Gender Differences in Recurrent Mental Health Contact After a Hospitalization for Interpersonal Violence

Abstract

Interpersonal violence and mental illness are significant public health issues. This study aimed to determine gender differences in risk factors for recurrent mental health contacts after a hospitalization for interpersonal violence in Western Australia between 1997 and 2008. This population-based retrospective cohort study used linked hospital morbidity data and mental health records to identify individuals who were hospitalized due to interpersonal violence and had recurrent mental health contacts following hospitalization. A total of 1,969 individuals had a first-ever mental health contact after their index hospitalization for violence. The most common reasons for a mental health contact after interpersonal violence hospitalization were anxiety and/or depression (n = 396, 20.1%), neurotic disorders (n=338, 11.8%), schizophrenia (n=232, 11.8%), and psychoactive substance use (n = 206, 10.5%). Different risk factors for recurrent contact with mental health services emerged for males and females. For males, factors significantly associated with increased risk of recurrent mental health contacts included advancing age and not being married. However, for females, type of violence, Indigenous status, age, and living in rural or remote areas affected the risk of recurrent mental health contacts, whereas marital status did not. These findings have implications for the targeting of mental health prevention programs tailored specifically for males and females affected by violence.

Keywords

interpersonal violence mental health gender differences population-based study

Background

Interpersonal violence is a significant global public health issue (Reza, Mercy, & Krug, 2001). In Australia, 11% of men and 6% of women experienced violence during the previous 12 months (Australian Bureau of Statistics, 2005). It was conservatively estimated that one third of the Western Australian health system cost due to injury in 2003 could be attributed to interpersonal violence (Hendrie & Milligan, 2005). The World Health Organization (WHO) has defined interpersonal violence as “The intentional use of physical force, or power, threatened or actual, against oneself, another person, or against a group or community, that either results in, or has a likelihood of resulting in injury, death, psychological harm, mal-development or deprivation” (Krug, Dahlberg, Mercy, Zwu, & Lozano, 2002, p. 5). This definition includes victimization perpetrated against intimate partners, parents, siblings, children, other relatives, friends, acquaintances, colleagues, and strangers (Krug et al., 2002).

Mental illness is another significant public health issue, constituting the leading cause of nonfatal disability burden and accounts for an estimated 24% of the total years lost due to disability in Australia (Begg et al., 2007). In Western Australia, one in five people experience mental health problems each year and nearly half the population will experience a diagnosable short- or long-term mental illness at least once in their lifetime, including depression, anxiety, and schizophrenia (Lawrence, Holman, & Jablensky, 2001). This accounts for considerable disability, incurring high direct and indirect costs and imposing a heavy burden of human suffering on the community. It is now widely recognized that mental illness and interpersonal violence share a strong association (Krug et al., 2002). This implies that the personal and financial burden of interpersonal violence victimization on the community is likely to be far reaching and much greater than simply the cost of treating physical injuries resulting from violence.

The direction of the relationship between interpersonal violence and mental illness is debated but evidence suggests it is interchangeable. Research examining the development of mental illness after interpersonal violence victimization has reported associations between interpersonal violence and increased risk of depression and anxiety (Coker, Davis, et al., 2002; Hedtke et al., 2008; Lau, Litrownik, Newton, & Landsverk, 2003), substance abuse (Carbone-Lopez, Kruttschnitt, & Macmillan, 2006; Coker, Davis, et al., 2002; Hedtke et al., 2008; Lau et al., 2003; Romito, Molzan Turan, & De Marchi, 2005), posttraumatic stress disorder (Hedtke et al., 2008), and suicide (Conner, Langley, Tomaszewski, & Conwell, 2003; Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008). For example, a U.S.-based cross-sectional study including 935 randomly selected participants found that childhood sexual and physical abuse were associated with a wide variety of psychological symptoms using the Trauma Symptoms Inventory (Briere & Elliott, 2003). Another study using telephone interviews of more than 4,000 women in the United States reported that lifetime violence exposure was associated with increased risk of posttraumatic stress disorder, depression, and substance use problems (Hedtke et al., 2008). The odds of these issues also increased incrementally with the number of different types of violence experienced (Hedtke et al., 2008). In addition, a study using linked data from New Zealand hospitals reported a significantly increased risk of self-injury and suicide among those previously hospitalized for assault (Conner et al., 2003). However, research has largely focused on mental health outcomes of intimate partner violence, particularly with women as victims, or on child abuse.

