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Influenza Other Respi Viruses. 2019;13:233–239.  |  233wileyonlinelibrary.com/journal/irv

Received: 29 August 2018  | Revised: 19 December 2018  | Accepted: 31 December 2018
DOI: 10.1111/irv.12633

O R I G I N A L A R T I C L E

Impact of influenza on hospitalization rates in children with a
range of chronic lung diseases

Nusrat Homaira1,2  | Nancy Briggs3 | Ju-Lee Oei1,4 | Lisa Hilder1,5 | Barbara Bajuk6 | 
Tom Snelling7,8,9,10 | Georgina M. Chambers1,5,11 | Adam Jaffe1,2

1Faculty of Medicine, Discipline of Pediatrics, School of Women’s and Children’s Health, UNSW Sydney, Sydney, New South Wales, Australia
2Respiratory Department, Sydney Children’s Hospital, Sydney, New South Wales, Australia
3Stats Central, Mark Wainwright Analytical Centre, UNSW Sydney, Sydney, New South Wales, Australia
4Department of Newborn Care, Royal Hospital for Women, Sydney, New South Wales, Australia
5Centre for Big Data Research in Health UNSW Sydney, Sydney, New South Wales, Australia
6NSW Pregnancy and Newborn Services Network, Sydney Children’s Hospitals Network, Sydney, New South Wales, Australia
7Princess Margaret Hospital, Perth, Western Australia, Australia
8Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
9Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
10School of Public Health, Curtin University, Bentley, Western Australia, Australia
11National Perinatal Epidemiology and Statistics Unit (NPESU), Kensington, New South Wales, Australia

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2019 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.

Correspondence
Nusrat Homaira, Discipline of Pediatrics,
School of Women’s and Children’s Health,
UNSW Medicine, Level-8, Centre for Child
Health Research and Innovation (ChERI), The
Bright Alliance, Randwick, NSW, Australia.
Email: n.homaira@unsw.edu.au

Funding information
This work was supported by The Rotary Club
of Sydney Cove. The funding organization
had no role in the study design, analyses or
drafting of the manuscript.

Background: Data on burden of severe influenza in children with a range of chronic
lung diseases (CLDs) remain limited.
Method: We performed a cohort study to estimate burden of influenza-associated
hospitalization in children with CLDs using population- based linked data. The cohort
comprised all children in New South Wales, Australia, born between 2001 and 2010
and was divided into five groups, children with: (a) severe asthma; (b) bronchopulmo-
nary dysplasia (BPD); (c) cystic fibrosis (CF); (d) other congenital/chronic lung condi-
tions; and (e) children without CLDs. Incidence rates and rate ratios for
influenza- associated hospitalization were calculated for 2001- 2011. Average cost/
episode of hospitalization was estimated using public hospital cost weights.
Results: Our cohort comprised 888 157 children; 11 058 (1.2%) had one of the CLDs.
The adjusted incidence/1000 child- years of influenza- associated hospitalization in
children with CLDs was 3.9 (95% CI: 2.6- 5.2) and 0.7 (95% CI: 0.5- 0.9) for children
without. The rate ratio was 5.4 in children with CLDs compared to children without.
The adjusted incidence/1000 child- years (95% CI) in children with severe asthma was
1.1 (0.6- 1.6), with BPD was 6.0 (3.7- 8.3), with CF was 7.4 (2.6- 12.1), and with other
congenital/chronic lung conditions was 6.9 (4.9- 8.9). The cost/episode (95% CI) of
influenza- associated hospitalization was AUD 19 704 (95% CI: 11 715- 27 693) for
children with CLDs compared to 4557 (95% CI: 4129- 4984) for children without.

www.wileyonlinelibrary.com/journal/irv

https://orcid.org/0000-0003-3341-7964

http://creativecommons.org/licenses/by/4.0/

mailto:n.homaira@unsw.edu.au

234  |     HOMAIRA et Al.

1 | INTRODUCTION

Globally, influenza is a major public health problem. Every year
during seasonal epidemics, 3- 5 million people develop severe in-
fluenza requiring hospitalization.1 Young children, especially those
aged <5 years, are particularly vulnerable to infection; around 10%- 30% of children are infected with the virus during each influenza season.2 Children also play an important role in transmission by shedding large quantities of virus for 7- 10 days and introducing the virus into households.3

Influenza virus infection may be especially problematic in chil-
dren with chronic lung diseases (CLDs). It can exacerbate the re-
spiratory symptoms of the underlying lung condition resulting in
unscheduled medical presentations and contributing to the total
burden of CLDs on the health system. Children with CLDs such as
asthma have been reported to be at double the risk of hospitalization
with influenza compared to children with other chronic conditions.4
Data on the burden of influenza among children with other CLDs are
more limited, and largely limited to the burden in children with cystic
fibrosis (CF).5 Such data are crucial for informing policy makers, clini-
cians, and public health professionals of the magnitude of the prob-
lem and for monitoring burden of disease over time and evaluate
vaccine effectiveness thus influencing influenza vaccine policy. We
therefore conducted a retrospective population- based cohort study
designed to measure the incidence rates and direct healthcare cost
related to influenza- associated hospitalization in children with CLDs.

2 | PATIENTS AND METHODS

2.1 | Study population

The study was conducted in New South Wales (NSW), Australia,
comprising all children born and residing in NSW during 2001- 2010
with follow- up until the end of 2011 (31 December 2011).

2.2 | Study design

The retrospective cohort study used linked population- based admin-
istrative data sets. In NSW, The Centre for Health Record Linkage
(CHeReL) (www.cherel.org.au) conducts linkage of administrative
health data sets for research purposes and provides each child with
a unique Patient Project Number (PPN). The de- identified data sets
with the unique PPNs were provided to the study investigators.
Records of the same child in the different data sets were combined
using the unique identifier key.6

The NSW Perinatal Data Collection (PDC) which records all births
in NSW was used as the primary data source for identifying the
study cohort. Information relating to maternal and child factors such
as maternal smoking during pregnancy, number of previous pregnan-
cies, Indigenous status of the mother, postcode of area of residence,
birth weight, gestational age at birth, and sex of the baby was as-
certained from PDC. Data relating to diagnosis of CLDs and influ-
enza-associated hospitalization were ascertained from the Admitted
Patient Data Collection (APDC) and Neonatal Intensive Care Unit
Data (NICU). The data sets have been described previously.6

2.3 | Exposure assessment

The birth cohort was divided into five mutually exclusive sub- groups.
We used the International Classification of Diseases, 10th edition
(ICD-10), primary diagnostic codes to identify children in each sub-
group, which was introduced in Australian hospitals in July 1998.7

1. Children with severe asthma: Children aged >2 years who had
≥2 asthma hospitalization after the age of 2 years with ICD-10
diagnostic codes associated with asthma (J45), predominantly
allergic asthma (J45.0), non-allergic asthma (J45.1), mixed asthma
(J45.8), asthma unspecified (J45.9), and status asthmaticus (J46).
As diagnosis of asthma is difficult in children aged <2 years 8 and as the national immunization guidelines recommend seasonal influenza vaccine for children with severe asthma (requiring frequent hospitalization),9 only these children were included in the analysis. Additionally, we excluded ICD codes associated with recurrent wheeze as many of these could have been due to respiratory viral infection and not due to asthma.

