Socioeconomic Inequality in Hearing Impairment Among Working-Age Australians: Evidence From a Cross-Sectional and Longitudinal Analyses.

OBJECTIVES: The objective of this study was to analyze the spatial and temporal association between socioeconomic gradient in hearing impairment among working-age Australians. DESIGN: We modeled the cross-sectional and longitudinal associations between individual- and area-level socioeconomic status (SES) and hearing impairment among working-age Australians using longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey for 10,719 working-age adults aged between 15 and 64 years surveyed between 2008 and 2018. Associations between self-reported hearing impairment and education, income, employment status, and area-level SES were estimated using a multivariate logistic regression model and Cox proportional hazards regression, controlling for age, sex, and a range of other sociodemographic factors. RESULTS: Among 10,719 participants, the prevalence of hearing impairment was higher among individuals with lower income, occupational status and socioeconomic disadvantage. The odds ratio (OR) of those with the lowest income quintile versus highest income quintile (OR = 2.10, 95% confidence interval [CI] = 1.40 to 3.14); for blue-collar occupation versus white-collar (OR = 1.92, 95% CI = 1.39 to 2.66) and most disadvantaged area quintile versus most advantaged area quintile (OR = 1.76, 95% CI = 1.10 to 2.83) were associated with higher odds of prevalence of hearing impairment. For the 10,046 participants without hearing loss at baseline, income quintile 1 versus quintile 5 (hazard ratio [HR] = 1.44, 95% CI = 1.33 to 1.56), ≤ year 11 versus ≥ bachelor's degree (HR = 2.15, 95% CI = 1.98-2.34) blue-collar occupation versus white collar (HR = 1.15, 95% CI = 1.07 to 1.25) and most disadvantaged area quintile versus most advantaged quintile (HR = 1.49, 95% CI = 1.37 to 1.63) was positively associated with incident hearing impairment. CONCLUSIONS: Lower individual-level and area-level SES was associated with an increased risk of prevalence and incidence of hearing impairment among working-age Australians. These findings are particularly concerning since working-age Australians are mostly not eligible for socially subsidized hearing-related health care in Australia. This lack of access to affordable hearing services could exacerbate the negative consequences of hearing impairment and increase social inequality.

A protocol for the Hearing impairment in Adults: A Longitudinal Outcomes Study (HALOS).

BACKGROUND: Often considered an "invisible disability", hearing loss is one of the most prevalent chronic diseases and the third leading cause for years lived with disability worldwide. Hearing loss has substantial impacts on communication, psychological wellbeing, social connectedness, cognition, quality of life, and economic independence. The Hearing impairment in Adults: a Longitudinal Outcomes Study (HALOS) aims to evaluate the: (1) impacts of hearing devices (hearing aids and/or cochlear implants), (2) differences in timing of these interventions and in long-term outcomes between hearing aid and cochlear implant users, and (3) cost-effectiveness of early intervention for adult-onset hearing loss among hearing device users. MATERIALS AND METHODS: HALOS is a mixed-methods study collecting cross-sectional and longitudinal data on health and social outcomes from 908 hearing aid and/or cochlear implant users aged ≥40 years, recruited from hearing service providers across Australia. The quantitative component will involve an online survey at baseline (time of recruitment), 24-months, and 48-months and will collect audiological, health, psychosocial, functional and employment outcomes using validated instruments. The qualitative component will be conducted in a subset of participants at baseline and involve semi-structured interviews to understand the patient journey and perspectives on the Australian hearing service model. ETHICS: This study has been approved by the Macquarie University Human Research Ethics Committee (ID: 11262) and Southern Adelaide Local Health Network (ID: LNR/22/SAC/88). Dissemination of results: Study findings will be disseminated to participants via a one-page summary, and to the public through publications in peer-reviewed journals and presentations at conferences. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry (ANZCTR) registration number: ACTRN12622000752763.

Mapping the Patient-Reported Outcomes Measurement Information System (PROMIS-29) to EQ-5D-5L.