In addition, studies examining outcomes of interpersonal violence have used varying definitions of violence victimization, ranging from perceived threat of assault to actual assault, with different degrees of severity of injury. Interpersonal violence victimization has also usually been measured using self-report that is liable to both under- and overreporting. While some studies have used self-report in combination with police or criminal records, data from crime databases are also subject to underreporting. For example, in Australia, it is estimated that only 33% of males and 28% of females who are victims of interpersonal violence report the incident to police (Australian Bureau of Statistics, 1999). Furthermore, several studies relied on participants choosing to partake, creating potential selection bias within the samples. Finally, the criterion for the presence of a mental illness varies between studies, with various things being used as proxy measures for a mental illness diagnosis such as substance use and measures of depressive symptoms including the Short Form (SF)-36 (Coker, Davis, et al., 2002). This presents an issue for the comparability and extrapolation of results to different diagnostic groups.

While evidence supports a strong association between violence and mental health, little is known about the different mental health outcomes for males and females following hospitalization for interpersonal violence. Many studies have examined the mental health outcomes of interpersonal violence for females but less have examined these outcomes for male victims of violence. However, the few studies examining males have consistently reported negative mental health outcomes after violence (Cerulli, Bossarte, & Dichter, 2014; Romito et al., 2005; Springer, Sheridan, Kuo, & Carnes, 2007). One U.S.-based national survey found that female violence victims were at almost 2.5 times the risk of anxiety compared with male violence victims but were at a 22% reduced risk of substance abuse and 14% reduced risk of disruptive behavior compared with males (Afifi et al., 2009). Romito and Grassi (2007) examined gender differences in the health impact of violence among 502 Italian university students using a self-administered questionnaire. They reported that panic attacks were more common among females and alcohol problems among males. They also suggested that the greater adverse effects of violence among females than males may be the result of more intense or more frequent experiences of violence among females (Romito & Grassi, 2007).

Another U.S.-based study of 780 men and women examined risk factors for poor mental health following sexual violence and reported that younger age, lower income, lower education, and lack of emotional support were associated with poorer mental health outcomes (Vandemark & Mueller, 2008). Gender was not significantly associated with mental health, but it should be noted that this study examined only outcomes of sexual violence.

These findings that the mental health impact of violence may differ for males and females in terms of severity and type of mental health issues suggest that there may also be different risk factors for poor mental health outcomes following interpersonal violence among males and females. However, to date, no study has examined risk factors for poor mental health outcomes by gender.

Therefore, this study aimed to determine risk factors for recurrent mental health contacts following hospitalization due to interpersonal violence among males and females. This will add useful information to the current literature by providing accurate and reliable evidence regarding different risk factors for poorer mental health outcomes among males and females following interpersonal violence victimization. This information could be used to inform treatment protocols at the time of victimization, guide policy development, and allow targeting of resources to reduce the burden of mental illness for the individual and the community.

Method

Study Design

A population-based retrospective cohort study was undertaken. It examined hospital admissions due to interpersonal violence in Western Australia between 1997 and 2008 and subsequent mental health contacts, using available administrative health records. The de-identified data were obtained from Data Linkage Western Australia at the Department of Health Western Australia following ethical approval from the Curtin University Human Research Ethics Committee, the Department of Health Western Australia Human Research Ethics Committee, and the Western Australian Aboriginal Health Information and Ethics Committee. The Western Australian Data Linkage System is a validated, continuing, dynamic data linkage system that creates links between administrative health records. This system captures all hospital admission data, birth and death records, mental health service contacts, crash records, cancer registrations, and midwives’ notifications for all Western Australians.

Participants and Databases

The inclusion criteria for the sample were as follows: a person who experienced a first-ever hospital admission (index admission) for interpersonal violence and an “injury” between 1997 and 2008; any person with a hospital admission for interpersonal violence prior to 1997 was excluded.

