An economic evaluation of the Safe Motherhood programme in Guangxi, China

Maternal and infant mortality is a global health issue with a significant social and economic impact. Each year, over half a million women worldwide die due to complications related to pregnancy or childbirth, four million infants die in the first 28 days of life, and eight million infants die in the first year. Ninety-nine percent of maternal and infant deaths are in developing countries. Reducing maternal and infant mortality is among the key international development goals. In China, the national maternal mortality ratio and infant mortality rate were reduced greatly in the past two decades, yet a large discrepancy remains between urban and rural areas. To address this problem, a large-scale Safe Motherhood Programme was initiated in 2000. The programme was implemented in Guangxi in 2003. Interventions in the programme included both demand-side and supply side-interventions focusing on increasing health service use and improving birth outcomes. Little is known about the effects and economic outcomes of the Safe Motherhood Programme in Guangxi, although it has been implemented for seven years. The aim of this research is to estimate the effectiveness and cost-effectiveness of the interventions in the Safe Motherhood Programme in Guangxi, China. The objectives of this research include: 1. To evaluate whether the changes of health service use and birth outcomes are associated with the interventions in the Safe Motherhood Programme. 2. To estimate the cost-effectiveness of the interventions in the Safe Motherhood Programme and quantify the uncertainty surrounding the decision. 3. To assess the expected value of perfect information associated with both the whole decision and individual parameters, and interpret the findings to inform priority setting in further research and policy making in this area. A quasi-experimental study design was used in this research to assess the effectiveness of the programme in increasing health service use and improving birth outcomes. The study subjects were 51 intervention counties and 30 control counties. Data on the health service use, birth outcomes and socio-economic factors from 2001 to 2007 were collected from the programme database and statistical yearbooks. Based on the profile plots of the data, general linear mixed models were used to evaluate the effectiveness of the programme while controlling for the effects of baseline levels of the response variables, change of socio-economic factors over time and correlations among repeated measurements from the same county. Redundant multicollinear variables were deleted from the mixed model using the results of the multicollinearity diagnoses. For each response variable, the best covariance structure was selected from 15 alternatives according to the fit statistics including Akaike information criterion, Finite-population corrected Akaike information criterion, and Schwarz.s Bayesian information criterion. Residual diagnostics were used to validate the model assumptions. Statistical inferences were made to show the effect of the programme on health service use and birth outcomes. A decision analytic model was developed to evaluate the cost-effectiveness of the programme, quantify the decision uncertainty, and estimate the expected value of perfect information associated with the decision. The model was used to describe the transitions between health states for women and infants and reflect the change of both costs and health benefits associated with implementing the programme. Result gained from the mixed models and other relevant evidence identified were synthesised appropriately to inform the input parameters of the model. Incremental cost-effectiveness ratios of the programme were calculated for the two groups of intervention counties over time. Uncertainty surrounding the parameters was dealt with using probabilistic sensitivity analysis, and uncertainty relating to model assumptions was handled using scenario analysis. Finally the expected value of perfect information for both the whole model and individual parameters in the model were estimated to inform priority setting in further research in this area.The annual change rates of the antenatal care rate and the institutionalised delivery rate were improved significantly in the intervention counties after the programme was implemented. Significant improvements were also found in the annual change rates of the maternal mortality ratio, the infant mortality rate, the incidence rate of neonatal tetanus and the mortality rate of neonatal tetanus in the intervention counties after the implementation of the programme. The annual change rate of the neonatal mortality rate was also improved, although the improvement was only close to statistical significance. The influences of the socio-economic factors on the health service use indicators and birth outcomes were identified. The rural income per capita had a significant positive impact on the health service use indicators, and a significant negative impact on the birth outcomes. The number of beds in healthcare institutions per 1,000 population and the number of rural telephone subscribers per 1,000 were found to be positively significantly related to the institutionalised delivery rate. The length of highway per square kilometre negatively influenced the maternal mortality ratio. The percentage of employed persons in the primary industry had a significant negative impact on the institutionalised delivery rate, and a significant positive impact on the infant mortality rate and neonatal mortality rate. The incremental costs of implementing the programme over the existing practice were US $11.1 million from the societal perspective, and US $13.8 million from the perspective of the Ministry of Health. Overall, 28,711 life years were generated by the programme, producing an overall incremental cost-effectiveness ratio of US $386 from the societal perspective, and US $480 from the perspective of the Ministry of Health, both of which were below the threshold willingness-to-pay ratio of US $675. The expected net monetary benefit generated by the programme was US $8.3 million from the societal perspective, and US $5.5 million from the perspective of the Ministry of Health. The overall probability that the programme was cost-effective was 0.93 and 0.89 from the two perspectives, respectively. The incremental cost-effectiveness ratio of the programme was insensitive to the different estimates of the three parameters relating to the model assumptions. Further research could be conducted to reduce the uncertainty surrounding the decision, in which the upper limit of investment was US $0.6 million from the societal perspective, and US $1.3 million from the perspective of the Ministry of Health. It is also worthwhile to get a more precise estimate of the improvement of infant mortality rate. The population expected value of perfect information for individual parameters associated with this parameter was US $0.99 million from the societal perspective, and US $1.14 million from the perspective of the Ministry of Health. The findings from this study have shown that the interventions in the Safe Motherhood Programme were both effective and cost-effective in increasing health service use and improving birth outcomes in rural areas of Guangxi, China. Therefore, the programme represents a good public health investment and should be adopted and further expanded to an even broader area if possible. This research provides economic evidence to inform efficient decision making in improving maternal and infant health in developing countries.