BACKGROUND AND OBJECTIVE: The Patient-Reported Outcomes Measurement Information System (PROMIS-29) is gaining popularity as healthcare system funders increasingly seek value-based care. However, it is limited in its ability to estimate utilities and thus inform economic evaluations. This study develops the first mapping algorithm for estimating EuroQol 5-Dimension 5-Level (EQ-5D-5L) utilities from PROMIS-29 responses using a large dataset and through extensive comparisons between econometric models. METHODS: An online survey was conducted to collect responses to PROMIS-29 and EQ-5D-5L from the general Australian population (N = 3013). Direct and indirect mapping methods were explored, including linear regression, Tobit, generalised linear model, censored regression model, beta regression (Betamix), the adjusted limited dependent variable mixture model (ALDVMM) and generalised ordered logit. The most robust model was selected by assessing the performance based on average ten-fold cross-validation geometric mean absolute error and geometric mean squared error, the predicted mean, maximum and minimum utilities, as well as the fitting across the entire distribution. RESULTS: The direct approach using ALDVMM was considered the preferred model based on lowest geometric mean absolute error and geometric mean squared error in cross-validation (0.0882, 0.0299) and its superiority in predicting the actual observed mean, full health states and lower utility extremes. The robustness and precision in prediction across the entire distribution of utilities with ALDVMM suggest it is an accurate and valid mapping algorithm. Moreover, the suggested mapping algorithm outperformed previously published algorithms using Australian data, indicating the validity of this model for economic evaluations. CONCLUSIONS: This study developed a robust algorithm to estimate EQ-5D-5L utilities from PROMIS-29. Consistent with the recent literature, the ALDVMM outperformed all other econometric models considered in this study, suggesting that the mixture models have relatively better performance and are an ideal candidate model for mapping.

An examination of machine learning to map non-preference based patient reported outcome measures to health state utility values.

Non-preference-based patient-reported outcome measures (PROMs) are popular in health outcomes research. These measures, however, cannot be used to estimate health state utilities, limiting their usefulness for economic evaluations. Mapping PROMs to a multi-attribute utility instrument is one solution. While mapping is commonly conducted using econometric techniques, failing to specify the complex interactions between variables may lead to inaccurate prediction of utilities, resulting in inaccurate estimates of cost-effectiveness and suboptimal funding decisions. These issues can be addressed using machine learning. This paper evaluates the use of machine learning as a mapping tool. We adopt a comprehensive approach to compare six machine learning techniques with eight econometric techniques to map the Patient-Reported Outcomes Measurement Information System Global Health 10 (PROMIS-GH10) to the EuroQol five dimensions (EQ-5D-5L). Using data collected from 2015 Australians, we find the least absolute shrinkage and selection operator (LASSO) model out-performed all machine learning techniques and the adjusted limited dependent variable mixture model (ALDVMM) out-performed all econometric techniques, with the LASSO performing better than ALDVMM. The variable selection feature of LASSO was then used to enhance the performance of the ALDVMM in a hybrid model. Our analysis identifies the potential benefits and challenges of using machine learning techniques for mapping and offers important insights for future research.

An Economic Evaluation of Australia's Newborn Hearing Screening Program: A Within-Study Cost-Effectiveness Analysis.

