Environmental health

To the Editor: We agree with San Martin Porter and colleagues1 about the importance of mental health screening during pregnancy and acknowledge the role of the Edinburgh Postnatal Depression Scale (EPDS) in screening in Australia and internationally. In the article, the authors stressed that the EPDS has been validated. However, the high heterogeneity demonstrated during these validation studies suggests that it is not equally valid across all populations and settings.2 The authors also suggested that low uptake of screening with Aboriginal women is related to less frequent attendance to antenatal checks. This interpretation fails to consider broader cultural safety issues surrounding antenatal care, and more specifically, the language and cultural appropriateness of the EPDS.3 This tool has not been validated with Aboriginal and Torres Strait Islander women. Many Aboriginal women find the EPDS language complex and confusing, and providers find using it with Aboriginal women challenging.3 Screening processes need to be acceptable to patients and staff, and seen to be easy to use and helpful, or they are unlikely to be well implemented. The need to consider the language and cultural appropriateness of the tool used was acknowledged in the latest Clinical practice guidelines: pregnancy care.4 The Kimberley Mum's Mood Scale (KMMS) is a locally designed approach to screening Aboriginal women.3 Part 1 is an adaption of the EPDS. Part 2 is a “yarn” between health professionals and women about contextual or psychosocial factors that are important to the women. Health professionals work with women to identify how they are coping (strengths focus) without minimising risk factors. Validation of the KMMS demonstrated clinical efficacy and high levels of user acceptability.5 Women identified that “just yarning” was a positive start to understanding and managing their perinatal mental health. An approach such as the KMMS, which values listening (health professional) and talking (woman), is a positive, contemporary and logical next step from the EPDS. We suggest that all women, Aboriginal and non‐Aboriginal, would benefit from this approach. Traditional screening practices are not enough, but the next generation of screening tools provides new opportunities for women and their health professionals.

Julia V Marley · Emma Carlin · Catherine Engelke

In reply

Macarena A San Martin Porter · Steve Kisely · Rosa Alati

To the Editor: We agree with Catalano and colleagues1 that nicotine liquid needs to be regulated. However, we feel that their letter overstates the risk from nicotine poisoning. The authors state that the minimum potentially lethal dose of nicotine in humans is 60 mg, but the reference used for this claim actually estimates a far higher minimum lethal dose of 500–1000 mg.2 While it is correct to say that the “ingestion of even a small volume could cause serious harm or even death,” the reality is less worrying. The bioavailability of ingested nicotine is as little as 20% due to hepatic first pass metabolism.3 Furthermore, most cases of significant ingestion result in prompt vomiting.4 A recent review of all cases of nicotine exposure reported to the Australian Poisons Information Centres between 2009 and 2016 found that most cases resulted in only mild gastrointestinal symptoms.5 We agree with the recommendation to mandate safety labelling and childproof packaging to reduce risk. However, regulation needs to go further; legalising and enforcing quality and safety standards would help to ensure a safer product and minimise unwanted contamination, as found in a recent Australian study.6 Vaping has a potential role in reducing smoking‐related disease in Australia. A recent large randomised controlled trial demonstrated that vaping is nearly twice as effective as nicotine replacement therapy.7 Regulation needs to find a balance between reducing the risk to children and non‐smokers while making high quality reduced‐risk products available to smokers who are otherwise unable to quit. Overly restrictive regulations are likely to have a net negative effect on public health.

Colin P Mendelsohn · Alex D Wodak

In reply

Anthony C Catalano · Noel E Cranswick · Joanne Grindlay · Mick Creati · Margie H Danchin · Jeff Robinson · Nicola Williams · Amanda Gwee

To the Editor: In the recently published article by Morgan and colleagues1 and associated podcast, the authors raised the issue of future research into the outcomes of identification of Aboriginal and Torres Strait Islander peoples in hospital. The implementation of a visual identification methodology has previously been described2 and was put in place in partnership with the hospital department of Aboriginal health. The purpose of this identification initiative was to encourage all medical professionals who care for Aboriginal and Torres Strait Islander patients to question what they can do to assist them while they are in hospital. We describe here the positive outcomes of this process. In addition to hospital pharmacists,2 the visual alert system is also used by other departments and professionals within the hospital, such as cardiothoracic care, the emergency department (ED), Aboriginal health, and speech pathology, as well as ward‐based nursing and medical staff. The Aboriginal and Torres Strait Islander patients’ identification system is used by health care providers within the hospital to easily identify the patients they need to visit, to provide culturally appropriate resources and services and links to other services, and to enhance the care patients receive and enable them to remain in a caring hospital environment. At ward level, nursing and medical staff use the identification system to highlight the referral process needed to link with Aboriginal health workers — connecting the right resources to the right people. Because of the visual alert,2 staff feel more aware of the cultural needs of the patient before they meet them. Specifically in the ED, there is a system‐wide approach that firstly identifies Aboriginal and Torres Strait Islander patients presenting to the ED using the visual alert at triage, and then implementing initiatives that aim to reduce the level of “did not wait for treatment” episodes. The Heart and Lung Stream at St Vincent's Hospital uses the system to identify Aboriginal and Torres Strait Islander patients early during their admission in order to provide culturally specific education, resources and follow‐up after hospital discharge. We encourage others to explore this initiative in their hospital, together with cultural responsiveness training, to enhance the care of Aboriginal and Torres Strait Islander peoples during and after their hospital visit.

Susan A Welch · Sonia Robinson · Tamra Langley · Pauline Deweerd

In reply

David JR Morgan · Martin Whitely · Tania Harris