Mental health-related service and medicine use among a cohort of urban Aboriginal children and young people: Data linkage study.

OBJECTIVE: The objective was to describe mental health service and psychotropic medicine use among a cohort of Aboriginal young people and quantify their relation to sociodemographic, family and health factors. METHODS: In a prospective cohort study with data linkage, 892 Aboriginal children aged 0-17 years living in urban and regional areas of New South Wales, Australia, were included. We assessed mental health-related service use, paediatric service use and psychotropic medicine dispensing claims covered by the Australian Government Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme from July 2012 to June 2017. RESULTS: Most children (71%) did not have a record of mental health service or psychotropic medication use. 18.7% had ⩾1 mental health-related service claim; 26.7% had ⩾1 paediatric service claim; and 20.3% had ⩾1 psychotropic medicine dispensing claim. General practitioner services were the most accessed mental health-related service (17.4%) and 12.7% had been dispensed attention-deficit hyperactivity disorder medicines. Child characteristics associated with treatment included emotional and behavioural problems (prevalence ratio: 1.97, 95% confidence interval = [1.46, 2.64] for mental health services; prevalence ratio: 2.87, 95% confidence interval = [2.07, 3.96] for medicines) and risky behaviour (prevalence ratio: 1.56, 95% confidence interval = [1.12, 2.16] for mental health services; prevalence ratio: 2.28, 95% confidence interval = [1.54, 3.37] for medicines). Parent-related factors included chronic illness (prevalence ratio: 1.42, 95% confidence interval = [1.03, 1.95] for mental health services; prevalence ratio: 2.00, 95% confidence interval = [1.49, 2.69] for medicines) and functional limitations (prevalence ratio: 1.61, 95% confidence interval = [1.16, 2.24] for mental health services; prevalence ratio: 1.86, 95% confidence interval = [1.34, 2.59] for medicines). CONCLUSIONS: Most Aboriginal children and young people did not have claims for mental health services or medicines. Aboriginal children with emotional and behavioural problems, or parents with health problems were more likely to have mental health service or medicine claims.

Ear health and hearing in urban Aboriginal children.

OBJECTIVE: Evaluate ear health and hearing among urban Aboriginal children and quantify relationships with child, family and social factors. METHODS: Baseline questionnaire and ear health examinations from 1430 children with diagnoses (0.5-18 years) attending Aboriginal Health Services enrolled in SEARCH. Ear health outcomes were Otitis Media (OM), and hearing loss (three-frequency average hearing loss >20dB) diagnosed using pneumatic otoscopy, tympanometry, and audiometry. RESULTS: Half the children 0.5-3 years had OM (51.5%, 136/264). One third 0.5-18 years (30.4%; 435/1430) had OM, including 1.8% (26/1430) with perforation (0.8% chronic suppurative OM, 0.6% dry perforation and 0.4% acute OM with perforation). One quarter 0.5-18 years (25.7%; 279/1087) had hearing loss; 12.4% unilateral, 13.2% bilateral (70.6% with bilateral loss had concurrent OM). OM was associated with: younger age (0.5-<3 years versus 6-18 years) age-sex-site; adjusted prevalence ratio (aPR)=2.64, 95%, 2.18-3.19); attending childcare/preschool (aPR=1.24, 95%CI, 1.04-1.49); foster care (aPR=1.40, 95%CI, 1.10-1.79); previous ear infection/s (aPR=1.68, 95%CI, 1.42-1.98); and ≥2 people/bedroom (aPR=1.66, 95%CI, 1.24-2.21). Hearing impairment was associated with younger age (0.5-<6 years vs. ≥6 years aPR=1.89, 95%CI, 1.40-2.55) and previous ear infection (aPR=1.87, 95%CI, 1.31-2.68). CONCLUSIONS: Half the urban Aboriginal children in this cohort had OM and two-thirds with hearing impairment had OM. IMPLICATIONS FOR PUBLIC HEALTH: Findings highlight importance of early detection and support for ear health, particularly in pre-school-aged children with risk factors.

Social acceptability of standard and behavioral economic inspired policies designed to reduce and prevent obesity.