OBJECTIVES: Hearing loss is one of the most prevalent congenital disorders among children. Many countries have implemented universal newborn hearing screening (UNHS) for the early diagnosis and treatment of hearing loss. Despite widespread implementation, the value for money of UNHS is unclear due to lack of cost and outcomes data from rigorous study designs. The objective of this research is to conduct a within-study cost-effectiveness analysis of UNHS compared with targeted screening (targeting children with risk factors of hearing loss) from the Australian healthcare system perspective. This evaluation is the first economic evaluation to assess the cost-effectiveness of UNHS compared to targeted screening using real-world data from a natural experiment. DESIGN: The evaluation assumed the Australian healthcare system perspective and considered a time horizon of 5 years. Utilities were estimated using responses to the Health Utilities Index Mark III. Screening costs were estimated based on the Victorian Infant Hearing Screening Program. Ongoing costs were estimated based on administrative data, while external data sources were used to estimate costs related to hearing services. Missing data were handled using the multiple imputation method. Outcome measures included quality-adjusted life years (QALYs) and four language and communication-related outcomes: Peabody Picture Vocabulary Test, Wechsler Nonverbal Scale of Ability, Progressive Achievement Test, and comprehensive, expressive, and total language scores based on the Preschool Language Scale. RESULTS: On average, the UNHS cost an extra Australian dollar (A$)22,000 per diagnosed child and was associated with 0.45 more QALYs per diagnosed child compared with targeted screening to 5 years, resulting in an incremental cost-effectiveness ratio (ICER) of A$48,000 per QALY gained. The ICERs for language outcomes lay between A$3,900 (for expressive language score) and A$83,500 per one-point improvement in language score (for Wechsler Nonverbal Scale of Ability). UNHS had a 69% probability of being more cost-effective compared to targeted screening at a willingness to pay threshold of A$60,000 per QALY gained. ICERs were most sensitive to the screening costs. CONCLUSIONS: The evaluation demonstrated the usefulness of a within-study economic evaluation to understand the value for money of the UNHS program in the Australian context. Findings from this evaluation suggested that screening costs were the key driver of cost-effectiveness results. Most outcomes were not significantly different between UNHS and targeted screening groups. The ICER may be overestimated due to the short follow-up period. Further research is warranted to include long-term resource use and outcome data, late diagnosis, transition and remission between severity levels, and timing of diagnosis and treatment.

Do socioeconomic health gradients persist over time and beyond income? A distributional analysis using UK biomarker data.

This paper analyses the relationship between health and socioeconomic disadvantage by adopting a dynamic approach accounting for spatial and temporal changes across ten domains including social isolation, environment, financial hardship and security. As a first step we develop a measure of overall multidimensional deprivation and undertake a decomposition analysis to explore the role of breadth and duration of deprivation on shaping the deprivation gradient in health. Subsequently, we employ unconditional quantile regression to conduct a distributional analysis of the gradient to understand how the gradient evolves for people with vulnerability in health. In contrast to the majority of existing studies, we capture health status using a range of nurse measured biomarkers, rather than self reported health measures, taken from the UKHLS and BHPS databases. The first main finding is that the socioeconomic gradient in most of our health measures is not solely attributed to income as it accounts for only 3.8% of total deprivation and thus it is important to account for other domains through a multidimensional deprivation measure in health gradient analysis. Our second finding is the existence of a systematic deprivation gradient for BMI, waist circumference, heart rate, C-reactive protein and HbA1c where evolution over time is an important factor particularly for individuals with greater burden of illness lying at the right tail of the biomarker distribution. Thus cost effective health policy would need to adopt targeted interventions prioritising people experiencing persistent deprivation in dimensions such as housing conditions and social isolation.

The impact of introducing a national scheme for paid parental leave on maternal mental health outcomes.

Paid maternity leave is an essential component of a progressive society. It can enhance postnatal health, improve mother and child wellbeing, and deliver better labor market outcomes for mothers. We evaluate the impact of the introduction of Australia's national Paid Parental Leave (PPL) scheme in 2011 and complementary Dad and Partner Pay (DAPP) in 2013 on maternal mental health. Using a sample of 1480 births to eligible, partnered women between 2004 and 2016 and examining a range of mental health outcomes from the Household, Income, andLabour Dynamics in Australia survey, we find depression likelihood reduced significantly in post-reform years. When focusing on post-DAPP years and women whose partners had concurrent access to DAPP, significant mental health improvements were found across a wider range of measures including the Mental Component Summary score and specific Short Form-36 items with a high sensitivity for detecting major depression. Subgroup analysis suggests significant improvements applied specifically to first-time mothers and mothers with employer-paid maternity leave and unpaid leave entitlements. These results suggest that an increase in PPL and DAPP entitlements for mothers without access to employer-paid and unpaid leave entitlements, particularly those in less secure employment, may further reduce postnatal depression and improve health equity in Australia.

Mapping the Strengths and Difficulties Questionnaire onto the Child Health Utility 9D in a large study of children.