International Classification for Diseases (ICD) codes were used to extract records from the Hospital Morbidity Data System. Records listed as “injury, poisoning and certain other consequences of external injury” as designated by a diagnosis code between 800.00 and 999.99 (Chapter 17, ICD-9-clinical modification [CM]), or between S00.0 and T98.3 (Chapter XIX, ICD-10-Australian modification [AM]), and a primary external cause indicating that at least one injury in the record was inflicted by another person, “assault” as designated by an external cause code between E960.0 and E969 (ICD-9-CM) or between X85 and Y09 (ICD-10-AM; National Coding Centre, 1995, 2006) were extracted for the analysis.

These records were then linked to the Mental Health Information System to identify those who had mental health inpatient and/or mental health public outpatient contacts after the index admission for interpersonal violence, “mental and behavioural disorders,” as designated by a diagnosis code between F00 (290 to 319, Chapter V, ICD-9-AM) and F99 (Chapter V, ICD-10-AM). Those who had a mental health contact before their index interpersonal violence hospitalization were not included in this analysis. Any extra hospital admissions generated by transfers of a patient between wards on the same day in the Mental Health Information System were combined with the original admission into one inpatient episode.

In addition, the external cause codes for injury inflicted by another were divided into four subgroups designating the following methods of inflicting injury: by bodily force (E960.0 [ICD-9-CM] or Y04 [ICD-10-AM]), by sharp or blunt object (E966, E968.2 [ICD-9-CM] or Y99, Y00 [ICD-10-AM]), by maltreatment or rape (E960.1, E967.0-9 [ICD-9-CM] or Y05, Y06.0-9, Y07.0-9 [ICD-10-AM]), and by other methods (all other codes between E960.0 and E969 [ICD-9-CM] or X85 and Y09 [ICD-10-AM]).

Demographic information including age, gender, residential location, marital status, and the presence of comorbid conditions were also extracted for analysis. Residential location was defined as metropolitan, rural, or remote based on the patient’s postcode at violence hospital admission. Patients who had a partner (married or de facto) were classified as “married” for the purposes of this study. Indigenous status was defined as being recorded as Indigenous and/or Torres Strait Islander or not at index interpersonal violence hospital admission. Age was treated as a continuous variable in the analysis. A 5-year look-back period was used to identify comorbidities. An unweighted comorbidity score was assigned to each patient as the cumulative number of different comorbid conditions identified from all hospital admissions up to 1 year before and including the index hospital admission for interpersonal violence. The presence or absence of comorbid conditions was used in the analysis.

Statistical Analysis

Descriptive statistics were used to characterize those who were hospitalized due to interpersonal violence and had a mental health contact and those who had no mental health contacts.

The outcome of interest was recurrent mental health contacts. Two separate multivariate negative binomial regression models were used to identify risk factors associated with recurrent mental health contacts after a hospitalization due to interpersonal violence for males and females. Risk factors examined included age, Indigenous status, residential location, type of violence, marital status, and comorbidities. Those who had more than one interpersonal violence hospitalization during the study period were flagged and accounted for only once in the model. An offset term was specified in each model to adjust for the varying lengths of observation period for each individual. The negative binomial regression models were performed using the STATA (version 9) statistical package. Results were considered significant at the .05 level.

Results

Between 1997 and 2008, in Western Australia, 20,689 individuals experienced a first-time hospital admission (index admission) for injury due to violence. Those who had a mental health contact prior to index interpersonal violence admission were excluded (n = 3,395, 16.4%) from the analysis. Of the remaining sample (n = 17,294), 1,969 individuals (11.4%) had a first-ever mental health contact recorded after their index hospitalization for interpersonal violence and 15,325 individuals (88.6%) had no recorded mental health contacts before or after hospitalization for violence. Table 1 presents the characteristics of those hospitalized for interpersonal violence by mental health contact and no mental health contact.

Table 1.

Characteristics of Individuals With and Without a Mental Health Contact After an Index Hospitalization for Interpersonal Violence in Western Australia, 1997-2008.

