Referral patterns and proximity to palliative care inpatient services by level of socio-economic disadvantage : a national study using spatial analysis

Background: A range of health outcomes at a population level are related to differences in levels of social disadvantage. Understanding the impact of any such differences in palliative care is important. The aim of this study was to assess, by level of socio-economic disadvantage, referral patterns to specialist palliative care and proximity to inpatient services. Methods: All inpatient and community palliative care services nationally were geocoded (using postcode) to one nationally standardised measure of socio-economic deprivation – Socio-Economic Index for Areas (SEIFA; 2006 census data). Referral to palliative care services and characteristics of referrals were described through data collected routinely at clinical encounters. Inpatient location was measured from each person’s home postcode, and stratified by socio-economic disadvantage. Results: This study covered July – December 2009 with data from 10,064 patients. People from the highest SEIFA group (least disadvantaged) were significantly less likely to be referred to a specialist palliative care service, likely to be referred closer to death and to have more episodes of inpatient care for longer time. Physical proximity of a person’s home to inpatient care showed a gradient with increasing distance by decreasing levels of socio-economic advantage. Conclusion: These data suggest that a simple relationship of low socioeconomic status and poor access to a referral-based specialty such as palliative care does not exist. Different patterns of referral and hence different patterns of care emerge.

The effectiveness of a short-term group music therapy intervention for parents who have a child with a disability

The relationship between the quality of parent-child interactions and positive child developmental trajectories is well established (Guralnick, 2006; Shonkoff & Meissels, 2000; Zubrick et al., 2008). However, a range of parental, family, and socio-economic factors can pose risks to parents’ capacity to participate in quality interactions with their children. In particular, families with a child with a disability have been found to have higher levels of parenting stress, and are more likely to experience economic disadvantage, as well as social isolation. The importance of early interventions to promote positive parenting and child development for these families is widely recognised (Shonkoff & Meissels, 2000). However, to date, there is a lack of evidence about the effectiveness of early parenting programs for families who have a young child with a disability. This thesis investigates the impact of a music therapy parenting program, Sing & Grow, on 201 parent-child dyads who attended programs specifically targeted to parents who had a young child with a disability. Sing & Grow is an Australian national early parenting intervention funded by the Australian Government Department of Families, Housing, Community Services and Indigenous Affairs and delivered by Playgroup Queensland. It is designed and delivered by Registered Music Therapists for families with children aged from birth to three years. It aims to improve parenting skills and confidence, improve family functioning (positive parent-child interactions), enhance child development, and provide social networking opportunities to socially isolated families. The intervention targets a range of families in circumstances that have the potential to impact negatively on family functioning. This thesis uses data from the National Evaluation Study of Sing & Grow from programs which were targeted at families who had a young child with a disability. Three studies were conducted to address the objectives of this thesis. Study 1 examines the effects of the Sing & Grow intervention on parent reported pre and post parent mental health, parenting confidence, parenting skills, and child development, and other parent reported outcomes including social support, use of intervention resources, satisfaction with the intervention and perceived benefits of and barriers to participation. Significant improvements from pre to post were found for parent mental health and parent reported child communication and social skills, along with evidence that parents were very satisfied with the program and that it brought social benefits to families. Study 2 explored the pre to post effects of the intervention on children’s developmental skills and parent-child interactions using observational ratings made by clinicians. Significant pre to post improvements were found for parenting sensitivity, parental engagement with child and acceptance of child as well as for child responsiveness to parent, interest, and participation in the intervention, and social skills. Study 3 examined the nature of child and family characteristics that predicted better outcomes for families while taking account of the level of participation in the program. An overall outcome index was calculated and served as the dependent variable in a logistic regression analysis. Families who attended six or more sessions and mothers who had not completed high school were more likely to have higher outcome scores at post intervention than those who attended fewer sessions and those with more educated mothers respectively. The findings of this research indicate that the intervention had a positive impact on participants’ mental health, parenting behaviours and child development and that level of attendance was associated with better outcomes. There was also evidence that the program reached its target of high risk families (i.e., families in which mothers had lower educational levels) and that for these families better outcomes were achieved. There were also indications that the program was accessible and highly regarded by families and that it promoted social connections for participants. A theoretical model of how the intervention is currently working for families is proposed to explain the connections between early parenting, child development and maternal wellbeing. However, more research is required to further elucidate the mechanisms by which the intervention creates change for families. This research presents promising evidence that a short term group music therapy program can elicit important therapeutic benefits for families who have a child with a disability.