2. Children with bronchopulmonary dysplasia (BPD): Children who
were born at gestational age (GA) ≤32 weeks and required oxygen
and/or any type of respiratory support at 36 weeks’ GA 10 or had
any history of hospitalization with ICD-10 diagnostic code associ-
ated with bronchopulmonary dysplasia originating in the perinatal
period (P27.1). The NICU data set and the APDC data sets were
used to identify children with BPD.

3. Children with CF: Children with any history of hospitalization with
ICD-10 diagnostic codes associated with CF (E84), CF with pulmo-
nary manifestations (E84.0), CF with intestinal manifestations
(E84.1), CF with other manifestations (E84.8), CF unspecified (E84.9).

4. Children with other congenital and chronic lung conditions:
Children with any hospitalization code associated with congeni-
tal/chronic lung conditions for which there was an available ICD
code including congenital diaphragmatic hernia (Q79.0-Q79.4),

Discussion: This large population- based study suggests a significant healthcare bur-
den associated with influenza in children with a range of CLDs.

KEY WORDS

chronic lung diseases, influenza burden, pediatrics

http://www.cherel.org.au

     |  235HOMAIRA et Al.

congenital tracheo-esophageal fistula (Q39.2-Q39.8), congenital
tracheomalacia (Q32.0-32.4), congenital malformation of lung
and respiratory system (Q33-Q34), bronchiectasis (Q33.4), de-
pendence on ventilators (Z99.1), interstitial emphysema (J98.2),
other specified and unspecified interstitial lung diseases (J84.8
and J84.9), and Kartegener’s syndrome (Q89.3).

5. All other children without chronic lung diseases.

2.4 | Primary outcome

Influenza- associated hospitalization: The ICD-10, primary diagnos-
tic codes associated with influenza-associated hospitalizations were
used to identify all influenza- associated hospitalizations from APDC.
Any ICD- 10 diagnostic codes listed as influenza and pneumonia (J09,
J10, J10.0, J10.1, and J10.8) where influenza virus was identified
were considered to be associated with influenza. All other hospi-
talizations associated with influenza and pneumonia code but where
a virus was not identified (J11.0, J11.1, and J11.8) and where the
hospitalization occurred during influenza season (usually between
May- September in Australia) were also considered to be associated
with influenza.

2.5 | Other co- variates

Data on maternal and child factors considered to be independent risk
factors for acute lower respiratory infections 11 including multipar-
ity of the mother (previous pregnancy lasting >20 weeks), maternal
smoking during pregnancy, Indigenous status of the mother, residen-
tial postcode of the mother at birth, small for gestational age, and sex
of the cohort child were ascertained from the PDC. Frequency of all-
cause- associated hospitalizations in the cohort child was retrieved
from the APDC. Socioeconomic disadvantage was inferred from the
maternal postcode using the Socioeconomic Index of Areas (SEIFA)
and Index of Relative Socioeconomic Advantage and Disadvantage
(IRSAD) compiled by the Australian Bureau of Statistics.12

2.6 | Bias

This was a large population- based cohort study with minimum selec-
tion bias.

2.7 | Study size

This was a whole- of- population study including all children born in
NSW between 2001 and 2010.

2.8 | Analyses

The overall and year- specific incidence rates for influenza- associated
hospitalizations were calculated for years 2001- 2011. We calculated
incidence as the number of new influenza-associated hospitaliza-
tions divided by the child- years at risk in each of the disease groups.
A lag of 14 days between two successive influenza- associated

hospitalizations was considered to be a new hospitalization. We used
Poisson estimation to calculate incidences and incidence rate ratios
(including 95% confidence interval around the estimates) of influenza-
associated hospitalizations. The incidence rates and rate ratios were
adjusted for parity of the mother, maternal smoking during pregnancy,
Indigenous status, IRSAD, sex of the child, small for gestational age,
and frequency of previous hospitalizations in the cohort child. There
were 0.5% missing data for variables including Indigenous status of
the mother, socioeconomic disadvantage of the area of residence,
and maternal smoking during pregnancy. Observations with one or
more variables missing were dropped from the analyses.

Inpatient hospital costs associated with influenza was estimated
using NSW Cost of Care Standards 2009/10.13 These standards
specify costs and cost weights based on Australian Refined Diagnosis
Related Group Version (AR- DRG) for each episode of acute admitted
hospital services. The cost weights provide a measure of resource
consumption relative to a reference value of one in NSW represent-
ing the average inpatient hospital (public and private) admission in a
given year. At discharge, each episode of acute hospital care is as-
signed an AR- DRGs and associated cost weight which represents its
relative resource consumption relative to the reference value. The
cost weights account for admission through emergency department
presentation and admission in to the intensive care unit. Further
adjustments are made to the cost weights to account for same- day
admissions, extended length of stay, transfer episodes, Indigenous
status, private hospital stays, neonates, and death.

To estimate hospital costs for influenza admissions, we assigned
the weighted “total standard NSW public hospital cost” to the cost
weights assigned to each episode of acute hospital care in the APDC
using the NSW Costs of Care Standards 2009/10.13 The average
costs for acute admitted care were 4280 Australian dollars (AUD) for
2009/10 which was indexed for each study year (average annual dis-
count rate of 3.5%) using the deflators specified in the NSW Costs of
Care Standards to reflect constant 2009/10 Australian dollars. For
hospitalizations that resulted in transfer to other facilities, the cost
was equivalent to the sum of total cost incurred at each of facility. We
divided the total cost of all influenza- associated hospitalization iden-
tified over the 11- year period by 11 to estimate the annual direct cost
of influenza- associated hospitalizations. All analyses were done using
STATA (STATA release 13; StataCorp LP, College Station, TX, USA).

2.9 | Ethics approval

The project was approved by the NSW Population and Health
Service Research (HREC/09/CIPHS/33; 2009/05/155) and the
Aboriginal Health and Medical Research Council Ethics (726/10).

3 | RESULTS

3.1 | Profile of the Cohort

The cohort comprised 888 157 children born between 2001 and
2010. Of these, 11 058 (1.2%) had one of the CLDs, and 6724

236  |     HOMAIRA et Al.

(61.0%) were male. Around 4.0% of all children with CLDs were of
Indigenous origin (Table 1).

