Exploring Heterogeneity in Cost-Effectiveness Using Machine Learning Methods: A Case Study Using the FIRST-ABC Trial.

OBJECTIVE: The aim of this study was to explore heterogeneity in the cost-effectiveness of high-flow nasal cannula (HFNC) therapy compared with continuous positive airway pressure (CPAP) in children following extubation. DESIGN: Using data from the FIRST-line support for Assistance in Breathing in Children (FIRST-ABC) trial, we explore heterogeneity at the individual and subgroup levels using a causal forest approach, alongside a seemingly unrelated regression (SUR) approach for comparison. SETTINGS: FIRST-ABC is a noninferiority randomized controlled trial (ISRCTN60048867) including children in UK paediatric intensive care units, which compared HFNC with CPAP as the first-line mode of noninvasive respiratory support. PATIENTS: In the step-down FIRST-ABC, 600 children clinically assessed to require noninvasive respiratory support were randomly assigned to HFNC and CPAP groups with 1:1 treatment allocation ratio. In this analysis, 118 patients were excluded because they did not consent to accessing their medical records, did not consent to follow-up questionnaire or did not receive respiratory support. MEASUREMENTS AND MAIN RESULTS: The primary outcome of this study is the incremental net monetary benefit (INB) of HFNC compared with CPAP using a willingness-to-pay threshold of £20,000 per QALY gain. INB is calculated based on total costs and quality adjusted life years (QALYs) at 6 months. The findings suggest modest heterogeneity in cost-effectiveness of HFNC compared with CPAP at the subgroup level, while greater heterogeneity is detected at the individual level. CONCLUSIONS: The estimated overall INB of HFNC is smaller than the INB for patients with better baseline status suggesting that HFNC can be more cost-effective among less severely ill patients.

Heterogeneity within the Oregon Health Insurance Experiment: An application of causal forests.

Existing evidence regarding the effects of Medicaid expansion, largely focused on aggregate effects, suggests health insurance impacts some health, healthcare utilization, and financial hardship outcomes. In this study we apply causal forest and instrumental forest methods to data from the Oregon Health Insurance Experiment (OHIE), to explore heterogeneity in the uptake of health insurance, and in the effects of (a) lottery selection and (b) health insurance on a range of health-related outcomes. The findings of this study suggest that the impact of winning the lottery on the health insurance uptake varies among different subgroups based on age and race. In addition, the results generally coincide with findings in the literature regarding the overall effects: lottery selection (and insurance) reduces out-of-pocket spending, increases physician visits and drug prescriptions, with little (short-term) impact on the number of emergency department visits and hospital admissions. Despite this, we detect quite weak evidence of heterogeneity in the effects of the lottery and of health insurance across the outcomes considered.

Parent's preferences for unscheduled paediatric healthcare: A discrete choice experiment.

BACKGROUND: Unscheduled healthcare is a key component of healthcare delivery and makes up a significant proportion of healthcare access, with children being particularly high users of unscheduled healthcare. Understanding the relative importance of factors that influence this behaviour and decision-making is fundamental to ensuring the system is best designed to meet the needs of users and foster appropriate cost-effective usage of health system resources. OBJECTIVE: The aim of the study was to identify the parent's preferences for unscheduled healthcare for a common mild childhood illness. DESIGN: A discrete choice experiment (DCE) was developed to identify the preferences of parents accessing unscheduled healthcare for their children. SETTING AND PARTICIPANTS: Data were collected from parents in Ireland (N = 458) to elicit preferences across five attributes: timeliness, appointment type, healthcare professional attended, telephone guidance before attending and cost. RESULTS: Using a random parameters logit model, all attributes were statistically significant, cost (ß = -5.064, 95% confidence interval, CI [-5.60, -4.53]), same-day (ß = 1.386, 95% CI [1.19, 1.58]) or next-day access (ß = 0.857, 95% CI [0.73, 0.98]), coupled with care by their own general practitioner (ß = 0.748, 95% CI [0.61, 0.89]), identified as the strongest preferences of parents accessing unscheduled healthcare for their children. DISCUSSION: The results have implications for policy development and implementation initiatives that seek to improve unscheduled health services as understanding how parents use these services can maximise their effectiveness. PATIENT OR PUBLIC CONTRIBUTION: The development of the DCE included a qualitative research component to ensure that the content accurately reflected parents experiences when seeking healthcare. Before data collection, a pilot test was carried out with the target population to gather their views on the survey.