PURPOSE: Non-preference-based measures cannot be used to directly obtain utilities but can be converted to preference-based measures through mapping. The only mapping algorithm for estimating Child Health Utility-9D (CHU9D) utilities from Strengths and Difficulties Questionnaire (SDQ) responses has limitations. This study aimed to develop a more accurate algorithm. METHODS: We used a large sample of children (n = 6898), with negligible missing data, from the Longitudinal Study of Australian Children. Exploratory factor analysis (EFA) and Spearman's rank correlation coefficients were used to assess conceptual overlap between SDQ and CHU9D. Direct mapping (involving seven regression methods) and response mapping (involving one regression method) approaches were considered. The final model was selected by ranking the performance of each method by averaging the following across tenfold cross-validation iterations: mean absolute error (MAE), mean squared error (MSE), and MAE and MSE for two subsamples where predicted utility values were < 0.50 (poor health) or > 0.90 (healthy). External validation was conducted using data from the Child and Adolescent Mental Health Services study. RESULTS: SDQ and CHU9D were moderately correlated (ρ = - 0.52, p < 0.001). EFA demonstrated that all CHU9D domains were associated with four SDQ subscales. The best-performing model was the Generalized Linear Model with SDQ items and gender as predictors (full sample MAE: 0.1149; MSE: 0.0227). The new algorithm performed well in the external validation. CONCLUSIONS: The proposed mapping algorithm can produce robust estimates of CHU9D utilities from SDQ data for economic evaluations. Further research is warranted to assess the applicability of the algorithm among children with severe health problems.

Pricing as a means of controlling alcohol consumption.

Background: Reducing the affordability of alcohol, by increasing its price, is the most effective strategy for controlling alcohol consumption and reducing harm. Sources of data: We review meta-analyses and systematic reviews of alcohol tax/price effects from the past decade, and recent evaluations of tax/price policies in the UK, Canada and Australia. Areas of agreement: While the magnitudes of price effects vary by sub-group and alcoholic beverage type, it has been consistently shown that price increases lead to reductions in alcohol consumption. Areas of controversy: There remains, however, a lack of consensus on the most appropriate taxation and pricing policy in many countries because of concerns about effects by different consumption level and income level and disagreement on policy design between parts of the alcoholic beverage industries. Growing points: Recent developments in the research highlight the importance of obtaining accurate alcohol price data, reducing bias in estimating price responsiveness, and examining the impact on the heaviest drinkers. Areas timely for developing research: There is a need for further research focusing on the substitution effects of taxation and pricing policies, estimation of the true tax pass-through rates, and empirical analysis of the supply-side response (from alcohol producers and retailers) to various alcohol pricing strategies.

The Effect of Introducing a Minimum Price on the Distribution of Alcohol Purchase: A Counterfactual Analysis.

We use counterfactual analysis techniques to evaluate the impact of a $2 minimum unit price (MUP) on the distribution of Australian (Victorian) household off-trade alcohol purchases. Our estimates suggest that a $2 MUP significantly reduces the purchases of at-risk households by up to -0.92 [90% CI: -1.55, -0.28] standard drinks at the highest quantiles and has substantially less effect on households purchasing at light and moderate levels. A $2 MUP may reduce the proportions of male and female shoppers purchasing at the public health threshold of more than two standard drinks per household member per day by -3.03 [90% CI: -4.83, -1.22] percentage points (relative variation: -17%); and -1.85 [90% CI: -2.60, -1.10] percentage points (relative variation:-22%), respectively. Implementing an MUP on alcohol thus promises significant positive impacts on public health. Copyright © 2016 John Wiley & Sons, Ltd.

A longitudinal study of the cost of food in Victoria influenced by geography and nutritional quality.