A Fair Go Beyond the School Gate? Systemic factors affecting participation and attainment in tertiary education by Queensland students from LSES backgrounds

The purpose of this project was to conduct an empirical study that would result in findings that inform systemic policy development aimed at improving tertiary participation and attainment by students from low socioeconomic status (LSES) backgrounds in Queensland. The project focuses on systemic policy, initiatives and programs that encourage tertiary education participation and attainment by individuals from LSES backgrounds, rather than on institution-specific initiatives or programs. While the broad remit was to consider tertiary education participation, the study particularly highlights issues pertaining to LSES student participation and attainment in the higher education sector, given the notable under representation of this demographic subgroup in Australian universities. This study supports the strategic priority of addressing professional skills shortages and innovations aiming to improve human and social capital in the state of Queensland. The ultimate goal is to contribute to the enhancement of Queensland’s education and training system by maximising participation and attainment by people from LSES backgrounds in higher education, thereby improving their quality of life and future life choices and opportunities. The study addressed the following five research questions: 1. What are the major factors that promote or inhibit participation and attainment in tertiary education by LSES students in Queensland? 2. To what extent do systemic policies or practices(systemic factors) of Queensland’s tertiary education system promote or inhibit participation and attainment by LSES students? That is, what features of Queensland’s tertiary education system have a significant effect on participation and attainment by LSES students? 3. What system policies or practices are found to boost participation and attainment by LSES students in other jurisdictions? 4. What evidence is there to suggest that policies or practices that have boosted participation and attainment by LSES students in other jurisdictions would be successful if implemented in Queensland? 5. What are the implications of the research findings for Queensland’s tertiary education system to improve participation and attainment by LSES students? The project adopted a mixed methods approach to data collection. A comprehensive review of the literature was conducted to identify relevant state, national and international literature. Both qualitative and quantitative methodologies were used to collect data from a range of key stakeholders.

Education in City and Suburban Communities

This chapter will discuss how environmental factors, specifically one’s backgrounds and where one lives, has an impact on teaching and learning. You have learned from previous chapters that inclusive education is underpinned by human rights and social justice issues. This chapter takes up that argument by identifying the diversity of students in city and suburban schools and how some are excluded, leading to disengagement with learning. We suggest possible pedagogy such as differentiated instruction and a ‘pedagogy of hope’ to counter student disengagement. Inclusive education, as an ‘act of imagination’ engages students in creative ways with the curriculum, where they can find meaning and purpose in what they are doing. Such engagement allows student to make connections between their school work and their own life worlds.

Widening participation in university learning

This paper reports how one Australian university and the Queensland Department of Education and Training (DET) are working together to increase the number of school students from low socio-economic backgrounds enrolling in undergraduate university degrees. This innovative program involves university lecturers and school teachers working together in the delivery and assessment of four Bachelor of Education units (or subjects) to a cohort of Year eleven and twelve students at a secondary school. Focus group interviews collected data from 26 students, 7 parents, 4 school and 3 university staff to assess the effectiveness of the program. All stakeholders viewed the program as a highly valuable opportunity to experience university learning with 31 high school graduating students being made offers to enter full-time university in the 2010 and 2011. This positive result has particular significance in the current drive in Australia and elsewhere to increase the participation in higher education of young people from under-represented groups.

Disengaged and disruptive : behaviour intervention for boys from year four to year seven