An umbrella review of the effectiveness of fiscal and pricing policies on food and non-alcoholic beverages to improve health.

Poor quality diets represent major risk factors for the global burden of disease. Modeling studies indicate a potential for diet-related fiscal and pricing policies (FPs) to improve health. There is real-world evidence (RWE) that such policies can change behavior; however, the evidence regarding health is less clear. We conducted an umbrella review of the effectiveness of FPs on food and non-alcoholic beverages in influencing health or intermediate outcomes like consumption. We considered FPs applied to an entire population within a jurisdiction and included four systematic reviews in our final sample. Quality appraisal, an examination of excluded reviews, and a literature review of recent primary studies assessed the robustness of our results. Taxes and, to some extent, subsidies are effective in changing consumption of taxed/subsidized items; however, substitution is likely to occur. There is a lack of RWE supporting the effectiveness of FPs in improving health but this does not mean that they are ineffective. FPs may be important for improving health but their design is critical. Poorly designed FPs may fail to improve health and could reduce support for such policies or be used to support their repeal. More high-quality RWE on the impact of FPs on health is needed.

An umbrella review of the acceptability of fiscal and pricing policies to reduce diet-related noncommunicable disease.

CONTEXT: Poor diet has been implicated in a range of noncommunicable diseases. Fiscal and pricing policies (FPs) may offer a means by which consumption of food and non-alcoholic beverages with links to such diseases can be influenced to improve public health. OBJECTIVE: To examine the acceptability of FPs to reduce diet-related noncommunicable disease, based on systematic review evidence. DATA SOURCES: MEDLINE, EMBASE, PsychInfo, SCI, SSCI, Web of Science, Scopus, EconLit, the Cochrane Library, Epistemonikos, and the Campbell Collaboration Library were searched for relevant studies published between January 1, 1990 and June 2021. DATA EXTRACTION: The studies included systematic reviews of diet-related FPs and: used real-world evidence; examined real or perceived barriers/facilitators; targeted the price of food or non-alcoholic beverages; and applied to entire populations within a jurisdiction. A total of 9996 unique relevant records were identified, which were augmented by a search of bibliographies and recommendations from an external expert advisory panel. Following screening, 4 systematic reviews remained. DATA ANALYSIS: Quality appraisal was conducted using the AMSTAR 2 tool. A narrative synthesis was undertaken, with outcomes grouped according to the WHO-INTEGRATE criteria. The findings indicated a paucity of high-quality systematic review evidence and limited public support for the use of FPs to change dietary habits. This lack of support was related to a number of factors that included: their perceived potential to be regressive; a lack of transparency, ie, there was mistrust around the use of revenues raised; a paucity of evidence around health benefits; the deliberate choice of rates that were lower than those considered necessary to affect diet; and concerns about the potential of such FPs to harm economic outcomes such as employment. CONCLUSION: The findings underscore the need for high-quality systematic review evidence on this topic, and the importance of responding to public concerns and putting in place mechanisms to address these when implementing FPs. This study was funded by Safefood [02A-2020]. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42021274454.

Supporting family carers of people with dementia: A discrete choice experiment of public preferences.

Community-based care for people with dementia is mainly provided by family carers, many of whom experience decreased mental, physical and financial well-being due to their caring role. Many countries are now implementing ageing-in-place policies that have increased pressure on family carers as care-work is redistributed from residential to community-based settings. Family caring responsibilities for people with dementia are made even more complicated by the economic, social and cultural expectations that underpin existing provision. Support for family carers is, therefore, an important policy topic across many countries. The focus of this paper is on the propensity of citizens to support enhanced care for family carers in Ireland, as demonstrated by their willingness-to-pay additional taxation to fund different combinations of carer support measures, developed through careful and sustained dialogue with multiple stakeholders, especially family carers themselves. We carried out a discrete choice experiment (DCE) with 509 members of the general public in Ireland between January and February 2021. Using mixed logit models, our findings show that citizens value four key attributes: regular caring breaks for family carers (day-care and long-break respite); financial compensation (carer's allowance); and emotional support (carer peer support groups). We also estimated the welfare impact of moving from current provision to enhanced support packages for family carers of people with dementia. The welfare gains accumulate to €1035.80 for the most complete levels of provision across the four support attributes. Overall, respondents in this paper showed empathy and understanding towards family carers of people with dementia through their willingness to contribute to funding additional services and supports.

A discrete choice experiment exploring farmer preferences for insurance against extreme weather events.