Development and evaluation of the Clinician Suicide Risk Assessment Checklist

This paper describes the development and evaluation of a new instrument - the Clinician Suicide Risk Assessment Checklist (CSRAC). The instrument assesses the clinician's competency in three areas: clinical interviewing, assessment of specific suicide risk factors, and formulating a management plan. A draft checklist was constructed by integrating information from 1) literature review 2) expert clinician focus group and 3) consultation with experts. It was utilised in a simulated clinical scenario with clinician trainees and a trained actor in order to test for inter-rater agreement. Agreement was calculated and the checklist was re-drafted with the aim of maximising agreement. A second phase of simulated clinical scenarios was then conducted and inter-rater agreement was calculated for the revised checklist. In the first phase of the study, 18 of 35 items had inadequate inter-rater agreement (60%>), while in the second phase, using the revised version, only 3 of 39 items failed to achieve adequate inter-rater agreement. Further evidence of reliability and validity are required. Continued development of the CSRAC will be necessary before it can be utilised to assess the effectiveness of risk assessment training programs.

A communitarian theory of the education rights of students with disabilities

There is a lack of writing on the issue of the education rights of people with disabilities by authors of any theoretical persuasion. While the deficiency of theory may be explained by a variety of historical, philosophical and practical considerations, it is a deficiency which must be addressed. Otherwise, any statement of rights rings out as hollow rhetoric unsupported by sound reason and moral rectitude. This paper attempts to address this deficiency in education rights theory by postulating a communitarian theory of the education rights of people with disabilities. The theory is developed from communitarian writings on the role of education in democratic society. The communitarian school, like the community within which it nests, is inclusive. Schools both reflect and model the shape of communitarian society and have primary responsibility for teaching the knowledge and virtues which will allow citizens to belong to and function within society. Communitarians emphasise responsibilities, however, as the corollary of rights and require the individual good to yield to community good when the hard cases arise. The article not only explains the basis of the right to an inclusive education, therefore, but also engages with the difficult issue of when such a right may not be enforceable.