Disengaged and disruptive students have been an ongoing concern for teachers for many years. Teaching is complex—complex students with complex lives and complex behaviours. How best to help these students is an ever-present question without a simple answer. Solutions need to be found. Under a positive behaviour support framework when serious, disruptive behaviour requires intervention, an individualised positive behaviour support plan (PBS plan) is developed and implemented. This multicase study (Stake, 2006) investigated how task engagement was changed for boys from year four to year seven who demonstrated serious, disruptive behaviour. The individualised PBS plan was the primary tool of behaviour intervention in each of the five cases. Using the Behaviour Support Plan Quality Evaluation Scoring Guide II (BSP-QE) (Browning- Wright, Saren & Mayer, 2003) the five PBS plans were evaluated prior to implementation and rated highly in terms of technical quality. Positive changes in student task engagement were forthcoming in all five cases. Eleven advisory visiting teachers in behaviour and eleven classroom teachers, five of whom were case-study participants, took part in this study. The classroom teachers were employed in south-east Queensland primary schools located in suburbs of economic disadvantage. All 22 participants expressed very similar perceptions of serious, disruptive behaviour emphasising the collateral impact upon the teaching and learning. Data obtained through direct observations, surveys and semi-structured interviews confirmed previous research to reveal a strong link between integrity of PBS plan implementation and student behaviour change. While classroom teachers, in the main, effectively managed the implementation of the PBS plan, social validity of goals, procedures and effects; in-class technical assistance and performance feedback were identified as three enablers to effective teacher implementation of the PBS plan. While the purpose of each PBS plan was to influence change in student behaviour, this study found that changing teacher behaviour was also instrumental in achieving positive student outcomes. Changing teacher behaviour and building capacity was facilitated by trusting, collaborative partnerships established between the Advisory Visiting Teacher-Behaviour and the classroom teacher responsible for the plan implementation. The Advisory Visiting Teacher-Behaviour provides assistance to teachers dealing with students who demonstrate ongoing, problematic behaviour. The inclusion of a teaching component as part of the implementation stage of the consultation process appeared to have considerable influence upon successful intervention. Results substantiated earlier understandings of the importance of teacher instruction highlighting the value of explicit teaching and performance feedback to the delivery of effective behaviour intervention. Conclusions drawn from this study have had a major impact upon the work of a regional team of Advisory Visiting Teachers-Behaviour. The focus of behaviour intervention has moved from being primarily upon the individual student to include a greater emphasis upon the critical role of the teacher. Procedures and processes are being re-evaluated to align with evidence-based practice and to include a collaborative consultation approach to improve teacher assistance. The framework and content of staff development and training is being created directly from the findings of this study. This practical application of the results has informed better ways of providing behaviour intervention for students demonstrating serious, disruptive behaviour. What this study has clearly shown is that when it comes to behaviour intervention, the important role of the teacher cannot be underestimated.

Promoting resilience in children with intellectual disability : a randomized controlled trial in Australian schools

Children with intellectual disability are more vulnerable to adverse developmental outcomes because of the lifelong risks associated with cognitive impairment. Difficulties with learning and adaptive behaviour inevitably produce considerable personal, social and economic disadvantage. Of concern is consistent evidence that psychiatric disorders affect a substantial proportion of people with intellectual disability. The estimated prevalence rate of between 35 and 49 % is three times that found in the general population (Wallander, Dekker, & Koot, 2006). Until recently, mental illness has been relatively neglected for people with intellectual disability, especially in relation to prevention or early detection (Kolaitis, 2008) and most research to date has been descriptive rather than focused on intervention (Bouras, 2013). Yet a considerable body of evidence demonstrates that efficacious interventions do exist for preventing psychopathology and enhancing resilience in typically developing children and adolescents (see Mallin, Walker, & Levin, 2013 for a review). In order to prevent the high comorbidity of intellectual disability and psychopathology, there is a compelling need for evidence-based practices that promote the resilience of individuals with intellectual disability (Matson, Terlonge, & Minshawi, 2008). In this chapter, we describe a randomized controlled trial of an intervention that was designed to enhance the resilience of a group of children with mild intellectual disability as they prepared to make the transition to high school. We report results from our evaluation of this intervention, and reflect on the difficulties of providing successful interventions for children whose lives are complicated not only by intellectual disability, but also by a range of contextual disadvantages.