OBJECTIVE: To monitor the cost and affordability of a nutritious diet and to assess the influence of distance from the capital city and socioeconomic status on the cost of nutritious food in Victoria. METHODS: Twenty-six of Victoria's 79 local government areas (33%) were randomly chosen for inclusion in the study. A random sample of stores was selected for inclusion from each local government area. The cost of the 44 'healthy' and 10 'discretionary' food and drinks in the healthy food basket for a family of four for a fortnight was collected during the winter and summer of 2012, 2013 and 2014. RESULTS: The mean cost of the basket increased from $424.06 ± 38.22 in winter 2012 to $451.19 ± 33.83 in summer 2014 (p<0.001), representing about 31% of government benefit household income. Fruit and vegetables prices were the most varied over time. Distance of the store from state capital city centre predicted difference in food cost. CONCLUSIONS: These findings show that a healthy diet may be unaffordable for some Victorians. IMPLICATIONS: The cost of food is a key factor influencing intake. Public health strategies may need to consider strategies to make healthy food more affordable for some.

Modelling utility weights for the Assessment of Quality of Life (AQoL)-8D.

PURPOSE: The objective of this paper is to describe the four-stage methodology used to obtain utility scores for the Assessment of Quality of Life (AQoL)-8D, a 35-item 8 dimension multi-attribute utility instrument, which was created to achieve a high degree of sensitivity to psycho-social health. METHODS: Data for the analyses were obtained from a representative group of 347 members of the Australian public and from 323 mental health patients each of whom provided VAS and time trade-off valuations of multiple health states. Data were used initially to create multiplicative scoring algorithms for each of the instrument's 8 dimensions and for the overall instrument. Each of the algorithms was then subject to a second-stage econometric 'correction'. RESULTS: Algorithms were successfully created for each of the AQoL-8D's dimensions, for physical and mental 'super-dimensions' and for the overall AQoL-8D instrument. The final AQoL-8D algorithm has good predictive power with respect to the TTO valuations. CONCLUSIONS: The AQoL-8D is a suitable instrument for researchers conducting cost utility analyses generally but, in particular, for the analysis of services affecting psycho-social health.

An instrument for measuring the social willingness to pay for health state improvement.

This paper describes an instrument for measuring the social value of changes in health status, the Relative Social Willingness to Pay. It is a unique combination of measurement attributes designed to minimise cognitive complexity and provide an additional option for measuring 'social value'. Similar to the person trade-off (PTO), it adopts a social perspective and asks respondents to evaluate programmes on behalf of society. Unlike the PTO, trade-offs between the options use dollars, not numbers of patients. Respondents are not, however, asked for their personal willingness to pay. Rather, the opportunity cost of funds spent on one service is as an offsetting reduction in funds for a second service. The amount spent on each service therefore indicates relative, not absolute, value. However, the two services combine to produce one Quality adjusted life year which allows the calculation of a Quality adjusted life year-like unit of social value on a 0-1 scale. A three-stage survey was used to test the instrument's reliability, validity and sensitivity to the framing of the main question. Results indicate that the Relative Social Willingness to Pay produces values similar to but less than the PTO and time trade-off techniques.

Maximising health versus sharing: measuring preferences for the allocation of the health budget.

Empirical evidence indicates that people consider sharing health resources to be important even in the absence of the attributes usually associated with equity (age, social class, ethnicity, disease severity or geographic location). If government is to take account of these preferences then survey methods are needed which allow their measurement. The present paper presents a new technique for measuring these preferences and reports the results of a representative survey of 626 Australians which employed the technique. The online and postal survey did not include any of the attributes usually associated with equity but was designed to quantify the respective importance of sharing life years (outcome egalitarianism), resource sharing per se and the changing importance of total health as other attributes varied. Results indicate respondents were primarily concerned with outcome egalitarianism, and that cost per life year had a relatively small effect upon their allocative decisions.

Utility weights for the vision-related Assessment of Quality of Life (AQoL)-7D instrument.

PURPOSE: To obtain utility weights consistent with the needs of economic evaluation for the Assessment of Quality of Life (AQoL)-7D, a generic instrument created to increase the sensitivity of the measurement of quality of life amongst people with impaired vision. METHODS: Two extant instruments were combined, the Vision-related Quality of Life Index (VisQoL) and the AQoL-6D. Utilities were obtained from patients with visual impairment and from the general population using time trade-off (TTO) methodology. Dimensions were combined and an econometric adjustment used to eliminate the effects of instrument redundancy. Bias was tested by comparison of holistic TTO values with utility scores predicted from the AQoL-7D scoring formula. RESULTS: The AQoL-7D instrument consists of 26 items and 7 dimensions each with good psychometric properties. Their combination into a single instrument resulted in significant redundancy which was successfully eliminated. Utility formulae for both the public and patients produced bias-free estimates of the utility of holistic health states describing visual impairment. Results imply differing valuations of health states by the public and by people with impaired vision. CONCLUSIONS: The AQoL-7D can detect changes in health states affecting people with impaired vision which are likely to be overlooked by other generic instruments due to content insensitivity. The utilities it produces are generated using a "mainstream" methodology, the TTO. Quality-adjusted life year values based on the AQoL-7D may therefore be used for economic evaluation of programs.