The obesity epidemic is a significant public policy issue facing the international community, resulting in substantial costs to individuals and society. Various policies have been suggested to reduce and prevent obesity, including those informed by standard economics (a key feature of which is the assumption that individuals are rational) and behavioral economics (which identifies and harness deviations from rationality). It is not known which policy interventions taxpayers find acceptable and would prefer to fund via taxation. We provide evidence from a discrete choice experiment on an Australian sample of 996 individuals to investigate social acceptability of eight policies: mass media campaign; traffic light nutritional labeling; taxing sugar sweetened beverages; prepaid cards to purchase healthy food; financial incentives to exercise; improved built environment for physical activity; bans on advertising unhealthy food and drink to children; and improved nutritional quality of food sold in public institutions. Latent class analysis revealed three classes differing in preferences and key respondent characteristics including capacity to benefit. Social acceptability of the eight policies at realistic levels of tax increases was explored using post-estimation analysis. Overall, 78% of the sample were predicted to choose a new policy, varying from 99% in those most likely to benefit from obesity interventions to 19% of those least likely to benefit. A policy informed by standard economics, traffic light labeling was the most popular policy, followed by policies involving regulation: bans on junk food advertising to children and improvement of food quality in public institutions. The least popular policies were behaviorally informed: prepaid cards for the purchase of only healthy foods, and financial incentives to exercise.

Asthma in urban Aboriginal children: A cross-sectional study of socio-demographic patterns and associations with pre-natal and current carer smoking.

AIM: To describe socio-demographic patterns of asthma prevalence in urban Aboriginal children and quantify associations between asthma prevalence and pre-natal maternal and current carer smoking. METHODS: Analyses used carer-reported survey data for 1290 urban Aboriginal children aged 2-17 years from the Study of Environment on Aboriginal Resilience and Child Health. Multilevel log-binomial regression was used to estimate asthma prevalence ratios (PRs) for child- and family-level socio-demographic factors, pre-natal maternal smoking and current carer smoking. Smoking-related PRs were compared with general-population estimates derived from meta-analyses of published cross-sectional data. RESULTS: Overall, 33.9% of children had ever had asthma, and 12.9% had received treatment for asthma in the past month. Prevalence estimates declined with increasing household income and increasing household size (posterior probabilities of decreasing trend >0.98), while children exposed to pre-natal maternal smoking had a higher risk of asthma ever than unexposed children (PR 1.18 (95% credible interval 1.00-1.40)). Recently treated asthma prevalence was not significantly associated with pre-natal maternal (0.98 (0.71-1.41)) or current carer smoking (0.97 (0.68-1.37)); however, there was substantial uncertainty in our PR estimates, and 95% credible intervals contained general-population estimates derived from the meta-analyses (1.37 (1.17-1.65) for pre-natal smoking, 1.28 (1.15-1.44) for current parental or household smoking). CONCLUSION: Among urban Aboriginal children in the Study of Environment on Aboriginal Resilience and Child Health cohort, asthma prevalence declines as household income and household size increase, while children exposed to pre-natal maternal smoking are at increased risk of ever having asthma. Our results emphasise the importance of reducing smoking in Aboriginal communities, particularly among pregnant women.

Developmental risk among Aboriginal children living in urban areas in Australia: the Study of Environment on Aboriginal Resilience and Child Health (SEARCH).