Agriculture represents one of the most vulnerable sectors to extreme weather events that are projected to increase with climate change. Insurance has been advocated as a more efficient means to ensure financial security to farmers, than post-disaster aid for damages. A potential drawback of insurance however, is that unless carefully designed it could dis-incentivise farmers to engage in wider farm adaptation measures or lead to more risk-taking behaviour. This paper analyses the attractiveness of publicly-backed climate risk insurance offerings to farmers and explores their preferences for elements of insurance schemes that do not negatively affect incentives for wider farm adaptation. Specifically, a discrete choice experiment is used to reveal Irish farmers' preferences for multi-annual insurance contracts and weather-indexed versus traditional indemnity insurance and cost. Results indicate that a majority of farmers are willing to buy publicly-backed insurance for protection from extreme weather events. Younger farmers, farmers who currently have farm insurance, farmers from certain geographical locations and farmers who have been previously affected by extreme weather events are more likely to buy insurance. With respect to the design of insurance schemes, farmers prefer multi-annual coverage versus annual renewal. They also prefer indexed-insurance and have a strong preference for cheaper coverage. Despite the important role that insurance could play in protecting farms financially from damage caused by extreme weather events, few studies have examined preference for weather-indexed insurance within a European context. New evidence on farmer preferences and intended behaviours is therefore critical to inform policy in this area.

An Exploration on Attribute Non-attendance Using Discrete Choice Experiment Data from the Irish EQ-5D-5L National Valuation Study.

BACKGROUND: Generic measures of health-related quality of life (HRQoL) permit comparisons of competing demands for healthcare resources using outcomes that reflect the preferences of tax payers. EQ-5D instruments are the most commonly used generic, preference-based measures of HRQoL. The EQ-5D-5L enables respondents to describe their health state using five dimensions of health, each with five response levels. The standardised protocol for the valuation of EQ-5D-5L health states comprises use of the composite time trade-off valuation technique, supplemented by a discrete choice experiment (DCE). OBJECTIVE: This paper presents the first exploration on attribute non-attendance (ANA) to the dimensions of the EQ-5D-5L using DCE data collected following the standardised protocol. METHOD: This paper uses the equality constrained latent class model and the endogenous attribute attendance model to examine ANA to the dimensions of the EQ-5D-5L. RESULTS: The results suggest that respondents are less likely to consider the physical dimensions of the EQ-5D-5L (such as self-care and usual activities) when evaluating the health states. The effects of ANA on utility scores depends on the interpretation of the underlying reasons for ANA. CONCLUSIONS: We recommend that future value sets based in whole or in part on DCE data examine the impact of and reasons for non-attendance in national valuation studies.

Budget impact analysis of an early identification and referral model for diagnosing patients with suspected rheumatoid arthritis in Ireland.

OBJECTIVE: To estimate the budget impact from the perspective of the Irish health-care system attributable to a reconfiguration in the diagnostic care pathway for patients with suspected RA by adopting an early identification and referral model (EIM). METHODS: The budget impact model evaluated the total health-care use and costs attributable to an EIM to diagnose patients with suspected RA relative to the reference scenario of current practice. The modelling also assessed a primary outcome of effect, which examined how many patients can be diagnosed by a rheumatologist within 3 months of symptom onset. The budget impact analysis model was estimated over a 5-year time frame. RESULTS: The EIM generated a cost saving for the Irish health-care system of €237 547 over the time frame relative to current practice. The cost savings were realized owing to a reduction in the number of general practitioner (GP) visits of 18 790 and a reduction in diagnostic tests carried out by GPs. The results showed that 1027 (510%) more patients were diagnosed within 3 months of symptom onset in the EIM compared with current practice. CONCLUSION: This paper has presented an alternative rheumatologist-led service design that can be used in diagnosing patients with suspected RA. The rheumatologist-led service provision detailed in this study has the potential simultaneously to reduce demand for primary care services and to improve the health outcomes of patients. The use of an EIM sees rheumatologist activity incorporate patient demand.

The COVID-19 pandemic in Ireland: An overview of the health service and economic policy response.

OBJECTIVES: To outline the situation in Ireland with regard to the COVID-19 pandemic. METHODS: Analyse the evolution of the COVID-19 pandemic in Ireland. Review the key public health and health system responses. RESULTS: Over 1700 people have died with COVID-19 by July 19th while almost 3000 people had been admitted to hospital with COVID-19. A high proportion of the deaths occurred in nursing homes and other residential centres who did not receive sufficient attention during the early phase of the pandemic. CONCLUSIONS: Ireland's response to the COVID-19 crisis has been comprehensive and timely. Transparency, a commitment to a relatively open data policy, the use of traditional and social media to inform the population, and the frequency of updates from the Department of Health and the Health Services Executive are all commendable and have led to a high level of compliance among the general public with the various non-medical measures introduced by the government.