	No Mental Health Contact^a (n = 15,325)		Mental Health Contact^b (n = 1,969)		Total (N = 17,294)		p Value
	n	%	n	%	n	%	p Value
Gender
Male	11,600	75.7	1,181	60.0	11,278	73.9
Female	3,725	24.3	788	40.0	4,513	26.1	<.001
Age (years)
0-4	493	3.2	15	0.8	508	2.9
5-9	116	0.8	16	0.8	132	0.8
10-14	349	2.3	66	3.4	415	2.4
15-19	2,764	18.0	330	16.8	3,094	17.9
20-24	3,267	21.3	356	18.1	3,623	20.9
25-29	2,391	15.6	358	18.2	2,749	15.9
30-34	1,861	12.1	273	13.9	2,134	12.3
35-39	1,356	8.9	217	11.0	1,573	9.1
40-44	984	6.4	138	7.0	1,122	6.5
45-49	644	4.2	83	4.2	727	4.2
50-54	457	3.0	51	2.6	508	2.9
55-59	245	1.6	19	1.0	264	1.5
60-64	139	0.9	11	0.6	150	0.9
65-69	81	0.5	11	0.6	92	0.5
70+	178	1.2	25	1.3	203	1.2	<.001
Marital status^c
Married	3,610	25.0	428	22.9	4,038	24.8
Not married	10,807	75.0	1,439	77.1	12,246	75.2	.046
Indigenous status
Indigenous	4,707	30.7	515	26.2	5,222	30.2
Non-Indigenous	10,618	69.3	1,454	73.8	12,072	69.8	<.001
Comorbidities
Yes	2,801	16.2	476	24.2	3,277	17.0
No	14,493	83.8	1,493	75.8	15,986	83.0	<.001
Area of residence^c
Metropolitan	8,061	48.1	1,010	51.3	9,071	48.4
Rural	3,556	21.2	404	20.5	3,960	21.1
Remote	5,150	30.7	555	28.2	5,705	30.4	<.001
Type of violence^c
Bodily force	7,984	52.3	990	50.5	8,974	52.0
Sharp or blunt object	3,658	23.9	345	17.6	4,003	23.2
Rape and maltreatment	1,159	7.6	231	11.8	1,390	8.1
Other specified and nonspecified	2,480	16.2	396	20.2	2,876	16.7	<.001

Individuals with no mental health contacts before or after index hospitalization for interpersonal violence.

Mental health contact after index hospitalization for interpersonal violence only.

Totals do not add up to 17,294 due to missing data.

The 1,969 individuals had a total of 3,983 mental health contacts after hospitalization for interpersonal violence, with a range of 1 to 18 mental health contacts per person. Table 1 describes the sample. The majority of these individuals were male (60.0%), not married (77.1%), non-Indigenous (73.8%), aged between 15 and 29 years (53.1%), did not have a comorbid condition (75.8%), resided in the metropolitan area (51.3%), and were involved in violence by bodily force (50.5%).

The most common reasons for a mental health contact after interpersonal violence hospitalization were for anxiety and/or depression (n = 396, 20.1%), neurotic disorders (n=338, 11.8%), schizophrenia (n=232, 11.8%) and psychoactive substance use (n = 206, 10.5%).

Table 2 presents factors affecting the risk of recurrent mental health contacts after interpersonal violence hospitalization for males. For males, advancing age (incidence rate ratio [IRR] = 1.04, 95% confidence interval [CI] = [1.03, 1.04]) and not being married (IRR = 2.08, 95% CI = [1.68, 2.58]) were significantly associated with increased risk of recurrent mental health contacts. Living in a remote area of Western Australia was associated with a 21% decreased risk of recurrent mental health contacts compared with living in metropolitan areas (IRR = 0.79, 95% CI = [0.64, 0.97]). However, there was no significant difference in risk for living in a rural area for males. There were also no significant differences in risk for recurrent mental health contacts after interpersonal violence hospitalization in relation to Indigenous status, type of violence or comorbid conditions (Table 2).

Table 2.

Factors Affecting the Risk of Recurrent Mental Health Contacts After Interpersonal Violence Hospitalization Among Males in Western Australia, 1997-2008 (n = 1,181).

	IRR^a	95% Confidence Interval	p value
Indigenous status
Non-Indigenous	1
Indigenous	1.08	[0.87, 1.33]	.481
Age (years)	1.04	[1.03, 1.04]	<.001
Type of violence
Bodily force	1
Sharp or blunt object	1.08	[0.89, 1.32]	.428
Rape and maltreatment	1.17	[0.73, 1.86]	.520
Other specified and nonspecified	1.16	[0.94, 1.42]	.164
Marital status
Married	1
Not married	2.08	[1.68, 2.58]	<.001
Area of residence
Metropolitan	1
Rural	0.85	[0.69, 1.03]	.104
Remote	0.79	[0.64, 0.97]	.025
Comorbidities
No	1
Yes	1.00	[0.80, 1.23]	.964

Adjusted incidence rate ratio.