BACKGROUND: Most Australian Aboriginal children are on track with their development, however, the prevalence of children at risk of or with a developmental or behavioural problem is higher than in other children. Aboriginal child development data mostly comes from remote communities, whereas most Aboriginal children live in urban settings. We quantified the proportion of participating children at moderate and high developmental risk as identified by caregivers' concerns, and determined the factors associated with developmental risk among urban Aboriginal communities. METHODS: Study methods were co-designed and implemented with four participating urban Aboriginal Community Controlled Health Services in New South Wales, Australia, between 2008 and 2012. Caregiver-reported data on children < 8 years old enrolled in a longitudinal cohort study (Study of Environment on Aboriginal Resilience and Child Health: SEARCH) were collected by interview. The Parents' Evaluation of Developmental Status (PEDS) was used to assess developmental risk through report of caregiver concerns. Odds ratios (OR) were calculated using multinomial logistic regression to investigate risk factors and develop a risk prediction model. RESULTS: Of 725 children in SEARCH with PEDS data (69% of eligible), 405 (56%) were male, and 336 (46%) were aged between 4.5 and 8 years. Using PEDS, 32% were at high, 28% moderate, and 40% low/no developmental risk. Compared with low/no risk, factors associated with high developmental risk in a mutually-adjusted model, with additional adjustment for study site, were male sex (OR 2.42, 95% confidence intervals 1.62-3.61), being older (4.5 to < 8 years versus < 3 years old, 3.80, 2.21-6.54), prior history of ear infection (1.95, 1.21-3.15), having lived in 4 or more houses versus one house (4.13, 2.04-8.35), foster care versus living with a parent (5.45, 2.32-12.78), and having a caregiver with psychological distress (2.40, 1.37-4.20). CONCLUSION: In SEARCH, 40% of urban Aboriginal children younger than 8 years were at no or low developmental risk. Several factors associated with higher developmental risk were modifiable. Aboriginal community-driven programs to improve detection of developmental problems and facilitate early intervention are needed.

Validation of a novel diabetic retinopathy utility index using discrete choice experiments.

BACKGROUND/AIMS: To validate a preference-based Diabetic Retinopathy Utility Index (DRU-I) using discrete choice experiment (DCE) methods and assess disutilities associated with vision-threatening DR (VTDR: severe non-proliferative DR, proliferative DR and clinically significant macular oedema) and associated vision impairment. METHODS: The DRU-I comprises five quality-of-life dimensions, including Visual symptoms, Activity limitation/mobility, Lighting and glare, Socio-emotional well-being and Inconvenience, each rated as no, some, or a lot of difficulty. The DRU-I was developed using a DCE comprising six blocks of nine choice sets which, alongside the EuroQoL-5D (EQ-5D-3L) and Vision and Quality of Life (VisQoL) utility instruments, were interviewer-administered to participants. To ensure the DRU-I was sensitive to severe disease, we oversampled patients with VTDR. Data were analysed using conditional logit regression. RESULTS: Of the 220 participants (mean±SD age 60.1±11.3 years; 70.9% men), 57 (29.1%) and 139 (70.9%) had non-VTDR and VTDR, respectively, while 157 (71.4%), 20 (9.4%) and 37 (17.3%) had no, mild or moderate/severe vision impairment, respectively. Regression coefficients for all dimensions were ordered as expected, with worsening levels in each dimension being less preferred (theoretical validity). DRU-I utilities decreased as DR severity (non-VTDR=0.87; VTDR=0.80; p=0.021) and better eye vision impairment (none=0.84; mild=0.78; moderate/severe=0.72; p=0.012) increased. DRU-I utilities had low (r=0.39) and moderate (r=0.58) correlation with EQ-5D and VisQoL utilities, respectively (convergent validity). DISCUSSION: The DRU-I can estimate utilities associated with vision-threatening DR and associated vision impairment. It has the potential to assess the cost-effectiveness of DR interventions from a patient perspective and inform policies on resource allocation relating to DR.

Agreement between diagnoses of otitis media by audiologists and otolaryngologists in Aboriginal Australian children.

OBJECTIVES: To determine the degree of agreement of diagnoses by audiologists and otolaryngologists of otitis media (OM) in Aboriginal children. DESIGN: Cross-sectional study of agreement between diagnoses. SETTING: Study of Environment on Aboriginal Resilience and Child Health (SEARCH), a prospective cohort study of Aboriginal children attending four Aboriginal Community Controlled Health Services in New South Wales (three metropolitan, one regional) during 2008-2012. PARTICIPANTS: 1310 of 1669 SEARCH participants (78.5%; mean age, 7.0 years; SD, 4.4 years) were assessed and received a diagnosis from one of five experienced audiologists. Test results (but not case histories) were forwarded to one of three otolaryngologists for blinded independent assessment. MAIN OUTCOME MEASURES: Agreement of OM diagnoses by audiologists and otolaryngologists at ear and child levels; correctness of audiologist diagnoses (otolaryngologist diagnosis as reference). RESULTS: Paired diagnoses by audiologists and otolaryngologists were available for 863 children at the child level and 1775 ears (989 children) at the ear level. Otolaryngologists diagnosed OM in 251 children (29.1%), including 11 (1.3%) with tympanic membrane perforation, and in 396 ears (22.3%), including 12 (0.7%) with perforation. Agreement between audiologists and otolaryngologists for OM at the ear level was 92.2% (κ = 0.78; 95% CI, 0.74-0.82), and at the child level 91.7% (κ = 0.81; 95% CI, 0.77-0.85). No otolaryngologist-diagnosed perforation was missed by audiologists. Among 1000 children triaged by an audiologist, there would be 45 false positives and 30 false negatives when compared with assessments by an otolaryngologist, with no missed perforations. CONCLUSIONS: There was substantial agreement between audiologists' and otolaryngologists' diagnoses of OM in a high prevalence population of Aboriginal children. In settings with limited access to otolaryngologists, audiologists may appropriately triage children and select those requiring specialist review.