3.2 | Incidence of influenza-associated 
hospitalization

During 2001- 2011, there were 3.101 influenza- associated hospi-
talizations, and 2.4% of the children with CLDs compared to 0.3%
children without CLDs had one or more influenza- associated hospi-
talizations. The unadjusted and adjusted incidence/1000 child- years
of influenza- associated hospitalization in children with CLDs was 3.7
(95% CI: 3.0- 4.3) and 3.9 (95% CI: 2.6- 5.2) and for all other children
without CLDs was 0.5 (95% CI: 0.4- 0.5) and 0.7 (95% CI: 0.5- 0.9),
respectively. During 2001- 2011, the annual incidence of influenza-
associated hospitalization in children with CLDs ranged between 0.0
and 25.4/1000 child- years (Figure 1). The adjusted incidence rate
ratio for influenza- associated hospitalization in children with CLDs
compared to children without CLDs was 5.4.

The unadjusted incidence/1000 child- years of influenza-
associated hospitalization in each CLD group was 1.1 (0.7- 1.4) for
children with severe asthma, 5.4 (3.6- 7.2) for BPD, 6.9 (2.5- 11.4) for
CF, and 7.7 (5.9- 9.4) for children with other congenital and chronic
lung conditions. The adjusted age- specific incidence rates and rate
ratios are presented in Table 2.

3.3 | Inpatient resource consumption of 
influenza illness

The length of stay (days) for each episode of influenza- associated
hospitalization in children with and without CLDs is presented in
Figure 2. The longest median length of stay was for children with

BPD (7.0 days; IQR 1.7- 27.3). A total of 13% of the episodes of in-
fluenza-associated hospitalization in children with CLDs required
referral to another hospital for continuity of care compared to 7%
in children without CLDs. The average cost/episode of influenza-
associated hospitalization for children with CLDs was AUD 19 704
(95% CI: 11 715- 27 693) equating to an average annual cost to the
NSW hospital system of AUD 428 132 (equivalent to approximately
US$ 314 902) and for children without CLDs was 4557 (95% CI:
4129- 4984) which was equivalent to AUD 867 033 annually (ap-
proximately US$ 637 808).

4 | DISCUSSION

This large population- based study has demonstrated that children
with CLDs are at least five times more likely than children with-
out CLDs to be hospitalized with influenza. A previous study from
the USA has also demonstrated that children with acute cardio-
pulmonary diseases were 2- 4 times more likely to be hospitalized
with influenza- associated illness than other children.4 The direct
medical cost of AUD 19 704/episode of influenza- associated hospi-
talization in children with CLDs was also four times higher compared
to children without, representing a high economic burden on the
healthcare system. Furthermore, the hospitalization rates in our co-
hort were highest in the youngest children and decreased with age,
a finding that is consistent with the USA study.4 Younger children
especially those aged <2 years are at higher risk than older children of severe influenza,14 which is increased in the presence of an under- lying CLD. Vaccination against influenza is the primary strategy to control seasonal outbreaks. Influenza vaccination has been proven to be a safe and effective in people with CLDs.15 The Australian

TABLE 1 Descriptive profile of the cohort children born between 2001 and 2010 in NSW, Australia

N = 888 157

Exposures

Children with 
severe asthma Children with BPD Children with CF

Children with other 
congenital and chronic
lung conditions

All other children 
without chronic
lung diseases

n = 7736 n = 1055 n = 260 n = 2007 n = 877 099

n (%)

Multiparity of the mother 4446 (57.5) 510 (48.3) 137 (52.7) 1161 (58.0) 510 288 (58.2)

Maternal smoking during pregnancy 1315 (17.0) 253 (24.0) 41 (15.8) 330 (16.4) 120 397 (13.7)

Indigenous status of the mother 291 (3.8) 68 (6.5) 13 (5.1) 91 (4.6) 29 228 (3.4)

IRSAD

1 (most disadvantaged) 1990 (25.7) 268 (25.5) 56 (21.5) 469 (23.4) 195 668 (22.3)

2 1893 (24.5) 229 (22.0) 64 (24.6) 486 (24.2) 202 308 (23.1)

3 1979 (25.6) 263 (25.0) 74 (28.5) 495 (24.7) 223 744 (25.5)

4 (most advantaged) 1873 (24.2) 290 (27.6) 66 (25.4) 553 (27.6) 254 923 (29.1)

Male sex of the baby 4839 (62.5) 595 (56.4) 126 (48.5) 1164 (58.0) 449 943 (51.3)

Small for gestational age at birth 320 (4.1) 56 (5.3) 14 (5.4) 147 (7.4) 28 080 (3.2)

BPD, Bronchopulmonary dysplasia; CF, Cystic fibrosis; IRSAD, Index of Relative Socioeconomic Advantage and Disadvantage.

     |  237HOMAIRA et Al.

immunization guidelines emphasize the need for seasonal influenza
vaccine for people aged ≥6 months with chronic medical conditions.9
Maternal immunization to protect infants in their first 6 months of
life 16 followed by active immunization annually may help lower the
exceptionally high burden on the health system associated with in-
fluenza illness in young children with CLDs.

The rate of influenza- associated hospitalization in children aged
2- 5 years with asthma in our cohort was much higher than the re-
ported annual rate of 0.6/1000 person- years in children with asthma
in the USA.17 This could be due to differences between the study
populations; the study from USA only included children who were
hospitalized with acute respiratory infection or fever whereas we
considered any hospitalization with ICD- 10 codes associated with
influenza. Additionally, Australia has a universal healthcare system
where most inpatient care for children is covered by federal state
governments. Australia’s immunization guidelines emphasize the
need for seasonal influenza vaccination for children with severe
asthma requiring frequent hospitalizations.9 Although the national
vaccine uptake data for asthmatic children are limited, a survey con-
ducted by Asthma Australia in 2016 demonstrated that 41% of peo-
ple with asthma (mostly children) were not likely to be vaccinated
against influenza clearly indicating very low uptake which is unac-
ceptable for any other pediatric vaccine.