Evaluation of the 2010 child restraint legislation in Queensland

Occupant injury comprises the largest proportion of child road crash trauma in most highly motorised countries. In Australia, road crashes are the primary cause of death for children aged 1-14 years and are among the top three causes of serious injury to this age group. For this reason considerable research attention has been focused on understanding the contributing factors and the most effective ways of improving children’s safety as car passengers. Australia has been particularly active in this area, with well regarded work being conducted on levels of use of dedicated child restraints, restraint crash performance in laboratory conditions, examination of real world restraint crash performance (case review), and studies of psychosocial factors influencing perceptions about restraints and their use (Brown & Bilston, 2006; Brown, McCaskill, Henderson & Bilston, 2006; Edwards, Anderson & Hutchinson, 2006; Lennon, 2005, 2007). New legislation for the restraint of children as vehicle passengers was enacted in Queensland in March 2010. This new legislation recognises the importance of dedicated restraint use for children up to at least age 7 years and the protective benefits of rear seating position in the event of a crash. As part of improving children’s safety and addressing key priority areas, the Queensland Injury Prevention Council (QIPC) and Department of Transport and Main Roads (TMR) commissioned the Centre for Accident Research and Road Safety, Queensland (CARRS-Q) to evaluate the impact of the new legislation. Although at the time of commencing the research the legislation had only been in force for 14 months, it was deemed critical to review its effectiveness in guiding parental choices and compliance in order to inform the design and focus of further supporting initiatives and interventions. Specifically, the research sought clear evidence of exactly what impact, if any, the legislation has had on compliance levels and what difficulties (if any) parents/carers experience in relation to interpreting as well as complying with the requirements of the new law. Knowledge about these barriers or difficulties will allow any future changes or improvements to the legislation to address such barriers and thus improve its effectiveness. Moreover, better information about how the legislation has affected parents will provide a basis to plan non-legislative comprehensive multi-strategy interventions such as community, educational or behavioural interventions with parents/carers and other stakeholder groups. In addition, it will allow identification of the most effective aspects of the legislation and those areas in need of extra attention to improve effectiveness/compliance and thus better protect children travelling in cars and improve their health and safety. This report presents the findings from the four components of the research: the literature review; observational study; intercept interviews and focus group with parents; and the interviews with key stakeholders.

Evaluation of the Airdrie Sheriff Youth Court Pilot

A pilot Youth Court was introduced at Airdrie Sheriff Court in June 2004. Its objectives were to: • reduce the frequency and seriousness of re-offending by 16 and 17 year old offenders, particularly persistent offenders (and some 15 year olds who are referred to the court); • promote the social inclusion, citizenship and personal responsibility of these young offenders while maximising their potential; • establish fast track procedures for those young persons appearing before the Youth Court; • enhance community safety, by reducing the harm caused to individual victims of crime and providing respite to those communities which are experiencing high levels of crime; and • test the viability and usefulness of a Youth Court using existing legislation and to demonstrate whether legislative and practical improvements might be appropriate. An evaluation of the pilot commissioned by the Scottish Executive found that it appeared in many respects to be working well. It was a tightly run court that dealt with a heavy volume of business. With its fast track procedures and additional resources it was regarded as a model to be aspired to in all summary court business. Whether a dedicated Youth Court was required or whether procedural improvements would have been possible in the absence of dedicated resources and personnel was, however, more difficult to assess. Two issues in particular required further attention. First, consideration needed to be given to whether the Youth Court should be more explicitly youth focused and what this might entail. Second, greater clarity was required regarding for whom the Youth Court was intended to avoid the risk of net-widening and its consequences for young people.

Evaluation of the skills for preventing injury in youth program : impact on health risk behaviors, injury and school connectedness