Relation of child, caregiver, and environmental characteristics to childhood injury in an urban Aboriginal cohort in New South Wales, Australia.

OBJECTIVE: Despite being disproportionately affected by injury, little is known about factors associated with injury in Aboriginal children. We investigated factors associated with injury among urban Aboriginal children attending four Aboriginal Community Controlled Health Services in New South Wales, Australia. METHODS: We examined characteristics of caregiver-reported child injury, and calculated prevalence ratios of 'ever-injury' by child, family, and environmental factors. RESULTS: Among children in the cohort, 29% (n=373/1,303) had ever broken a bone, been knocked out, required stitches or been hospitalised for a burn or poisoning; 40-78% of first injuries occurred at home and 60-91% were treated in hospital. Reported ever-injury was significantly lower (prevalence ratio ≤0.80) among children who were female, younger, whose caregiver had low psychological distress and had not been imprisoned, whose family experienced few major life events, and who hadn't experienced alcohol misuse in the household or theft in the community, compared to other cohort members. CONCLUSIONS: In this urban Aboriginal child cohort, injury was common and associated with measures of family and community vulnerability. Implications for public health: Prevention efforts targeting upstream injury determinants and Aboriginal children living in vulnerable families may reduce child injury. Existing broad-based intervention programs for vulnerable families may present opportunities to deliver targeted injury prevention.

The influence of asthma control on psychosocial outcomes for pregnant women with asthma.

OBJECTIVE: To investigate the relationship between asthma control and psychosocial outcomes in pregnant women with asthma. METHODS: Secondary analysis (N = 221) of a randomized controlled trial of treatment adjustments, based on fractional exhaled nitric oxide versus clinical guideline-based algorithms. Psychosocial variables included generic and asthma-specific quality of life (SF12, AQLQ-M), illness perceptions (BIPQ), perceived control (PCAQ), perceived risk of side effects (PRSE) and anxiety (STAI-6). Asthma control was defined as controlled (Asthma Control Questionnaire (ACQ7) ≤1.5 at randomization and end of study), improved (ACQ7 > 1.5 at randomization and ≤1.5 at end of study) and unimproved (ACQ7 >1.5 at end of study). Regression models were fitted for each psychosocial measure at the end of the study, with adjustment for baseline values and smoking status, with predictor variable asthma control. RESULTS: Women with unimproved asthma had poorer physical (SF12, p = 0.012) and asthma-specific quality of life across all domains (AQLQ-M, p ≤ 0.012) compared to women with controlled asthma. They believed that they had less control over their asthma (PCAQ total p = 0.014), had more symptoms and that their illness had a greater effect on their emotions and their lives in general (BIPQ identity, consequences, concern, emotional response p ≤ 0.015). Women with improved asthma control had significantly lower AQLQ-M breathlessness (p = 0.048) and lower total scores (p = 0.04) than women with controlled asthma. CONCLUSIONS: Pregnant women who are not able to get control of their asthma symptoms may experience worse quality of life and are likely to have more negative perceptions about their condition.

Valuing SF-6D Health States Using a Discrete Choice Experiment.