Health inequities in unscheduled healthcare for children with intellectual disabilities in Ireland: a study protocol.

Background: Health inequities for children with intellectual disabilities  are prevalent within different health systems, and children with intellectual disabilites  have shorter life expectancies than the general population, higher mortality rates before the age of 17 and have a greater risk of potentially preventable hospitalisations. A health systems approach to research in this area provides a useful means through which research can inform policy and practice to ensure people with intellectual disabilities receive equitable healthcare; however, there is a paucity of evidence regarding how to address differences that have been described in the literature to date. The overall aim of this research is to establish the extent of health inequities for children with intellectual disabilities  in Ireland compared to children without intellectual disabilities with respect to their utilisation of primary care and rates of hospitalisation, and to gain a better understanding of what influences utilisation of primary care and emergency department services in this population. Methods and analysis: The design of this research adopts a multi-methods approach: statistical analysis of health data to determine the extent of health inequities in relation to healthcare utilisation; discrete choice experiments to explore General Practitioners' decision making and parental preferences for optimal care; and concept mapping to develop consensus between stakeholders on how to address current healthcare inequities. Discussion: By applying a systems lens to the issue of health inequities for children with intellectual disabilities, the research hopes to gain a thorough understanding of the varying components that can contribute to the maintenance of such healthcare inequities. A key output from the research will be a set of feasible solutions and interventions that can address health inequities for this population.

Choosing Healthy Eating for Infant Health (CHErIsH) study: protocol for a feasibility study.

INTRODUCTION: Childhood obesity is a public health challenge. There is evidence for associations between parents' feeding behaviours and childhood obesity risk. Primary care provides a unique opportunity for delivery of infant feeding interventions for childhood obesity prevention. Implementation strategies are needed to support infant feeding intervention delivery. The Choosing Healthy Eating for Infant Health (CHErIsH) intervention is a complex infant feeding intervention delivered at infant vaccination visits, alongside a healthcare professional (HCP)-level implementation strategy to support delivery. METHODS AND ANALYSIS: This protocol provides a description of a non-randomised feasibility study of an infant feeding intervention and implementation strategy, with an embedded process evaluation and economic evaluation. Intervention participants will be parents of infants aged ≤6 weeks at recruitment, attending a participating HCP in a primary care practice. The intervention will be delivered at the infant's 2, 4, 6, 12 and 13 month vaccination visits and involves brief verbal infant feeding messages and additional resources, including a leaflet, magnet, infant bib and sign-posting to an information website. The implementation strategy encompasses a local opinion leader, HCP training delivered prior to intervention delivery, electronic delivery prompts and additional resources, including a training manual, poster and support from the research team. An embedded mixed-methods process evaluation will examine the acceptability and feasibility of the intervention, the implementation strategy and study processes including data collection. Qualitative interviews will explore parent and HCP experiences and perspectives of delivery and receipt of the intervention and implementation strategy. Self-report surveys will examine fidelity of delivery and receipt, and acceptability, suitability and comprehensiveness of the intervention, implementation strategy and study processes. Data from electronic delivery prompts will also be collected to examine implementation of the intervention. A cost-outcome description will be conducted to measure costs of the intervention and the implementation strategy. ETHICS AND DISSEMINATION: This study received approval from the Clinical Research Ethics Committee of the Cork Teaching Hospitals. Study findings will be disseminated via peer-reviewed publications and conference presentations.

The impact of childhood overweight and obesity on healthcare utilisation.

Rising levels of childhood overweight and obesity represent a major global public health challenge. A number of studies have explored the association between childhood overweight and obesity and healthcare utilisation and costs. This paper adds to the literature by estimating the causal effect of child overweight and obesity status on use of general practitioner (GP) and hospital inpatient stays at two time points using instrumental variable (IV) methods The paper uses data from two waves of the Growing Up in Ireland survey of children when they are 9 and 13 years respectively and uses the biological mother's body mass index (BMI) as an instrument for the child's BMI. Our results demonstrate that child overweight and obesity status do not have a significant effect on healthcare utilisation for children when they are 9 years, but do have a large and significant effect at 13 years. Across all our models, the effects on both GP and hospital inpatient stays are found to be larger when endogeneity in childhood BMI status is addressed. Previous studies that did not address endogeneity concerns are likely to have significantly underestimated the impact of child overweight and obesity status on healthcare utilisation.