Injury is the leading cause of death among young people, and involvement in health risk behaviors, such as alcohol use and transport-related risks, is related to increased risk for injury. Effective health promotion programs for adolescents focus on multiple levels, including relationships with peers and parents, student knowledge, behavior and attitudes, and school-level factors such as school connectedness. This study describes the pilot evaluation of a comprehensive, multi-level injury prevention program for 13-14 year old adolescents, targeting change in injury associated with transport and alcohol risks. The program, called Skills for Preventing Injury in Youth (SPIY), incorporates two primary elements: an 8-week, teacher delivered attitude and behavior change curriculum with peer protection and first aid messages; and professional development for program teachers focusing on strategies to increase students’ connectedness to school. Five Australian high schools were recruited for the pilot evaluation research, with three being assigned to receive intervention components and two assigned as curriculum-as-usual controls. In the intervention schools, 118 Year 8 students participated in surveys at baseline, with 105 completing surveys at follow up, six months following the intervention. In the control schools, 196 Year 8 students completed surveys at baseline and 207 at follow up. Survey measures included self-reported injury, risk taking behavior and school connectedness. Results showed that students in the control schools were significantly more likely to report riding bikes without helmets, riding with dangerous drivers, having driven cars on the road, and using alcohol six months after the program, while the intervention group showed no such increase in these behaviors. Additionally, students in the control schools were significantly more likely to report having had pedestrian-related injuries at follow up than they were at the baseline measurement, while intervention school students showed no change. There was also a trend observed in terms of a decrease in bicycle related injuries among intervention school students, compared with a slight increasing trend in bicycle injuries among control students. Overall, scores on the school connectedness scale decreased significantly from baseline to follow up for both intervention and control students, however measurement limitations may have impacted on results relating to students’ connectedness. Overall, the SPIY program has shown promising results in regards to prevention of students’ health risk behavior and injuries. Evidence suggests that the curriculum component was important; however there was limited evidence to suggest that teacher training in school connectedness strategies contributed to these promising results. While school connectedness may be an important factor to target in risk and injury prevention programs, programs may need to incorporate whole-of-school strategies or target a broader range of teachers than were selected for the current research.

Evaluation of the control of carbon emissions of construction facilities in Hong Kong

This paper investigates the policies and instruments adopted in Hong Kong to control the carbon emissions of construction facilities, including the whole building life cycle: production of material stage, construction stage, operation stage and demolition stage. This commences with a literature review comparing activities world-wide to those in Hong Kong to identify the main issues at stake, followed by a report on a series of local interviews to evaluate the present situation in Hong Kong, as well as future opportunities for local carbon mitigation. The interviewees included practitioners from engineering contracting firms, consulting firms, clients and energy provider, together with two university experts and a counsellor. A small case study is also provided of a building project in Hong Kong to illustrate some of the innovative design aspects being incorporated into buildings in Hong Kong as a result of the current emphasis on sustainability. The paper concludes with a summary of main findings and proposals for improvement in policy related to carbon mitigation and building sustainability in Hong Kong.

Evaluation of the iPhone with an acrylic sleeve versus the Scoliometer for rib hump measurement in scoliosis

Background. Vertebral rotation found in structural scoliosis contributes to trunkal asymmetry which is commonly measured with a simple Scoliometer device on a patient's thorax in the forward flexed position. The new generation of mobile 'smartphones' have an integrated accelerometer, making accurate angle measurement possible, which provides a potentially useful clinical tool for assessing rib hump deformity. This study aimed to compare rib hump angle measurements performed using a Smartphone and traditional Scoliometer on a set of plaster torsos representing the range of torsional deformities seen in clinical practice. Methods. Nine observers measured the rib hump found on eight plaster torsos moulded from scoliosis patients with both a Scoliometer and an Apple iPhone on separate occasions. Each observer repeated the measurements at least a week after the original measurements, and were blinded to previous results. Intra-observer reliability and inter-observer reliability were analysed using the method of Bland and Altman and 95% confidence intervals were calculated. The Intra-Class Correlation Coefficients (ICC) were calculated for repeated measurements of each of the eight plaster torso moulds by the nine observers. Results. Mean absolute difference between pairs of iPhone/Scoliometer measurements was 2.1 degrees, with a small (1 degrees) bias toward higher rib hump angles with the iPhone. 95% confidence intervals for intra-observer variability were +/- 1.8 degrees (Scoliometer) and +/- 3.2 degrees (iPhone). 95% confidence intervals for inter-observer variability were +/- 4.9 degrees (iPhone) and +/- 3.8 degrees (Scoliometer). The measurement errors and confidence intervals found were similar to or better than the range of previously published thoracic rib hump measurement studies. Conclusions. The iPhone is a clinically equivalent rib hump measurement tool to the Scoliometer in spinal deformity patients. The novel use of plaster torsos as rib hump models avoids the variables of patient fatigue and discomfort, inconsistent positioning and deformity progression using human subjects in a single or multiple measurement sessions.