Community wide interventions for increasing physical activity

Background Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown. Objectives To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity. Search methods We searched the Cochrane Public Health Group Segment of the Cochrane Register of Studies,The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, the British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORTDiscus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.org; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA); the US Centre for Disease Control and Prevention (CDC) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were searched and we contacted experts in the field. The searches were updated to 16 January 2014, unrestricted by language or publication status. Selection criteria Cluster randomised controlled trials, randomised controlled trials, quasi-experimental designs which used a control population for comparison, interrupted time-series studies, and prospective controlled cohort studies were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded. Data collection and analysis At least two review authors independently extracted the data and assessed the risk of bias. Each study was assessed for the setting, the number of included components and their intensity. The primary outcome measures were grouped according to whether they were dichotomous (per cent physically active, per cent physically active during leisure time, and per cent physically inactive) or continuous (leisure time physical activity time (time spent)), walking (time spent), energy expenditure (as metabolic equivalents or METS)). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated percentage change from baseline, unadjusted and adjusted. Main results After the selection process had been completed, 33 studies were included. A total of 267 communities were included in the review (populations between 500 and 1.9 million). Of the included studies, 25 were set in high income countries and eight were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (29 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity. However, of those included studies undertaken in high income countries, 14 studies were described as being provided to deprived, disadvantaged or low socio-economic communities. Nineteen studies were identified as having a high risk of bias, 10 studies were unclear, and four studies had a low risk of bias. Selection bias was a major concern with these studies, with only five studies using randomisation to allocate communities. Four studies were judged as being at low risk of selection bias although 19 studies were considered to have an unclear risk of bias. Twelve studies had a high risk of detection bias, 13 an unclear risk and four a low risk of bias. Generally, the better designed studies showed no improvement in the primary outcome measure of physical activity at a population level. All four of the newly included, and judged to be at low risk of bias, studies (conducted in Japan, United Kingdom and USA) used randomisation to allocate the intervention to the communities. Three studies used a cluster randomised design and one study used a stepped wedge design. The approach to measuring the primary outcome of physical activity was better in these four studies than in many of the earlier studies. One study obtained objective population representative measurements of physical activity by accelerometers, while the remaining three low-risk studies used validated self-reported measures. The study using accelerometry, conducted in low income, high crime communities of USA, emphasised social marketing, partnership with police and environmental improvements. No change in the seven-day average daily minutes of moderate to vigorous physical activity was observed during the two years of operation. Some program level effect was observed with more people walking in the intervention community, however this result was not evident in the whole community. Similarly, the two studies conducted in the United Kingdom (one in rural villages and the other in urban London; both using communication, partnership and environmental strategies) found no improvement in the mean levels of energy expenditure per person per week, measured from one to four years from baseline. None of the three low risk studies reporting a dichotomous outcome of physical activity found improvements associated with the intervention. Overall, there was a noticeable absence of reporting of benefit in physical activity for community wide interventions in the included studies. However, as a group, the interventions undertaken in China appeared to have the greatest possibility of success with high participation rates reported. Reporting bias was evident with two studies failing to report physical activity measured at follow up. No adverse events were reported.The data pertaining to cost and sustainability of the interventions were limited and varied. Authors' conclusions Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings in the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that the multi-component community wide interventions studied effectively increased physical activity for the population, although some studies with environmental components observed more people walking. Plain language summary Community wide interventions for increasing physical activity Not having enough physical activity leads to poorer health. Regular physical activity can reduce the risk of chronic disease and improve one's health and wellbeing. The lack of physical activity is a common and in some cases a growing health problem. To address this, 33 studies have used improvement activities directed at communities, using more than one approach in a single program. When we first looked at the available research in 2011 we observed that there was a lack of good studies which could show whether this approach was beneficial or not. Some studies claimed that community wide programs improved physical activities and other studies did not. In this update we found four new studies that were of good quality; however none of these four studies increased physical activity levels for the population. Some studies reported program level effects such as observing more people walking, however the population level of physical activity had not increased. This review found that community wide interventions are very difficult to undertake, and it appears that they usually fail to provide a measurable benefit in physical activity for a population. It is apparent that many of the interventions failed to reach a substantial portion of the community, and we speculate that some single strategies included in the combination may lack individual effectiveness. Laički sažetak Intervencije u zajednici za povećanje tjelesne aktivnosti Nedostatna tjelesna aktivnost povezana je s lošijim zdravljem.Redovita tjelesna aktivnost može umanjiti rizik od kroničnih bolesti te poboljšati zdravlje i kvalitetu života pojedinca.Manjak tjelesne aktivnosti čest je problem, a učestalost tog problema se povećava.Cochrane sustavni pregled je analizirao 33 studije koje su istražile programe za povećanje tjelesne aktivnosti u zajednici, u kojima se koristilo više od jednog pristupa.Kad su prvi put pregledani dokazi iz istraživanja koja su bila dostupna 2011. godine, utvrđeno je da nema dovoljno dobrih studija koje bi mogle pokazati je li takav pristup koristan ili ne.Primjerice, neke studije tvrde da programi za povećanje tjelesne aktivnosti u zajednici poboljšavaju tjelesnu aktivnost pojedinaca u zajednici, a druge studije tvrde suprotno.U ovom obnovljenom sustavnom pregledu pronađene su 4 nove studije koje su bile visoke kvalitete, ail nijedna od tih studija nije pokazala da je istraživana intervencija dovela do povećanja tjelesne aktivnosti u zajednici.Neke su studije opisale učinak na način da je opisano da je uočeno da više ljudi u zajednici hoda, međutim, ukupna razina tjelesne aktivnosti u promatranoj populaciji nije se povećala.Ovaj sustavni pregled je utvrdio da je intervencije za povećanje tjelesne aktivnosti u zajednici teško provesti i čini se da one obično ne uspijevaju u svojoj namjeri da na mjerljiv način povećaju tjelesnu aktivnost u populaciji.Čini se da mnoge intervencije nisu uspjele doseći veći broj stanovnika u zajednici pa se može smatrati da neke od strategija uključene u analizirane kombinacije nisu zasebno učinkovite.