BACKGROUND: SF-6D utility weights are conventionally produced using a standard gamble (SG). SG-derived weights consistently demonstrate a floor effect not observed with other elicitation techniques. Recent advances in discrete choice methods have allowed estimation of utility weights. The objective was to produce Australian utility weights for the SF-6D and to explore the application of discrete choice experiment (DCE) methods in this context. We hypothesized that weights derived using this method would reflect the largely monotonic construction of the SF-6D. METHODS: We designed an online DCE and administered it to an Australia-representative online panel (n = 1017). A range of specifications investigating nonlinear preferences with respect to additional life expectancy were estimated using a random-effects probit model. The preferred model was then used to estimate a preference index such that full health and death were valued at 1 and 0, respectively, to provide an algorithm for Australian cost-utility analyses. RESULTS: Physical functioning, pain, mental health, and vitality were the largest drivers of utility weights. Combining levels to remove illogical orderings did not lead to a poorer model fit. Relative to international SG-derived weights, the range of utility weights was larger with 5% of health states valued below zero. CONCLUSION: s. DCEs can be used to investigate preferences for health profiles and to estimate utility weights for multi-attribute utility instruments. Australian cost-utility analyses can now use domestic SF-6D weights. The comparability of DCE results to those using other elicitation methods for estimating utility weights for quality-adjusted life-year calculations should be further investigated.

Best worst discrete choice experiments in health: methods and an application.

A key objective of discrete choice experiments is to obtain sufficient quantity of high quality choice data to estimate choice models to be used to explore various policy/clinically relevant issues. This paper focuses on a relatively new form of choice experiment, 'Best Worst Discrete Choice Experiments' (BWDCEs) and their relevance to health research as a new way to meet such an objective. We explain what BWDCEs are, how and when to apply them and we present several analytical approaches to model the resulting data. We demonstrate this preference elicitation approach in an empirical application exploring preferences of 898 members of the general public in Edmonton and Calgary, Canada for treatment of cardiac arrest occurring in a public place and show the gains achieved compared to traditional analysis of first best data. We suggest that BWDCEs are a valuable way to investigate preferences in the health sector and discuss implications for task design, analysis and areas for future research.

Is the Nintendo Wii Fit really acceptable to older people? A discrete choice experiment.

BACKGROUND: Interactive video games such as the Nintendo Wii Fit are increasingly used as a therapeutic tool in health and aged care settings however, their acceptability to older people is unclear. The aim of this study was to determine the acceptability of the Nintendo Wii Fit as a therapy tool for hospitalised older people using a discrete choice experiment (DCE) before and after exposure to the intervention. METHODS: A DCE was administered to 21 participants in an interview style format prior to, and following several sessions of using the Wii Fit in physiotherapy. The physiotherapist prescribed the Wii Fit activities, supervised and supported the patient during the therapy sessions. Attributes included in the DCE were: mode of therapy (traditional or using the Wii Fit), amount of therapy, cost of therapy program and percentage of recovery made. Data was analysed using conditional (fixed-effects) logistic regression. RESULTS: Prior to commencing the therapy program participants were most concerned about therapy time (avoiding programs that were too intensive), and the amount of recovery they would make. Following the therapy program, participants were more concerned with the mode of therapy and preferred traditional therapy programs over programs using the Wii Fit. CONCLUSIONS: The usefulness of the Wii Fit as a therapy tool with hospitalised older people is limited not only by the small proportion of older people who are able to use it, but by older people's preferences for traditional approaches to therapy. Mainstream media portrayals of the popularity of the Wii Fit with older people may not reflect the true acceptability in the older hospitalised population.

Tasmanian landowner preferences for conservation incentive programs: a latent class approach.

An empirical model of landowners' conservation incentive program choice is developed in which information about landowners' socio-economic and property characteristics and their attitudes, is combined with incentive program attributes. In a Choice survey landowners were presented with the choice of two incentive programs modelled as 'bundles of attributes' mimicking a voluntary choice scenario. Landowner behaviour and decision and the type of conditions and regulations they preferred were analyzed. Based on choice survey data, landowner heterogeneity was accounted for using a latent class approach to estimate the preference parameters. Three latent classes of landowners with different attitudes to the role and outcome of establishing conservation reserves on private land were identified: multi-objective owners; environment owners; and production owners. Only a small proportion of landowners, mostly environment owners, would voluntarily join a program. Although compensation funding contributed to voluntary program choice for multi-objective owners and environment owners, welfare losses were around 4000 AUD per hectare, which is less than the average agricultural land value in Tasmania. Landowners for whom compensation funding contributed to voluntary program choice were also most likely to set aside land for conservation without payment. This raises the possibility that the government's compensation expenditure could potentially be either reduced or re-allocated to landowners who will not voluntarily take conservation action. Increasing participation in conservation incentive programs and minimizing the welfare losses associated with meeting conservation targets may be best achieved by offering programs that allow flexibility in terms of legal arrangements and other program attributes.