Evaluation of the GHR car following model for traffic safety studies

Traffic safety studies mandate more than what existing micro-simulation models can offer as they postulate that every driver exhibits a safe behaviour. All the microscopic traffic simulation models are consisting of a car-following model and the Gazis–Herman–Rothery (GHR) car-following model is a widely used model. This paper highlights the limitations of the GHR car-following model capability to model longitudinal driving behaviour for safety study purposes. This study reviews and compares different version of the GHR model. To empower the GHR model on precise metrics reproduction a new set of car-following model parameters is offered to simulate unsafe vehicle conflicts. NGSIM vehicle trajectory data is used to evaluate the new model and short following headways and Time to Collision are employed to assess critical safety events within traffic flow. Risky events are extracted from available NGSIM data to evaluate the modified model against the generic versions of the GHR model. The results from simulation tests illustrate that the proposed model does predict the safety metrics better than the generic GHR model. Additionally it can potentially facilitate assessing and predicting traffic facilities’ safety using microscopic simulation. The new model can predict Near-miss rear-end crashes.

Evaluation of the luminous environment in open-plan offices with skylights

High Dynamic Range (HDR) imaging was used to collect luminance information at workstations in 2 open-plan office buildings in Queensland, Australia: one lit by skylights, vertical windows and electric light, and another by skylights and electric light. This paper compares illuminance and luminance data collected in these offices with occupant feedback to evaluate these open-plan environments based on available and emerging metrics for visual comfort and glare. This study highlights issues of daylighting quality and measurement specific to open plan spaces. The results demonstrate that overhead glare is a serious threat to user acceptance of skylights, and that electric and daylight integration and controls have a major impact on the perception of daylighting quality. With regards to measurement of visual comfort it was found that the Daylight Glare Probability (DGP) gave poor agreement with occupant reports of discomfort glare in open-plan spaces with skylights, and the CIE Glare Index (CGI) gave the best agreement. Horizontal and vertical illuminances gave no indication of visual comfort in these spaces.

Experimental evaluation of the culture performance of three exotic and a ‘local’ Giant Freshwater Prawn (Macrobrachium rosenbergii, De Man 1879) culture strain in Fiji

Giant freshwater prawn (GFP; Macrobrachium rosenbergii) aquaculture has expanded rapidly since 1990. Most local culture industries, however, have developed in an unsystematic way. Fiji has a small culture industry producing the ‘Anuenue’ strain; however, performance of this strain has never been systematically evaluated. Recently, some Fijian farmers have reported declines in stock productivity. The current project evaluated the relative performance of three exotic strains with different genetic backgrounds from Malaysia, Indonesia and Vietnam, against the ‘local’ strain in Fiji in a 4 × 3 replicated pond trial experiment. A total of 5827 prawns were harvested after 143 days growout. Individual growth rate and relative survival of the Fiji strain were not statistically different from any of the introduced strains, but Vietnam strain was superior to that of the Malaysia strain. Genetic diversity showed significant differences in variability among strains, with the Malaysian strain displaying the lowest genetic diversity. Indonesia strain showed that females were reaching maturation earlier than other strains and were smaller in size. This study suggests that Malaysian and Indonesian strains would constitute a poor choice for Fiji, whereas the Vietnam strain consistently performed well on all criteria measured. High variation among replicate ponds within strains unfortunately confounded among-strain variation.