Children with CF in our cohort were at least 11 times more likely
to be hospitalized with influenza- associated illness compared to chil-
dren without CLDs. While much attention is given to bacterial infec-
tions in children with CF, respiratory viral infections have also been
associated with pulmonary deterioration and disease progression.18
Studies from the USA have associated increases in influenza trans-
mission with increased frequency of pulmonary exacerbations 19 and
found comparable high rates of influenza-associated hospitalization
(12.97/1000 person- year) among children aged 0- 17 years with CF.5
Influenza vaccine is widely recommended for people with CF, and
the vaccine has been shown to be safe in these patients 20 and, in
contrast to children with asthma, the uptake of seasonal influenza
vaccine has been reported to be high (≥80%).21, 22 There is a need for
further research into the impact of regular seasonal influenza vaccine
on pulmonary function in patients with CF.23, 24 Additionally, there is
a need to examine the benefit of timely use of antivirals in these chil-
dren with proven or suspected influenza infection in reducing lung
damage.20

In our study, children with BPD also had very high rates of hos-
pitalizations associated with influenza. The median length of hospi-
talization was also very long for children with BPD. Studies suggest
that although symptoms of BPD improve with age, children with
BPD continue to have abnormal lung function and are at elevated

FIGURE 1 Annual incidence/1000
child- years of influenza- associated
hospitalization in children with and
without chronic lung diseases, 2001- 2011,
NSW, Australia

0
2
4
6
8

10
12
14
16
18
20
22
24
26
28
30

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

In
ci

de
nc

e
of

in
lfu

en
za

-a
ss

oc
ia

te
d

ho
sp

ita
lis

at
io

n/
10

00

ch
ild

-y
ea

rs

Children with chronic lung diseases All other children without chronic lung diseases

TABLE 2 Adjusted incidence/1000 child- years and incidence rate ratios of influenza- associated hospitalization in children with chronic
lung diseases, 2001- 2011, NSW, Australia

Incidence/1000 child- years (95% CI)
Incidence rate
ratio (95% CI)a0- 24 mo 2- 5 y 5- 10 y Overall incidence

Severe asthma N/A 5.4 (1.4- 9.4) 1.2 (0.3- 2.0) 1.1 (0.6- 1.6) 1.8 (1.2- 2.6)

BPD 41.6 (15.7- 67.5) 1.7 (−0.8 to 4.2) 1.0 (−0.8 to 4.4) 6.0 (3.7- 8.3) 9.0 (6.4- 12.7)

CF 44.5 (6.0- 83.0) 4.6 (−2.15 to 11.4) 0 (0- 0) 7.4 (2.6- 12.1) 11.12 (6.0- 20.9)

Other congenital and
chronic lung conditions

42.9 (18.1- 67.8) 6.0 (1.4- 10.6) 1.1 (0.2- 2.1) 6.9 (4.9- 8.9) 10.4 (7.9- 13.5)

All other children without
chronic lung diseases

9.3 (4.4- 14.2) 0.6 (0.3- 1.0) 0.1 (0.0- 0.1) 0.6 (0.4- 0.9) Reference group

BPD, Bronchopulmonary dysplasia; CF, Cystic fibrosis; IRSAD, Index of Relative Socioeconomic Advantage and Disadvantage; 95% CI, 95% Confidence
interval.
aThe rate of influenza-associated hospitalization in each of the groups of children with chronic lung diseases was significantly higher (P < 0.05) com- pared to rate in all other children without chronic lung diseases.

238  |     HOMAIRA et Al.

risk of being hospitalized with respiratory illness compared to other
children.25-27 While several studies have shown the significant bur-
den of respiratory syncytial virus among children with BPD,6, 28 the
impact of influenza illness remains less clearly defined.

Our study also showed that the rate of influenza-associated hos-
pitalization was 10 times higher in children with other congenital and
chronic lung diseases than all children without CLDs, yet there are
almost no available data on the burden of influenza in these children.

Our study has several important limitations. There are no na-
tional disease registries for children with CLDs (with the excep-
tion of CF) so our cohort was constructed from a comprehensive
hospitalization dataset based on ICD codes. Ascertainment of
influenza- associated hospitalization was also based on ICD codes.
Even though not all influenza- associated hospitalizations are labo-
ratory confirmed but as influenza is a notifiable condition in NSW,
it is likely that most hospitalizations receiving an influenza- specific
code were laboratory confirmed; however, we were not able to
substantiate this. Not all children hospitalized with acute lower
respiratory illness are routinely tested for influenza so it is likely
that the true burden of influenza- associated hospitalization in chil-
dren with CLDs is even higher than our estimates. We considered
all influenza- coded hospitalizations where an influenza virus was
not identified to be associated with influenza which may have in-
flated our estimates; however, none of the influenza-associated
hospitalization in our cohort was associated with an ICD code for
influenza where an influenza virus was not identified. We did not
have access to data on primary care or emergency presentations
and therefore we could not assess the rate of ambulatory influ-
enza infection in children with CLDs, where the burden is likely to
be higher. Although we adjusted our estimated rates for a num-
ber of known potential confounders, we did not have access to
direct information on other potential confounders such as house-
hold exposure to tobacco smoke or presence of siblings at home.

Instead, we used maternal smoking during pregnancy as a proxy
for household smoke exposure and previous pregnancy/parity
(lasting at least 20 weeks) as a proxy for having older siblings at
home. We used the IRSAD score of the mother’s postcode at the
time of delivery, a measure of average socioeconomic disadvan-
tage in that postcode, as a proxy for family level socioeconomic
disadvantage.29 We estimated incidence rate ratio for influenza-
associated hospitalization in children with CLDs compared to all
other children which included children with other chronic condi-
tions and may have led to lower rate ratios. Influenza vaccination
status is not routinely recorded in the national immunization data
base, and we did not have access to antiviral use in these children.

In summary, although only around 1.4% of the total pediatric
population in our cohort had one of the chronic lung diseases, these
children form a special group because of their ongoing need for
healthcare services. Our data clearly show that influenza illness in
these children add to the existing burden of chronic diseases on the
health system. While there are no effective vaccines or antivirals for
most childhood respiratory viral infections, fortunately we do have
a vaccine against influenza. There are also effective antivirals which,
if administered in a timely manner, may reduce disease severity.30-32
However, such high burden of hospitalizations indicates that cur-
rent efforts at influenza prevention are inadequate among children
with CLDs. Further studies investigating the effectiveness of newer
vaccines, treatment, or chemoprophylaxis in these children will help
lower the burden of disease.

ACKNOWLEDGEMENTS

The authors would like to thank Sydney Children’s Hospital Foundation
and Rotary Club of Sydney Cove for their continued support in our
research endeavors. We also thank all the Directors, the NICUs mem-
bers and the audit officers of all the tertiary units in supporting this

FIGURE 2 Length of stay for
influenza- associated hospitalization in
the cohort children, 2001- 2011, NSW,
Australia

     |  239HOMAIRA et Al.

collaborative study. We are grateful to the Respiratory Department
of Sydney Children’s Hospital, Randwick, Sydney for their coopera-
tion. We thank the Aboriginal Health and Medical Research Council
and Ministry of Health, NSW. We also thank the babies and their fam-
ilies, the nursing and midwifery, obstetric and medical records staff of
the obstetric and children’s hospitals in NSW and the ACT.

CONFLICT OF INTEREST

The authors have no conflicts of interest relevant to this article to
disclose.