For females, advancing age was associated with increased risk of recurrent mental health contacts (IRR = 1.02, 95% CI = [1.01, 1.02]; Table 3). Compared with non-Indigenous females, Indigenous females had a 36% lower risk of recurrent mental health contacts after hospitalization for violence (IRR = 0.64, 95% CI = [0.52, 0.78]). Being hospitalized due to interpersonal violence involving a sharp or blunt object (IRR = 0.55, 95% CI = [0.42, 0.73]) and other specified and nonspecified means (IRR = 0.67, 95% CI = [0.52, 0.87]) were associated with a lower risk of recurrent mental health contacts than being hospitalized due to bodily force. Living in both rural (IRR = 0.77, 95% CI = [0.61, 0.97]) and remote (IRR = 0.62, 95% CI = [0.49, 0.77]) areas was significantly associated with decreased recurrent mental health contacts than living in metropolitan Western Australia. There was no significant difference in risk between those hospitalized for bodily force or rape and maltreatment. Marital status also did not affect the risk of recurrent mental health contacts after violence hospitalization among women (Table 3).

Table 3.

Factors Affecting the Risk of Recurrent Mental Health Contacts After Hospitalization for Interpersonal Violence Among Females in Western Australian, 1997-2008 (n = 788).

	IRR^a	95% Confidence Interval	p Value
Indigenous status
Non-Indigenous	1
Indigenous	0.64	[0.52, 0.78]	<.001
Age (years)	1.02	[1.01, 1.02]	<.001
Type of violence
Bodily force	1
Sharp or blunt object	0.55	[0.42, 0.73]	<.001
Rape and maltreatment	0.87	[0.70, 1.08]	.210
Other specified and nonspecified	0.67	[0.52, 0.87]	.003
Marital status
Married	1
Not married	1.20	[0.99, 1.46]	.065
Area of residence
Metropolitan	1
Rural	0.77	[0.61, 0.97]	.027
Remote	0.62	[0.49, 0.77]	<.001
Comorbidities
No	1
Yes	0.95	[0.75, 1.21]	.682

Adjusted incidence rate ratio.

Discussion

This study found that different risk factors were associated with recurrent mental health contacts following interpersonal violence hospitalization for males and females. For males, age and being unmarried increased the risk for recurrent mental health contacts, whereas living in a remote area decreased the risk. However, for females, type of violence, Indigenous status, age, and living in rural or remote areas affected the risk of recurrent mental health contacts, whereas marital status did not.

An interesting finding was that unmarried males hospitalized for violence were at higher risk of recurrent mental health contacts than married males. However, unmarried females were at no significantly different risk to married females. Research has found that overall, having a partner is protective of mental health (Willitts, Benzeval, & Stansfeld, 2004). However, a U.K.-based study reported that single women had good mental health relative to other women but this was not true for single men compared to men in relationships (Willitts et al., 2004). This may have contributed to the different findings for the role of marriage in mental health outcomes after violence between men and women in the current study. Previous evidence has also suggested that support network characteristics may moderate the effect of traumatic stress on mental health symptoms (Coker, Smith, et al., 2002; Savage & Russell, 2005). Therefore, it is possible that unmarried males have less access to social or family support, therefore requiring more mental health services or suffering more severe mental health symptoms following interpersonal violence hospitalization. This requires further investigation.

This study found that living in remote areas of Western Australia for males and living in rural or remote areas for females, decreased the risk of recurrent mental health contacts. Rural and remote areas of Western Australia are overrepresented in terms of violence-related hospitalizations and it has been reported that the prevalence of mental health issues is at least as high in these areas as metropolitan areas, with suicide rates being significantly higher (Caldwell, Jorm, & Dear, 2004). It is therefore unlikely that this finding is due to people in rural and remote areas having better mental health outcomes after interpersonal violence (Meuleners, Hendrie, & Lee, 2008). Western Australia is vast and diverse, ranging from metropolitan to very remote areas and this is important to consider when interpreting the results of this study. It is possible that recurrent mental health contacts may indicate groups who have poorer mental health outcomes after violence hospitalization. However, it may also indicate groups who have better access to mental health services or are more willing to access such services.

