The textbook, has nine chapters covering study designs,

quantifying disease extent, descriptive statistics, probability,

confidence intervals, hypothesis testing, power and sample size

and multivariable methods including an introduction to linear and

logistic regression. Each chapter has practice (sic) problems. The

workbook runs in parallel to the textbook with good illustrations

on using Excel to do summaries of data and analysis and has

problems included. Together these books would provide the basis

for a semester introductory biostatistics unit in a Public Health

course. I think the books would have less appeal for individual use.

They would be a valuable resource in Public Health Department

libraries.

I discovered minor errors in the Figures in Chapter 2 of the

textbook: the study start time for both retrospective cohort designs

and case-control designs should be on the right hand side of the

time lime line. At present Figure 2-3 is identical to Figure 2-2.

Letters

data, to monitor the trends and the outcomes of interventions. We

argue in our paper that using hospital morbidity data enhances our

ability to compare data to other states and countries as hospital

data uses universal classification of diseases and conditions, while

child protection data is often influenced by definitional and policy

change. Hospital admission rates are only one possible indicator of

changing prevalence and it is not hospital admissions for alleged

child abuse and neglect which we are suggesting would be most

useful (for the very reasons outlined in the letter), but other types of

admissions e.g. the rate of infants admitted with burns, ingestions,

head injuries and retinal haemorrhages, are potential indicators of

supervisory neglect and physical abuse.9,10

Hospital data has also allowed us to monitor the birth prevalence

of conditions highly associated with future child maltreatment

allegations and substantiations, such as neonatal withdrawal

syndrome. Our paper, shows an increasing prevalence of neonatal

withdrawal, with children highly likely to have substantiated

allegations and enter periods of care.11 Using public health

research methods to investigate the characteristics of families

and children at risk, as well as factors that protect children from

maltreatment, will inform our efforts to target prevention and

intervention programs.

We welcome the debate around interventions and the research

required to underpin prevention of child abuse and neglect,

particularly around any new approaches which will enhance the

chances of success.

References1. De Bortoli L. Response to O’Donnell et al. on preventing child abuse and neglect

with public health principles. Aust N Z J Public Health. 2008;32(6):580-1.2. O’Donnell M, Scott D, Stanley F. Child abuse and neglect – is it time for a

public health approach? Aust N Z J Public Health. 2008;32(4):325-30.3. Strathearn L, Mamun AA, Najman JM, O’Callaghan MJ. Does breastfeeding

protect against substantiated child abuse and neglect? A 15-year cohort study. Pediatrics. 2009;123:483-93.

4. Zuravin SJ. Fertility patterns: their relationship to child physical abuse and child neglect. J Marriage Fam. 1988;50(4):983-93.

5. Doggett C, Burrett S, Osborne DA. Home visits during pregnancy and after birth for women with an alcohol or drug problem (Cochrane Review). In: The Cochrane Database for Systematic Reviews, Issue 4, 2005. Oxford (UK): Update Software; 2005.

6. Kingston DA, Fedoroff P, Firestone P, Curry S, Bradford JM. Pornography Use and Sexual Aggression: The impact of frequency and type of pornography use on recidivism among sexual offenders. Aggress Behav. 2008;34:341-51.

7. O’Brien J. Planned respite care: Hope for families under pressure. Australian Journal of Social Issues. 2001;36(1):51-65.

8. Loxley W, Toumbourou JW, Stockwell T, et al. The Prevention of Substance Use, Risk and Harm in Australia: A Review of the Evidence. Canberra (AUST): National Drug Research Institute and the Centre for Adolescent Health; 2004.

9. Bechtel K, Stoessel K, Leventhal JM, Ogle E, Teague B, Lavietes S, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics. 2004;114(1):165-8.

10. Chang DC, Knight V, Ziegfeld S, Haider A, Warfield D, Paidas C. The tip of the iceberg for child abuse: the critical roles of the pediatric trauma service and its registry. J Trauma. 2004;57(6):1189-98.

11. O’Donnell M, Nassar N, Leonard H, Hagan R, Mathews R, Patterson Y, et al. Increasing Prevalence of Neonatal Withdrawal Syndrome: Population study of Maternal Factors and Child Protection Involvement. Pediatrics. In press 2009.

Correspondence to: Melissa O’Donnell, Telethon Institute for Child Health Research, 100 Roberts Rd Subiaco, Western Australia 6008. Fax: 9489 7700, e-mail: melissao@ichr.uwa.edu.au.