ORCID

Nusrat Homaira https://orcid.org/0000-0003-3341-7964

REFERENCES

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How to cite this article: Homaira N, Briggs N, Oei J-L, et al.
Impact of influenza on hospitalization rates in children with a
range of chronic lung diseases. Influenza Other Respi Viruses.
2019;13:233–239. https://doi.org/10.1111/irv.12633

https://orcid.org/0000-0003-3341-7964

https://orcid.org/0000-0003-3341-7964

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/7B28E87511E08905CA257D4D001DB1F8/$File/Aus-Imm-Handbook

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/7B28E87511E08905CA257D4D001DB1F8/$File/Aus-Imm-Handbook

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/7B28E87511E08905CA257D4D001DB1F8/$File/Aus-Imm-Handbook

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/7B28E87511E08905CA257D4D001DB1F8/$File/Aus-Imm-Handbook

http://www1.health.nsw.gov.au/pds/ArchivePDSDocuments/GL2011_007

http://www1.health.nsw.gov.au/pds/ArchivePDSDocuments/GL2011_007

https://doi.org/10.1111/irv.12633

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56 JCN 2019, Vol 33, No 4

H
ealth promotion is an

important part of a
community nurse’s job role

(Lundberg et al, 2017). As a concept,
health promotion has become more
popular since the 1970s following
a Canadian health report (Lalonde,
1974). Recent publications have
shaped nurses understanding of
health promotion (Polan and Taylor,
2019), defining this role as being able
to empower patients to take control
of their own health needs while
enabling them to identify which
aspects of their health are most
important to them (Naidoo and
Wills, 2016).

The prevalence of smoking means
that almost every health and social
care practitioner, including those in
the community, will be involved in
the treatment or management of
conditions exacerbated by smoking.
Smoking cessation continues to be

Smoking cessation and the health
promotion role of community nurses

a goal for patients as they begin to
understand the effects that smoking
has on their overall health and
wellbeing. It is likely that, previously,
many patients were unaware of the
future detrimental effects smoking
would have on their health. However,
there is now a movement towards
preventing conditions before they
develop or worsen.

BENEFITS OF
STOPPING SMOKING

The benefits of smoking cessation
are significant (Blomster et al, 2016;
Baker et al, 2018; Barengo et al,
2019). Due to the high prevalence of
smoking, community nurses care for
many patients on a journey towards
cessation. In the authors’ clinical
opinion, they have one of the most
important health promoting roles
and are often involved in working
in partnership with patients,
highlighting how smoking cessation
will be able to positively change
their health. Tobacco smoking has
many detrimental effects, causing
it to be one of the main causes of
mortality worldwide (Golechha,
2016). Smoking cessation benefits
both physical and mental health.
Taylor et al (2014) suggested that
smoking cessation helps to relieve

symptoms of depression and
anxiety, as well as improving overall
psychological wellbeing.

ROLE OF COMMUNITY NURSES
IN HEALTH PROMOTION

Health promotion applies to all
nurses and healthcare professionals,
regardless of which arena they
specialise in (Raingruber, 2014).
However, community nurses are
often the first point of contact for
many patients, so it could be argued
that their health promotion role
is one of the most crucial. Zandee
et al (2010) studied the unique
relationship between community
practitioners and nursing students
in promoting public health in urban
areas. The research highlighted the
positive health promoting outcomes
of this relationship, which could
be directly applied to the patient
scenario included here (Mr Wilson’s
care), whereby the first author
was able to act independently as a
health promoter under the guidance
of a qualified and knowledgeable
community nurse.

The Ottawa charter (World
Health Organization [WHO],
1986), a founding health promotion
document, identified three key roles
that health promoters, including
community nurses, could use
to further advance their health
promoting skills, namely:
 Advocating
 Enabling
 Mediating.

Advocating is standing up for
the needs of the individual and
attempting to provide a healthy
environment, such as a strong social
background or economic conditions
(Choi, 2015). Enabling is about
striving to give people what they
require to be successful and aims at

Tara Bright, second year adult nursing student;
Teresa Burdett, senior lecturer in integrated
health care, both at Bournemouth University

Community nurses are well placed to initiate health promotion,
including the goal of smoking cessation. Changing health
behaviours, including smoking, may be directly addressed by working
collaboratively with patients to better understand their personal
situation, with the hope of enabling them to engage in a productive
manner in health promotion now and in the future (Lau-Walker,
2014). This paper critically discusses the first author’s health promotion
role during her time as a community student nurse working in a
community nursing team.

KEYWORDS:
 Smoking cessation  Health promotion  Make every contact
count (MECC)

Tara Bright, Teresa Burdett

SMOKING CESSATION

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ensuring people have equal access
to the resources which allow them
to pursue their best health (Hubley
and Coperman, 2018). Finally,
mediating concerns the idea that for
health promotion to be successful
it requires the cooperation of many
groups, including the government,
the healthcare sector and the media
(WHO, 1986).

The Ottawa charter (WHO, 1986)
has since been used to increase the
population’s health potential (WHO,
2007). However, the question now
is whether the charter remains as
significant today (Vinko et al, 2016).
Vinko et al (2016) identified that
there are still many challenges to
health promotion, including the
obstacle of ensuring that there
are enough sufficiently trained
professionals. Thompson et al (2018)
also concluded that there is still a
way to go and that health promotion
should be continually focusing on
reducing the inequalities faced by
the population, such as inadequate
housing and poverty. These two
factors clearly impacted on Mr Wilson
in the patient scenario here.

Naidoo and Wills (2016) have
highlighted three principles to help
guide clinicians, such as community
nurses, in their health promotion
role to gain the best outcomes for
patients, namely:
 Participation
 Collaboration
 Equity.

Participation means the public
playing a part in developing policies
surrounding health promotion. A
goal of partnership is ensuring that
patients feel that they are able to
contribute their own opinions. As
a principle, partnership remains
prevalent in recent literature (Gregory
et al, 2018). This applies directly to
Mr Wilson because the first author
regularly enabled him to express his
own wishes and ideas surrounding
his goals around smoking cessation,
thereby enhancing his own locus
of control.

Collaboration is similar to the
concept of participation, in that
it is the process of healthcare
professionals working together on

Patient scenario — Mr Wilson

As a student nurse, I had the privileged opportunity to experience
community nursing first hand. The patients I met had health issues, which
meant that they were unable to live independently and rarely left their own
homes. For confidentiality, in accordance with the Nursing and Midwifery
Council’s ‘Code of Conduct’ (NMC, 2018), the patient will be referred to as
Mr Wilson to protect his identity and any personal data (Royal College of
Nursing [RCN], 2016).