Therefore, it is possible that this finding is due to a lack of appropriate mental health services or access to these services in rural and remote Western Australia. Previous research has found that lack of transport, lack of qualified professionals, long waiting lists, stigma surrounding mental illness, and concerns about confidentiality provide specific barriers to the utilization of mental health services for people in rural or remote areas (Aisbett, Boyd, Francis, & Newnham, 2007; Sweeney & Kisely, 2003).

Interestingly, the study found that Indigenous females had in fact, a 36% lower risk of more frequent mental health contacts than non-Indigenous females. Again it is unlikely that Indigenous females have better mental health outcomes than non-Indigenous females after interpersonal violence. A possible explanation for this finding is that Indigenous females do not seek out or do not have access to culturally appropriate mental health services that take a holistic approach to physical and mental health and incorporate the spiritual beliefs of Indigenous people in Western Australia. A recent review of community health surveys in Australia reported that Indigenous adults had a 50% to 300% higher prevalence of self-reported psychological distress than the general community (Jorm, Bourchier, Cvetkovski, & Stewart, 2012). This was the case for both males and females. It has been previously reported that Indigenous people do not access mental health services in proportion to their need in Australia (Isaacs, Pyett, Oakley-Browne, Gruis, & Waples-Crowe, 2010). This may be due to lack of trust of mainstream services, cultural and language differences, living in remote areas, lack of access, or stigma associated with mental illness (Isaacs et al., 2010).

The study also found that the type of interpersonal violence experienced affected the risk of recurrent mental health contacts for females only. In contrast to other studies, rape and maltreatment was not significantly associated with recurrent mental health contacts. Previous studies indicate that the risk of depression is slightly higher for sexual assault than other types of assault (Carbone-Lopez et al., 2006; Hedtke et al., 2008; Romito et al., 2005). This finding may not have been reflected in our results due to the stigma associated with sexual assault preventing women seeking mental health services (Golding, 1999). It is also possible that the age at which the event occurred may have an impact on mental health outcomes. Further research is warranted.

The record linkage methodology used in this study makes available comprehensive information on the total Western Australian population. This methodology has the advantage of detecting small differences in risk due to its increased statistical power. However, there are several limitations when using the linked databases. First, they only capture victims of violence who were hospitalized due to their injuries. Many victims of violence seek treatment at an emergency department or from a general practitioner or never report their injury. Therefore, these findings can only be generalized to cases at the moderate to severe end of the injury spectrum. Similarly, the Mental Health Information System did not capture all patients with mental illnesses. For example, those who do not seek treatment, those who only see a general practitioner, and those who seek treatment from private mental health practitioners on an outpatient basis could not be identified in this study. Unfortunately, the results were also limited in terms of identifying the victim–perpetrator relationship. Recording of this variable in the hospital system needs to be improved so that the prevalence and mental health outcomes of different perpetrator relationships can be examined. Finally, the lack of lifestyle and personal information including information such as drug and alcohol usage, living conditions, and social support was a limitation of the study.

Conclusion

This population-based study has identified different risk factors for recurrent mental health contacts following hospitalization for interpersonal violence for males and females. It is recommended that prevention activities and programs be tailored to suit males and females by taking into account how risk factors such as type of violence, Indigenous status, marital status, and residential location may affect the mental health outcomes of males and females differently.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: This research was funded by an Australian Rotary Health grant.

Author Biographies

Lynn B. Meuleners is a professor and an injury epidemiologist. She has more than 9 years experience in injury research, with the focus of her work relating to road safety, interpersonal violence, data linkage, and injury surveillance. She has published widely in the area (60 journal articles, one book, and three book chapters) and has worked alongside both government and community stakeholders on a wide range of injury-related projects.

Michelle L. Fraser completed a bachelor of science (health promotion) in 2004 and a master of philosophy in 2012. She has worked as a research assistant in the School of Public Health and School of Occupational Therapy from 2005, at the Centre for Population Health Research from 2008, and in recent years at the Curtin-Monash Accident Research Centre, Curtin University. Her main areas of interest have focused on injury prevention and road safety and she has been involved in the planning, conduct, and analysis of numerous projects.

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