Early rehabilitation management after stroke: what do stroke patients prefer?

BACKGROUND: Stroke rehabilitation is moving towards more intense therapy models that incorporate technologies such as robotics and computer games. It is unclear how acceptable these changes will be to stroke survivors, as little is known about which aspects of rehabilitation programmes are currently valued. Discrete choice experiments are a potential approach to assessing patient preferences, as they reveal the characteristics of programmes that are most important to consumers. METHODS: A discrete choice experiment was presented as a face-to-face interview to assess the priorities and preferences of stroke survivors (n=50, mean age 72 years) for alternative rehabilitation service configurations. The discrete choice experiment was presented to the participants while they were on the stroke rehabilitation ward (approximately 3-4 weeks following stroke). RESULTS: Participants were highly focused on recovery and expressed strong preferences for therapy delivered one-to-one, but they did not favour very high intensity programmes (6 hours per day). While the attitudinal statements indicated high levels of agreement for programmes to incorporate the latest technology, the results from the discrete choice experiment indicated that participants were averse to computer-delivered therapy. CONCLUSION: Whilst rehabilitation therapy is highly valued, stroke survivors exhibited stronger preferences for low-intensity programmes and rest periods. High-intensity therapy protocols or approaches dependent on new technologies will require careful introduction to achieve uptake and acceptability.

Valuing Child Health Utility 9D health states with a young adolescent sample: a feasibility study to compare best-worst scaling discrete-choice experiment, standard gamble and time trade-off methods.

QALYs are increasingly being utilized as a health outcome measure to calculate the benefits of new treatments and interventions within cost-utility analyses for economic evaluation. Cost-utility analyses of adolescent-specific treatment programmes are scant in comparison with those reported upon for adults and tend to incorporate the views of clinicians or adults as the main source of preferences. However, it is not clear that the views of adults are in accordance with those of adolescents on this issue. Hence, the treatments and interventions most highly valued by adults may not correspond with those most highly valued by adolescents. Ordinal methods for health state valuation may be more easily understood and interpreted by young adolescent samples than conventional approaches. The availability of young adolescent-specific health state values for the estimation of QALYs will provide new insights into the types of treatment programmes and health services that are most highly valued by young adolescents. The first objective of this study was to assess the feasibility of applying best-worst scaling (BWS) discrete-choice experiment (DCE) methods in a young adolescent sample to value health states defined by the Child Health Utility 9D (CHU9D) instrument, a new generic preference-based measure of health-related quality of life developed specifically for application in young people. The second objective was to compare BWS DCE questions (where respondents are asked to indicate the best and worst attribute for each of a number of health states, presented one at a time) with conventional time trade-off (TTO) and standard gamble (SG) questions in terms of ease of understanding and completeness. A feasibility study sample of consenting young adolescent school children (n = 16) aged 11-13 years participated in a face-to-face interview in which they were asked to indicate the best and worst attribute levels from a series of health states defined by the CHU9D, presented one at a time. Participants were also randomly allocated to receive additional conventional TTO or SG questions and prompted to indicate how difficult they found them to complete. The results indicate that participants were able to readily choose 'best' and 'worst' dimension levels in each of the CHU9D health states presented to them and provide justification for their choices. Furthermore, when presented with TTO or SG questions and prompted to make comparisons, participants found the BWS DCE task easier to understand and complete. The results of this feasibility study suggest that BWS DCE methods are potentially more readily understood and interpretable by vulnerable populations (e.g. young adolescents). These findings lend support to the potential application of BWS DCE methods to undertake large-scale health state valuation studies directly with young adolescent population samples.