Mr Wilson, was visited twice a week so that the community nurses,
including the first author, could advise him on self-management of his
chronic obstructive pulmonary disease (COPD). Mr Wilson had always
been a heavy smoker and said that he had tried unsuccessfully to stop
multiple times. However, he believed that with the help of healthcare
professionals he could stop. He was living in a top floor flat, which left him
vulnerable should he ever need to get out. The flat itself was very cluttered
and in a state of disrepair. Mr Wilson said that this was because his pension
could not accommodate the repairs.

The first author recognised that Mr Wilson already had some motivation
to change, but knew that she had not only to acknowledge the effects of
smoking on his physical health concerning his COPD, but also to identify
how his smoking was affecting his emotional, social and mental health
and wellbeing. Conversations were initiated with Mr Wilson to gauge
his understanding of the effects of smoking on his long-term health. By
looking at all aspects of his situation, it became clear that smoking was also
negatively affecting his family life. His daughter had recently given birth to
a baby, Mr Wilson’s first granddaughter. However, due to his smoking, she
was refusing to let him spend time with her.

Rather than being dependent on the community nurse, Mr Wilson
would have loved spending more time going out with his family. The first
author explained to Mr Wilson that with her mentor she would work in
partnership with him towards enabling this goal to happen. Subsequently,
short conversations were had with Mr Wilson at each visit about the
positive effects that smoking cessation would have on his health. This
also meant that he had time to think about the information he was being
provided and could make his own informed decisions, and be the advocate
for his own health. However, despite attempting to promote Mr Wilson’s
health and wellbeing, due to the nature of the first author’s role, i.e. being
a student, meant that her time in placement ended before being able to
follow up on Mr Wilson’s progress. However, the community nursing team
continued to work in partnership with Mr Wilson to help him reach
his goals.

projects with the aim of achieving
more large-scale goals, such as
creating the most effective methods
of health promotion (Naidoo and
Wills, 2016). However, Meyer (2018)
highlights that there are challenges
to working in collaboration in
nursing, explaining that with
different stakeholders having diverse
philosophies, mutual respect is
required to provide the best patient
care. By working in collaboration with
Mr Wilson and demonstrating respect
and empathy for his situation, it was

hoped that this would encourage him
to open up about his feelings and
make his own healthcare decisions.

Equity is about having equal
access and parity to services and
health care (Naidoo and Wills 2016).
However, in the authors’ clinical
opinion, more work is required to
make this is a reality. Socio-economic
factors need to be tackled to have a
positive impact on the population’s
health (Commission on Social
Determinants of Health [CSDH],

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▼ Practice point
The role of community nurses can
often be the most central to health
promotion because they are the
professionals who have built up a
rapport with patients and may be
their first point of contact.

2008). While this report is useful for
addressing the challenges of health
equity, limitations have been noted.
However, its validity is still relevant
as Green et al (2019) identified
that health care needs to tackle the
effects of economic inequalities on
a person’s health. For example, poor
housing is likely to have a negative
impact on a patient’s health and
they will ultimately need more
healthcare treatment, i.e. the various
determinants of health, including
social or economic factors, are
equally influential (Scriven, 2017)
on health as a patient’s behavioural
choices. Thus, community nurses
need to consider the individual
situation and background of their
patients before approaching
health promotion.

A further principal,
empowerment, has been defined by
many experts throughout the years
as giving patients control over their
own behavioural change (Rogers,
1961; Yeh et al, 2018). The use of
empowerment has been encouraged
in health promotion to give people
autonomy. By allowing them to take
some responsibility, they develop
an increase in skills and knowledge
relating to their health (Powers et al,
2012). Despite this, there have been
criticisms of using empowerment
in health promotion. Tengland
(2012) argued that the approach of
empowerment in health promotion
is time-consuming and therefore
could cost the health service more
overall. While government money
may be saved if additional time is
not spent with patients and they
are not empowered, this will have
little positive impact for the patients,
directly contradicting the aims of
health promotion. It is likely that
patients who are not empowered
to improve their health behaviours
will develop more lifestyle-related

complications, increasing the burden
on community nurses.

These ideas are directly relatable
to Mr Wilson’s care because the
community nursing team were
striving to help him take control of
his own health. Although the first
author spent a considerable amount
of time with Mr Wilson and provided
him with research-based information
about the effects of smoking on his
health based on her training and
knowledge, she did not go further
and signpost him to other relevant
information, but rather attempted to
encourage him to be the advocate
for his own health. If Mr Wilson had
been readily provided with additional
information, he would perhaps have
been more likely to make his own
decisions about what was right
for him.

Todres et al (2009) said that nurses
should be working to increase the
autonomy of their patients, allowing
them to have a greater choice and
to share responsibility for decisions
made. However, there will always be
situations where this is not possible.
For example, although receptive to
health promotion advice and support,
Mr Wilson had a long history of
repeatedly trying to stop smoking
without success.

Varley and Murfin (2014) also
explained that a patient should only
be approached at a time when they
are ready and receptive to change,
and that health promotors should
not inflict their own suggestions of
change onto patients (PHE, 2015b).

MAKE EVERY CONTACT COUNT

Recent guidelines known as ‘Making
Every Contact Count’ (MECC)
are regarded as a fundamental
framework for staff to follow (Public
Health England [PHE], 2016a).
MECC is linked to the principle of
empowerment and is defined as
health and social care practitioners
being confident to encourage people
to change their health behaviours by
delivering healthy lifestyle messages
(PHE, 2016b). For a community
nurse to provide the most effective
health promotion, a set of skills are
necessary. These include the use of

open discovery questions to allow
the patient to further explore the
topic, as well as spending more time
listening to the patient, so they are
able to make their own suggestions
(PHE, 2015b).

Although MECC has been
developed as the ideal standard for
health promotion, in the authors’
clinical opinion, it is not easy for all
community practitioners to adopt
on top of their busy workloads.
There are some limitations to the
use of MECC. Nelson et al (2013)
identified that one of the barriers
to its success is practitioners’ view
that adopting this method would
increase workload. However, despite
its challenges, MECC as a means of
health promotion has been praised
as being a valuable and flexible
approach (Chisholm et al, 2018). That
said, awareness of MECC still needs
to increase. Keyworth et al (2018)
found that only 41% of nurses and
health visitors recognised the MECC
consensus statement.

▼ MECC…
The very nature of MECC means
that the knowledge can be passed
between practitioners to improve
practice. The MECC programme
is set up so that nurses or other
healthcare professionals are able
to attend the training and therefore
become a trainer themselves to help
reduce the number of people that
have to be trained to implement
MECC health promotion.
 Have you ever considered

becoming MECC trained?
 Have you or any of your

colleagues been MECC trained in
the past?

 Do you know what training is
available in and around your
local area?

Further information about
MECC training can be found on
the ‘Training in MECC’ webpage at:
www.makingeverycontactcount.
co.uk/training/. This page has
additional resources, including
easily accessible e-learning and
workbooks (Health Education
England, 2019).