Locating Indigenous Australia within community development practice : clients, consumers or change makers?

The philosophical promise of community development to “resource and empower people so that they can collectively control their own destinies” (Kenny 1996:104) is no doubt alluring to Indigenous Australia. Given the historical and contemporary experiences of colonial control and surveillance of Aboriginal bodies, alongside the continuing experiences of socio-economic disadvantage, community development reaffirms the aspirational goal of Indigenous Australians for self-determination. Self-determination as a national policy agenda for Indigenous Australians emerged in the 1970s and saw the establishment of a wide range of Aboriginal community-controlled services (Tsey et al 2012). Sullivan (2010:4) argues that the Aboriginal community controlled service sector during this time has, and continues to be, instrumental to advancing the plight of Indigenous Australians both materially and politically. Yet community development and self-determination remain highly problematic and contested in how they manifest in Indigenous social policy agendas and in practice (Hollinsworth 1996; Martin 2003; McCausland 2005; Moreton-Robinson 2009). Moreton-Robinson (2009:68) argues that a central theme underpinning these tensions is a reading of Indigeneity in which Aboriginal and Torres Strait Islander people, behaviours, cultures, and communities are pathologised as “dysfunctional” thus enabling assertions that Indigenous people are incapable of managing their own affairs. This discourse distracts us from the “strategies and tactics of patriarchal white sovereignty” that inhibit the “state’s earlier policy of self-determination” (Moreton-Robinson 2009:68). We acknowledge the irony of community development espoused by Ramirez above (1990), that the least resourced are expected to be most resourceful.; however, we wish to interrogate the processes that inhibit Indigenous participation and control of our own affairs rather than further interrogate Aboriginal minds as uneducated, incapable and/or impaired...

Enabling Indigenous education success beyond regional borders

Higher education is a powerful tool for reducing social and economic disadvantage. But access to higher education can be difficult, particularly for Indigenous Australians who face multiple levels of social, economic and geographical isolation. While enabling programs can support Indigenous students to gain university entry, the experience at Central Queensland University (CQUniversity) suggests that their past success has been limited. In this paper, the authors describe the enabling program available to Indigenous students at CQUniversity. They suggest that the newly developed, flexible, online version of the program is helping to address geographical and social isolation and improve successful outcomes for Indigenous Australians.

The influence of neighbourhood disadvantage on smoking cessation and its contribution to inequalities in smoking status