Interaction between HIV awareness, knowledge, safe sex practice and HIV prevalence: evidence from Botswana.

This paper makes methodological and empirical contributions to the study of HIV in the context of Botswana, a country with high HIV prevalence. Comparable evidence is presented from India to put the Botswana results in perspective. The results point to the strong role played by affluence and education in increasing HIV knowledge, promoting safe sex and reducing HIV prevalence. The study presents African evidence on the role played by the empowerment of women in promoting safe sex practices such as condom use. The lack of significant association between HIV prevalence and safe sex practice points to the danger of HIV-infected individuals spreading the disease through multiple sex partners and unprotected sex. This danger is underlined by the finding that females with multiple sex partners are at higher risk of being infected with HIV. These results take on special policy significance in the context of Botswana, where the issue of multiple sex partners has not been adequately addressed in the programme to contain the spread of HIV.

Measuring the multi-dimensional knowledge deprivation of HIV/AIDS: a new approach with Indian evidence on its magnitude and determinants.

Though HIV/AIDS poses serious risks to economic security, there is very little economics literature quantifying awareness and knowledge of this disease and their principal socioeconomic determinants. This is what the present study attempts to do in the context of India, which faces a significant threat from HIV/AIDS. The study is based on India's National Family Health Surveys covering the period of economic reforms and beyond. The contribution is both methodological and empirical. The study shows that the recent multi-dimensional deprivation approach to poverty can also be used to measure and analyse awareness and lack of knowledge of HIV/AIDS. The use of decomposable multi-dimensional measures helps in identifying regions, socioeconomic groups and aspects of HIV knowledge that should be targeted in policy interventions. The study identifies the importance of safe sex practices as an area that needs to be targeted in future information campaigns. The study also explores the impact of increased female autonomy in health and economic decision-making on their and their partners' knowledge of the disease, along with a host of other economic and demographic determinants.

Predicting time trade-off health state valuations of adolescents in four Pacific countries using the Assessment of Quality-of-Life (AQoL-6D) instrument.

OBJECTIVES: Pacific Obesity Prevention in Communities (OPIC) is a community-based intervention project targeting adolescent obesity in Australia, New Zealand, Fiji, and Tonga. The Assessment of Quality of Life Mark 2 (AQoL-6D) instrument was completed by 15,481 adolescents to obtain a description of the quality of life associated with adolescent overweight and obesity, and a corresponding utility score for use in a cost-utility analysis of the interventions. This article describes the recalibration of this utility instrument for adolescents in each country. METHODS: The recalibration was based on country-specific time trade-off (TTO) data for 30 multiattribute health states constructed from the AQoL-6D descriptive system. Senior secondary students, in a classroom setting, responded to 10 health state scenarios each. These TTO interviews were conducted for 24 groups, comprising 279 students in the four countries resulting in 2790 completed TTO scores. The TTO scores were econometrically transformed by regressing the TTO scores upon predicted scores from the AQoL-6D to produce country-specific algorithms. The latter incorporated country-specific "corrections" to the Australian adult utility weights in the original AQoL. RESULTS: This article reports two methodological elements not previously reported. The first is the econometric modification of an extant multi-attribute utility instrument to accommodate cultural and other group-specific differences in preferences. The second is the use of the TTO technique with adolescents in a classroom group setting. Significant differences in utility scores were found between the four countries. CONCLUSION: Statistical results indicate that the AQoL-6D can be validly used in the economic evaluation of both the OPIC interventions and other adolescent programs.