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REFLECTIONS ON PRACTICE —
MR WILSON

When caring for Mr Wilson, it was
important to consider the outside
influences on his health, looking at
his whole situation in depth, rather
than just examining the effects of
smoking as an individual behaviour.

The first author built up a
positive professional relationship
with Mr Wilson, which enabled her
to understand him as an individual.
This meant that he felt more open
to sharing information. Indeed,
DeVille-Almond (2013) found that
forging a relationship with patients
is one of the most effective ways
for community nurses to facilitate
behaviour change.

However, health promotion
was a challenging new role for
the first author to adopt, despite
working under the supervision of
her mentor and being helped with
health promoting ideas beneficial
to Mr Wilson. At a later visit with
her mentor, it was decided to give
Mr Wilson more information about
services because he had chosen not
to do so independently. This included
the local stop smoking service, which
aims to provide equal support to all
patients using a variety of different
methods, such as apps and websites
which track progress and offer
specialist advice (National Health
Service [NHS] England, 2016; PHE,
2016b).

The educational approach to
health promotion is when the
practitioner provides knowledge
and information which allows the
patient to make informed choices
about their care (Naidoo and Wills,
2016). It is likely that using such
an approach motivated Mr Wilson
further with wanting to change his
behaviour. Hinchliff (2009) suggested
that putting a patient in a positive

learning environment, builds a
trusting relationship with the health
promoter. In Mr Wilson’s case, this
meant that he would have felt more
able to express himself because he
felt psychologically safe.

CONCLUSION

The promotion of a patient’s health
and wellbeing is a vital aspect of
health care. However, there are many
challenges to this which are not
within the healthcare arena, i.e. social
determinants including poverty,
unequal access to housing, food
and health. Health promotion has
emerged to tackle these inequalities.
There is now a considerable amount
of research to support both nurses
and other healthcare professionals
with providing the most effective
health promoting care.

It is recognised that nurses should
be trained in health promotion,
but there is a conflict between
putting limited funding into health
promotion when funding challenges
exist in other areas. However, change
in health behaviours will benefit the
patient and potentially save money
for the National Health Service
overall. Continual work within the
health promotion arena can also
significantly enhance integrated,
person-centred care and help to ease
pressures on community nurses and
their teams.

REFERENCES

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Barengo NC, Antikainen R, Harald K,
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Blomster JI, Woodward M, Zoungas S, et al
(2016) The harms of smoking and benefits
of smoking cessation in women compared
with men with type 2 diabetes: an
observational analysis of the ADVANCE
(Action in Diabetes and Vascular Disease:
Preterax and Diamicron modified release
Controlled Evaluation) trial. Br Med J
Open 6(1): e009668

Chisholm A, Ang-Chen P, Peters S, et al
(2018) Public health practitioners’ views
of the ‘Making Every Contact Count’
initiative and standards for its evaluation.
J Public Health (Oxf) 41(1): e70–e77

Choi PP (2015) Patient advocacy: the role of
the nurse. Nurs Standard 29(41): 52–8

Commission on Social Determinants of
Health (2008) Health equity through action
on the social determinants of health. World
Health Organization, Geneva. Available
online: http://apps.who.int/iris/bitstream/
handle/10665/43943/9789241563703_eng.
pdf;jsessionid=B1664E2304954D47DFF
529020E7495B0?sequence=1 (accessed
January, 2019)

DeVille-Almond J (2013) Community nurses
need to make every contact count. J
Community Nurs 27(5): 76–8

Golechha M (2016) Health promotion
methods for smoking prevention and
cessation: A comprehensive review of
effectiveness and the way forward. Int J
Prev Med 7: 7

Green J, Cross R, Woodall J, et al (2019)
Health promotion: Planning & Strategies.
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Gregory A, Mackintosh S, Kumar S, et
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partnership in health care for older people
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Health Education England (2019) Training
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HEE, London. Available online: www.
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Hinchliff S (2009) The practitioner as teacher.
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Hubley J, Copeman J (2018) Practical health
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▼ Remember
Further training will improve
community nurse’s understanding of
the facets of health promotion.

JCN

▼ Practice point
The nature of community nursing
means practitioners working
towards building partnerships with
their patients.

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KEY POINTS
 Patients’ health may be

improved if they access
additional services
independently following
information given by
community nurses.

 Patients will be less reliant on
the care of community nurses
and primary practitioners and
may seek out other care options
which fit with their lifestyle.

 Not all community nurses need
to undertake the additional
training in health promotion,
but can share their knowledge
between themselves and
thereby reduce their workload.
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Thyroid Diseases and Conditions; Researchers at
National Cancer Institute Have Reported New
Data on Thyroid Diseases (PBDE flame
retardants, thyroid disease, and menopausal
status in US women)

Publication info: Women’s Health Weekly ; Atlanta [Atlanta]23 June 2016: 4357.

ProQuest document link

ABSTRACT
 

According to the news reporters, the research concluded: “Exposure to BDEs 47, 99, and 100 is associated with

thyroid disease in a national sample of U.S. women, with greater effects observed post-menopause, suggesting

that the disruption of thyroid signaling by PBDEs may be enhanced by the altered estrogen levels during

menopause.”

FULL TEXT
 

2016 JUN 23 (NewsRx) — By a News Reporter-Staff News Editor at Women’s Health Weekly — Fresh data on Thyroid

Diseases and Conditions are presented in a new report. According to news reporting from Research Triangle Park,

North Carolina, by NewsRx journalists, research stated, “Women have elevated rates of thyroid disease compared

to men. Environmental toxicants have been implicated as contributors to this dimorphism, including

polybrominated diphenyl ethers (PBDEs), flame retardant chemicals that disrupt thyroid hormone action.”

The news correspondents obtained a quote from the research from National Cancer Institute, “PBDEs have also

been implicated in the disruption of estrogenic activity, and estrogen levels regulate thyroid hormones. Post-

menopausal women may therefore be particularly vulnerable to PBDE induced thyroid effects, given low estrogen

reserves. The objective of this study was to test for an association between serum PBDE concentrations and

thyroid disease in women from the United States (U.S.), stratified by menopause status. Serum PBDE

concentrations (BDEs 47, 99, 100 and 153) from the National Health and Examination Survey (NHANES) and

reports on thyroid problems were available in the NHANES 2003-2004 cycle. Odds ratios (ORs) were calculated

using multivariate logistic regression models accounting for population-weighted survey techniques and

controlling for age, body mass index (BMI), education, smoking, alcohol consumption and thyroid medication.

Menopause status was obtained by self-reported absence of menstruation in the previous 12 months and declared

menopause. Women in the highest quartile of serum concentrations for BDEs 47, 99, and 100 had increased odds

of currently having thyroid disease (ORs: 1.5, 1.8, 1.5, respectively) compared to the reference group (1st and 2nd

quartiles combined); stronger associations were observed when the analysis was restricted to postmenopausal

women (ORs: 2.2, 3.6, 2.0, respectively).”