Introduction and aims: Individual smokers from disadvantaged backgrounds are less likely to quit, which contributes to widening inequalities in smoking. Residents of disadvantaged neighbourhoods are more likely to smoke, and neighbourhood inequalities in smoking may also be widening because of neighbourhood differences in rates of cessation. This study examined the association between neighbourhood disadvantage and smoking cessation and its relationship with neighbourhood inequalities in smoking. Design and methods: A multilevel longitudinal study of mid-aged (40-67 years) residents (n=6915) of Brisbane, Australia, who lived in the same neighbourhoods (n=200) in 2007 and 2009. Neighbourhood inequalities in cessation and smoking were analysed using multilevel logistic regression and Markov chain Monte Carlo simulation. Results: After adjustment for individual-level socioeconomic factors, the probability of quitting smoking between 2007 and 2009 was lower for residents of disadvantaged neighbourhoods (9.0%-12.8%) than their counterparts in more advantaged neighbourhoods (20.7%-22.5%). These inequalities in cessation manifested in widening inequalities in smoking: in 2007 the between-neighbourhood variance in rates of smoking was 0.242 (p≤0.001) and in 2009 it was 0.260 (p≤0.001). In 2007, residents of the most disadvantaged neighbourhoods were 88% (OR 1.88, 95% CrI 1.41-2.49) more likely to smoke than residents in the least disadvantaged neighbourhoods: the corresponding difference in 2009 was 98% (OR 1.98 95% CrI 1.48-2.66). Conclusion: Fundamentally, social and economic inequalities at the neighbourhood and individual-levels cause smoking and cessation inequalities. Reducing these inequalities will require comprehensive, well-funded, and targeted tobacco control efforts and equity based policies that address the social and economic determinants of smoking.

Multilevel determinants of breast cancer survival : association with geographic remoteness and area-level socioeconomic disadvantage

A major priority for cancer control agencies is to reduce geographical inequalities in cancer outcomes. While the poorer breast cancer survival among socioeconomically disadvantaged women is well established, few studies have looked at the independent contribution that area- and individual-level factors make to breast cancer survival. Here we examine relationships between geographic remoteness, area-level socioeconomic disadvantage and breast cancer survival after adjustment for patients’ socio- demographic characteristics and stage at diagnosis. Multilevel logistic regression and Markov chain Monte Carlo simulation were used to analyze 18 568 breast cancer cases extracted from the Queensland Cancer Registry for women aged 30 to 70 years diagnosed between 1997 and 2006 from 478 Statistical Local Areas in Queensland, Australia. Independent of individual-level factors, area-level disadvantage was associated with breast-cancer survival (p=0.032). Compared to women in the least disadvantaged quintile (Quintile 5), women diagnosed while resident in one of the remaining four quintiles had significantly worse survival (OR 1.23, 1.27, 1.30, 1.37 for Quintiles 4, 3, 2 and 1 respectively).) Geographic remoteness was not related to lower survival after multivariable adjustment. There was no evidence that the impact of area-level disadvantage varied by geographic remoteness. At the individual level, Indigenous status, blue collar occupations and advanced disease were important predictors of poorer survival. A woman’s survival after a diagnosis of breast cancer depends on the socio-economic characteristics of the area where she lives, independently of her individual-level characteristics. It is crucial that the underlying reasons for these inequalities be identified to appropriately target policies, resources and effective intervention strategies.

Transportation disadvantage impedance indexing: A methodological approach to reduce policy shortcomings

Access to transport systems and the connection to such systems provided to essential economic and social activities are critical to determine households' transportation disadvantage levels. In spite of the developments in better identifying transportation disadvantaged groups, the lack of effective policies resulted in the continuum of the issue as a significant problem. This paper undertakes a pilot case investigation as test bed for a new approach developed to reduce transportation policy shortcomings. The approach, ‘disadvantage-impedance index’, aims to ease transportation disadvantages by employing representative parameters to measure the differences between policy alternatives run in a simulation environment. Implemented in the Japanese town of Arao, the index uses trip-making behaviour and resident stated preference data. The results of the index reveal that even a slight improvement in accessibility and travel quality indicators makes a significant difference in easing disadvantages. The index, integrated into a four-step model, proves to be highly robust and useful in terms of quick diagnosis in capturing effective actions, and developing potentially efficient policies.

Economic consideration for reducing hospital presentations among patients with decompensated cirrhosis: not all presentations avoided can be considered equal

Individuals with decompensated cirrhosis and ascites requiring paracentesis utilize exceptionally high levels of hospital resources. Consequently, potential modifications to existing models of healthcare to assist patients in the management of their liver disease and reduce the need for hospital encounters have potential to improve patients’ health and reduce demand on acute hospital services. However, there is a paucity of data examining how much healthcare resources could be re-directed to interventions that prevent hospitalizations without net annual budgetary disadvantage (from the hospital’s perspective). The purpose of this study was to probabilistically examine how much healthcare resourcing could be saved per hospital presentation avoided among this clinical population.