Economic impact of medication error: a systematic review.

PURPOSE: Medication error is a significant source of morbidity and mortality among patients. Clinical and cost-effectiveness evidence are required for the implementation of quality of care interventions. Reduction of error-related cost is a key potential benefit of interventions addressing medication error. The aim of this review was to describe and quantify the economic burden associated with medication error. METHODS: PubMed, Cochrane, Embase, CINAHL, EconLit, ABI/INFORM, Business Source Complete were searched. Studies published 2004-2016 assessing the economic impact of medication error were included. Cost values were expressed in Euro 2015. A narrative synthesis was performed. RESULTS: A total of 4572 articles were identified from database searching, and 16 were included in the review. One study met all applicable quality criteria. Fifteen studies expressed economic impact in monetary terms. Mean cost per error per study ranged from €2.58 to €111 727.08. Healthcare costs were used to measure economic impact in 15 of the included studies with one study measuring litigation costs. Four studies included costs incurred in primary care with the remaining 12 measuring hospital costs. Five studies looked at general medication error in a general population with 11 studies reporting the economic impact of an individual type of medication error or error within a specific patient population. CONCLUSIONS: Considerable variability existed between studies in terms of financial cost, patients, settings and errors included. Many were of poor quality. Assessment of economic impact was conducted predominantly in the hospital setting with little assessment of primary care impact. Limited parameters were used to establish economic impact. Copyright © 2017 John Wiley & Sons, Ltd.

Since The Start Of The Vaccines For Children Program, Uptake Has Increased, And Most Disparities Have Decreased.

The Vaccines for Children program is a US government intervention aimed at increasing vaccination uptake by removing financial barriers that may prevent US children from accessing vaccinations. This study examined the impact that this intervention had on race and ethnicity-related and income-related disparities for diphtheria-tetanus-acellular pertussis, measles-mumps-rubella, and polio vaccinations, using data from the National Immunization Survey, 1995-2013. Vaccination rates increased across all races, ethnicities, and income groups following the introduction of the Vaccines for Children program. Disparities among race and ethnic groups narrowed considerably over time since the introduction of the vaccine program, although income-related disparities changed at different rates within racial and ethnic groups and in some cases increased. Government interventions aimed solely at reducing certain financial barriers to vaccination may fail to address other important aspects of cost or perceived benefits that influence vaccination uptake, especially among poorer children.

The prevalence, impact and cost of chronic non-cancer pain in Irish primary schoolchildren (PRIME-C): protocol for a longitudinal school-based survey.

INTRODUCTION: Previous research has indicated that pain influences children's daily lives, resulting in absence from school, sleep problems, poor school performance and problems with social activities. Our study aims to characterise the nature, extent, impact and cost of chronic pain among Irish children. METHODS AND ANALYSIS: Using cluster-systematic random sampling, primary schools will be invited to participate and 6000 5-12-year-olds asked to complete questionnaires in school classrooms, at time points 1 year apart. Questionnaires will use internationally valid psychometric measures to assess a range of quality of life factors and chronic pain indicators among children, with corresponding parental/primary caregiver questions, which will be completed at home. Data will also be gathered on the cost of chronic pain. Space will be given for comments on how pain impacts on participants' lives and possible coping mechanisms. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Research Ethics Committee, National University of Ireland, Galway. Dissemination of results will be via journal articles and conference presentations on the various aspects of the study (ie, prevalence, impact and economic cost of chronic pain among 5-12-year-olds living in Ireland).

Overweight and obesity on the island of Ireland: an estimation of costs.

OBJECTIVES: The increasing prevalence of overweight and obesity worldwide continues to compromise population health and creates a wider societal cost in terms of productivity loss and premature mortality. Despite extensive international literature on the cost of overweight and obesity, findings are inconsistent between Europe and the USA, and particularly within Europe. Studies vary on issues of focus, specific costs and methods. This study aims to estimate the healthcare and productivity costs of overweight and obesity for the island of Ireland in 2009, using both top-down and bottom-up approaches. METHODS: Costs were estimated across four categories: healthcare utilisation, drug costs, work absenteeism and premature mortality. Healthcare costs were estimated using Population Attributable Fractions (PAFs). PAFs were applied to national cost data for hospital care and drug prescribing. PAFs were also applied to social welfare and national mortality data to estimate productivity costs due to absenteeism and premature mortality. RESULTS: The healthcare costs of overweight and obesity in 2009 were estimated at €437 million for the Republic of Ireland (ROI) and €127.41 million for NI. Productivity loss due to overweight and obesity was up to €865 million for ROI and €362 million for NI. The main drivers of healthcare costs are cardiovascular disease, type II diabetes, colon cancer, stroke and gallbladder disease. In terms of absenteeism, low back pain is the main driver in both jurisdictions, and for productivity loss due to premature mortality the primary driver of cost is coronary heart disease. CONCLUSIONS: The costs are substantial, and urgent public health action is required in Ireland to address the problem of increasing prevalence of overweight and obesity, which if left unchecked will lead to unsustainable cost escalation within the health service and unacceptable societal costs.