According to the news reporters, the research concluded: “Exposure to BDEs 47, 99, and 100 is associated with
thyroid disease in a national sample of U.S. women, with greater effects observed post-menopause, suggesting

https://lopes.idm.oclc.org/login?url=https://search.proquest.com/docview/1797342

407?accountid=7374

https://lopes.idm.oclc.org/login?url=https://search.proquest.com/docview/1797342407?accountid=7374

that the disruption of thyroid signaling by PBDEs may be enhanced by the altered estrogen levels during
menopause.”

For more information on this research see: PBDE flame retardants, thyroid disease, and menopausal status in US

women. Environmental Health, 2016;15():1-9. Environmental Health can be contacted at: Biomed Central Ltd, 236

Grays Inn Rd, Floor 6, London WC1X 8HL, England. (BioMed Central – www.biomedcentral.com/; Environmental

Health – www.ehjournal.net)

Our news journalists report that additional information may be obtained by contacting J.G. Allen, Natl Canc Inst

NIEHS, Res Triangle Pk, NC, United States. Additional authors for this research include S. Gale, R.T. Zoeller, J.D.

Spengler, L. Birnbaum and E. McNeely.

Keywords for this news article include: Research Triangle Park, North Carolina, United States, North and Central

America, Thyroid Diseases and Conditions, Endocrine System Diseases, Flame Retardants, Thyroid Diseases,

Women’s Health, Endocrinology, Estrogens, Menopause, Hormones, Genetics, National Cancer Institute.

Our reports deliver fact-based news of research and discoveries from around the world. Copyright 2016, NewsRx

LLC

DETAILS

Subject: Womens health; Fire resistant materials; Health risk assessment; Estrogen

Location: United States–US

Company / organization: Name: National Cancer Institute; NAICS: 923120

Identifier / keyword: City:Research Triangle Park State:North Carolina Country:United States Region:North

and Central America Thyroid Diseases and Conditions Endocrine System Diseases

Flame Retardants Thyroid Diseases Women’s Health Endocrinology Estrogens

Menopause Hormones Genetics

Publication title: Women’s Health Weekly; Atlanta

First page: 4357

Publication year: 2016

Publication date: Jun 23, 2016

Publisher: NewsRx

Place of publication: Atlanta

Country of publication: United States, Atlanta

Publication subject: Medical Sciences, Women’s Interests

Database copyright  2020 ProQuest LLC. All rights reserved.
Terms and Conditions Contact ProQuest

ISSN: 10787240

Source type: Wire Feeds

Language of publication: English

Document type: Expanded Reporting

ProQuest document ID: 1797342407

Document URL: https://lopes.idm.oclc.org/login?url=https://search.proquest.com/docview/1797342

407?accountid=7374

Copyright: Copyright 2016, NewsRx LLC

Last updated: 2017-11-24

Database: ProQuest Central

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• Thyroid Diseases and Conditions; Researchers at National Cancer Institute Have Reported New Data on Thyroid Diseases (PBDE flame retardants, thyroid disease, and menopausal status in US women)

Rubic_Print_Format

N/A

10.0%

10.0%

10.0%

10.0%

10.0%

10.0%

10.0%

N/A

N/A

10.0%

N/A

N/A

10.0%

Course Code

Class Code

Assignment Title

Total Points

HLT-362V

HLT-362V-O501

Article Analysis 1

120.0

Criteria

Percentage

1: Unsatisfactory (0.00%)

2: Less Than Satisfactory (65.00%)

3: Satisfactory (75.00%)

4: Good (85.00%)

5: Excellent (100.00%)

Comments

Points Earned

Content

100.0%

Three Quantitative Articles

10.0%

Fewer than three articles are presented. None of the articles presented use quantitative research.

N/A

Three articles are presented. Of the articles presented, only two articles are based on quantitative research.

Three articles are presented. All three articles are based on quantitative research.

Article Citation and Permalinka 2

Article citation and permalink are omitted.

Article citation and permalink are presented. There are significant errors. Page numbers are not indicated to cite information, or the page numbers are incorrect.

Article citation and permalink are presented. Article citation is presented in APA format, but there are errors. Page numbers to cite information are missing, or incorrect, in some areas.

Article citation and permalink are presented. Article citation is presented in APA format. Page numbers are used to cite information. There are minor errors.

Article citation and permalink are presented. Article citation is accurately presented in APA format. Page numbers are accurate and used in all areas when citing information.

Broad Topic Area/Title

Broad topic area and title are omitted.

Broad topic area and title are referenced but are incomplete.

Broad topic area and title are summarized. There are some minor inaccuracies.

Broad topic area and title are presented. There are some minor errors, but the content overall is accurate.

Broad topic area and title are fully presented and accurate.

Independent and Dependent Variables and Type of Data for Variables

Variable types and data for variables are omitted.

Variable types and data for variables are presented. There are major inaccuracies or omissions.

Variable types and data for variables are presented. There are inaccuracies.

Variable types and data for variables are presented. Minor detail is needed for accuracy.

Variable types and data for variables are presented and accurate.

Population of Interest for the Study

Population of interest for the study is omitted.

Population of interest for the study is presented. There are major inaccuracies or omissions.

Population of interest for the study is presented. There are inaccuracies.

Population of interest for the study is presented. Minor detail is needed for accuracy.

Population of interest for the study is presented and accurate.

Sample

Sample is omitted.

Sample is presented. There are major inaccuracies or omissions.

Sample is presented. There are inaccuracies.

Sample is presented. Minor detail is needed for accuracy.

Sample is presented and accurate.

Sampling Method

Sampling method is omitted.

Sampling is presented. There are major inaccuracies or omissions.

Sampling is presented. There are inaccuracies.

Sampling is presented. Minor detail is needed for accuracy.

Sampling method is presented and accurate.

Descriptive Statistics (mean, median, mode; standard deviation) (Identify examples of descriptive statistics in the article.)

Descriptive statistic examples from the article are omitted. There are major inaccuracies or omissions.

Descriptive statistic examples from the article are presented. There are some very minor inaccuracies or omissions.

Descriptive statistic examples from the article are presented and accurate.

Inferential Statistics (Identify examples of inferential statistics in the article.)

Inferential statistic examples from the article are omitted. There are major inaccuracies or omissions.

Inferential statistic examples from the article are presented. There are some very minor inaccuracies or omissions.

Inferential statistic examples from the article are presented and accurate.

Mechanics of Writing (includes spelling, punctuation, grammar, and language use)

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is employed.

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.

Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.

The writer is clearly in command of standard, written, academic English.

Total Weightage

100%