Evaluation of the cost-effectiveness of strategies claiming to reduce the risk of surgical site infections following primary total hip arthroplasty

Background Total hip arthroplasty (THA) is a commonly performed procedure and numbers are increasing with ageing populations. One of the most serious complications in THA are surgical site infections (SSIs), caused by pathogens entering the wound during the procedure. SSIs are associated with a substantial burden for health services, increased mortality and reduced functional outcomes in patients. Numerous approaches to preventing these infections exist but there is no gold standard in practice and the cost-effectiveness of alternate strategies is largely unknown. Objectives The aim of this project was to evaluate the cost-effectiveness of strategies claiming to reduce deep surgical site infections following total hip arthroplasty in Australia. The objectives were: 1. Identification of competing strategies or combinations of strategies that are clinically relevant to the control of SSI related to hip arthroplasty 2. Evidence synthesis and pooling of results to assess the volume and quality of evidence claiming to reduce the risk of SSI following total hip arthroplasty 3. Construction of an economic decision model incorporating cost and health outcomes for each of the identified strategies 4. Quantification of the effect of uncertainty in the model 5. Assessment of the value of perfect information among model parameters to inform future data collection Methods The literature relating to SSI in THA was reviewed, in particular to establish definitions of these concepts, understand mechanisms of aetiology and microbiology, risk factors, diagnosis and consequences as well as to give an overview of existing infection prevention measures. Published economic evaluations on this topic were also reviewed and limitations for Australian decision-makers identified. A Markov state-transition model was developed for the Australian context and subsequently validated by clinicians. The model was designed to capture key events related to deep SSI occurring within the first 12 months following primary THA. Relevant infection prevention measures were selected by reviewing clinical guideline recommendations combined with expert elicitation. Strategies selected for evaluation were the routine use of pre-operative antibiotic prophylaxis (AP) versus no use of antibiotic prophylaxis (No AP) or in combination with antibiotic-impregnated cement (AP & ABC) or laminar air operating rooms (AP & LOR). The best available evidence for clinical effect size and utility parameters was harvested from the medical literature using reproducible methods. Queensland hospital data were extracted to inform patients’ transitions between model health states and related costs captured in assigned treatment codes. Costs related to infection prevention were derived from reliable hospital records and expert opinion. Uncertainty of model input parameters was explored in probabilistic sensitivity analyses and scenario analyses and the value of perfect information was estimated. Results The cost-effectiveness analysis was performed from a health services perspective using a hypothetical cohort of 30,000 THA patients aged 65 years. The baseline rate of deep SSI was 0.96% within one year of a primary THA. The routine use of antibiotic prophylaxis (AP) was highly cost-effective and resulted in cost savings of over $1.6m whilst generating an extra 163 QALYs (without consideration of uncertainty). Deterministic and probabilistic analysis (considering uncertainty) identified antibiotic prophylaxis combined with antibiotic-impregnated cement (AP & ABC) to be the most cost-effective strategy. Using AP & ABC generated the highest net monetary benefit (NMB) and an incremental $3.1m NMB compared to only using antibiotic prophylaxis. There was a very low error probability that this strategy might not have the largest NMB (<5%). Not using antibiotic prophylaxis (No AP) or using both antibiotic prophylaxis combined with laminar air operating rooms (AP & LOR) resulted in worse health outcomes and higher costs. Sensitivity analyses showed that the model was sensitive to the initial cohort starting age and the additional costs of ABC but the best strategy did not change, even for extreme values. The cost-effectiveness improved for a higher proportion of cemented primary THAs and higher baseline rates of deep SSI. The value of perfect information indicated that no additional research is required to support the model conclusions. Conclusions Preventing deep SSI with antibiotic prophylaxis and antibiotic-impregnated cement has shown to improve health outcomes among hospitalised patients, save lives and enhance resource allocation. By implementing a more beneficial infection control strategy, scarce health care resources can be used more efficiently to the benefit of all members of society. The results of this project provide Australian policy makers with key information about how to efficiently manage risks of infection in THA.