An examination of the relationships between service use and alternative measures of obesity among community-dwelling adults in Ireland.

Obesity has received increased attention arising from its increasing prevalence and the implications of obesity-related problems for society and the wider economy. To estimate healthcare and non-healthcare obesity impacts, many studies rely on body mass index (BMI) as a measure of obesity. However BMI is considered to be a noisy measure of total body fat that unlike some other measures does not capture fat distribution. This study uses one such measure, the waist-to-hip ratio, as both an alternative and in conjunction with BMI in the estimation of the relationship between adiposity and health service use. The article uses data from a large-scale study of older adults living in Ireland (the Tilda data set). The findings indicate that studies that include both measures of general and central adiposity may provide a more comprehensive characterisation of the relationship between healthcare service use and adiposity.

Comparing the clinical-effectiveness and cost-effectiveness of an internet-delivered Acceptance and Commitment Therapy (ACT) intervention with a waiting list control among adults with chronic pain: study protocol for a randomised controlled trial.

INTRODUCTION: Internet-delivered psychological interventions among people with chronic pain have the potential to overcome environmental and economic barriers to the provision of evidence-based psychological treatment in the Irish health service context. While the use of internet-delivered cognitive-behavioural therapy programmes has been consistently shown to have small-to-moderate effects in the management of chronic pain, there is a paucity in the research regarding the effectiveness of an internet-delivered Acceptance and Commitment Therapy (ACT) programme among people with chronic pain. The current study will compare the clinical-effectiveness and cost-effectiveness of an online ACT intervention with a waitlist control condition in terms of the management of pain-related functional interference among people with chronic pain. METHODS AND ANALYSIS: Participants with non-malignant pain that persists for at least 3 months will be randomised to one of two study conditions. The experimental group will undergo an eight-session internet-delivered ACT programme over an 8-week period. The control group will be a waiting list group and will be offered the ACT intervention after the 3-month follow-up period. Participants will be assessed preintervention, postintervention and at a 3-month follow-up. The primary outcome will be pain-related functional interference. Secondary outcomes will include: pain intensity, depression, global impression of change, acceptance of chronic pain and quality of life. A qualitative evaluation of the perspectives of the participants regarding the ACT intervention will be completed after the trial. ETHICS AND DISSEMINATION: The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Ireland Galway Research Ethics Committee (12/05/05). The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN18166896.

Decomposing socioeconomic inequality in child vaccination: results from Ireland.

BACKGROUND: There is limited knowledge of the extent of or factors underlying inequalities in uptake of childhood vaccination in Ireland. This paper aims to measure and decompose socioeconomic inequalities in childhood vaccination in the Republic of Ireland. METHODS: The analysis was performed using data from the first wave of the Growing Up in Ireland survey, a nationally representative survey of the carers of over 11,000 nine-month old babies collected in 2008 and 2009. Multivariate analysis was conducted to explore the child and parental factors, including socioeconomic factors that were associated with non-vaccination of children. A concentration index was calculated to measure inequality in childhood vaccination. Subsequent decomposition analysis identified key factors underpinning observed inequalities. RESULTS: Overall the results confirm a strong socioeconomic gradient in childhood vaccination in the Republic of Ireland. Concentration indices of vaccination (CI=-0.19) show a substantial pro-rich gradient. Results from the decomposition analysis suggest that a substantial proportion of the inequality is explained by household level variables such as socioeconomic status, household structure, income and entitlement to publicly funded care (29.9%, 24% 30.6% and 12.9% respectively). Substantial differences are also observed between children of Irish mothers and immigrant mothers from developing countries. CONCLUSIONS: Vaccination was less likely in lower than in higher income households. Access to publicly funded services was an important factor in explaining inequalities.