Willingness to initiate insulin among adults with type 2 diabetes in Australian primary care: results from the Stepping Up Study

AIMS: To determine 'hypothetical willingness' to initiate insulin, and identify associated factors, among adults with type 2 diabetes (T2DM) in primary care for whom insulin is clinically indicated.

METHODS: Eligible participants were adults with T2DM with an HbA1c ≥7.5% (58mmol/mol) and prescribed maximum oral hypoglycaemic agents. A total of 261 participants were recruited from 74 Victorian general practices: mean age 62±10 years; 39% (n=103) women; diabetes duration 10±6 years; HbA1c 9.0±1.3% (75±14mmol/mol). Data collected by the Stepping Up Study: demographic and clinical characteristics, 'willingness' to initiate insulin, insulin appraisals, depressive symptoms, and diabetes-related distress. A multinomial regression investigated predictors of 'willingness'.

RESULTS: Nineteen percent (n=50) were 'very willing' to initiate insulin, if recommended. The final regression model (R(2)=.44, χ(2)(12) 145.91, p<.001) demonstrated higher socioeconomic status and less negative attitudes to insulin were associated with increased willingness to initiate insulin.

CONCLUSIONS: Among adults with T2DM for whom insulin is clinically indicated, only one in five are 'very willing' to begin insulin therapy. Independent of demographics, clinical factors and emotional wellbeing, insulin appraisals were associated with 'willingness'. This study highlights the importance of addressing attitudinal barriers to insulin therapy among adults with T2DM in primary care to improve insulin receptiveness.

If the price is right : vagueness and values clarification in contingent valuation

The use of willingness to pay to value the benefits of health care is increasing. Much of this work assumes that health preferences are well formed or complete and readily revealed if the right question is asked in the right way. We examined this assumption, seeking evidence in a mixed-methods study that explored the meaning and implications of vague responses to a payment-scale based willingness to pay exercise.

One-half of the sample said that their vagueness meant that their maximum willingness to pay was actually greater than the amount that they had previously said it was. Thirty percent agreed that they would probably pay £10 more than a sum that they had previously said they would most definitely not pay, if they found this to be the cost of the vaccine. Interview data supported the view that the payment scale had failed to elicit the maximum willingness to pay and that some participants used the information on cost to help clarify their values, in contrast to the theory underpinning willingness to pay. The results suggest a need to consider values-clarification in health economic evaluations. Copyright © 2002 John Wiley & Sons, Ltd.

Contingent valuation in health care and the persistence of embedding effects without the warm glow

This paper reports a test of the presence of embedding effects in a health care contingent valuation study. A within-subject, mixed qualitative–quantitative approach was used to identify and explain the presence of embedding in estimates of willingness to pay for vaccinations. Embedding effects persisted despite controlling for known causes and did so even among respondents who perceived the effect to be anomalous. Results from the qualitative interviews suggest that embedding effects arise for varied reasons but might be indicative of incomplete preferences. It is questionable, however, whether survey techniques can be better designed to encourage values clarification.

Toward sustainable forest management : the potential contribution of timber certification and product labelling in Victoria

Sustainable forest management has emerged as a major international forestry issue. This research assessed the potential contribution of certification and labelling to sustainable forest management in Victoria. The results indicate a potential demand for certified forest products and a consumer willingness to pay to ensure forests are managed sustainably.

Economic value of mitigation of plant invaders in a subsistence economy : incorporating labour as a mode of payment

This paper presents the analysis of a choice experiment designed to estimate willingness-to-pay (WTP) to mitigate damages caused by invasive plant species in a rural community of Nepal. In order to address the cash constraints problem in a subsistence economy, two payment attributes, labour contribution and membership fee, were included in the choice sets. The results reveal that rural farmers have significant WTP for forest management activities, in terms of both cash and labour contributions. The results also suggest that rural farmers value their time in this context at a different rate from the current wage rate.

The cost-effectiveness of the Dose Adjustment for Normal Eating (DAFNE) structured education programme: an update using the Sheffield Type 1 Diabetes policy model

AIMS: 
To estimate the cost-effectiveness of training in flexible intensive insulin therapy [as provided in the Dose Adjustment for Normal Eating (DAFNE) structured education programme] compared with no training for adults with Type 1 diabetes mellitus in the UK using the Sheffield Type 1 Diabetes Policy Model.

METHODS: 
The Sheffield Type 1 Diabetes Policy Model was used to simulate the development of long-term microvascular and macrovascular diabetes-related complications and the occurrence of diabetes-related adverse events in 5000 adults with Type 1 diabetes. Total costs and quality-adjusted life years were estimated from a National Health Service perspective over a lifetime horizon, discounted at a rate of 3.5%. The treatment effectiveness of DAFNE was modelled as a reduction in HbA1c that affected the risk of developing long-term diabetes-related complications. Probabilistic and structural sensitivity analyses were conducted.

RESULTS:
DAFNE resulted in greater life expectancy and reduced incidence of some diabetes-related complications compared with no DAFNE. DAFNE was found to generate an average of 0.0294 additional quality-adjusted life years for an additional cost of £426 per patient, leading to an incremental cost-effectiveness ratio of £14 400 compared with no DAFNE. There was a 54% probability that DAFNE would be cost-effective at a willingness-to-pay threshold of £20 000 per quality-adjusted life year.

CONCLUSIONS: 
The results of this study suggest that DAFNE is a cost-effective structured education programme for people with Type 1 diabetes and support its provision by the National Health Service in the UK.

Entecavir for the treatment of chronic hepatitis B infection

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of entecavir for the treatment of chronic hepatitis B (CHB) in adults based upon a review of the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submission's evidence came from five randomised controlled trials (RCTs), of good methodological quality and measuring a range of clinically relevant outcomes, comparing entecavir with lamivudine. After 1 year of treatment entecavir was statistically superior to lamivudine in terms of the proportion of patients achieving hepatitis B virus (HBV) DNA suppression, alanine aminotransferase (ALT) normalisation and histological improvement, but not in terms of the proportion of patients achieving hepatitis B e antigen (HBeAg) seroconversion. The incidence of adverse or serious adverse events was similar for both treatments. The results of the manufacturer's mixed treatment comparison (MTC) model to compare entecavir with the comparator drugs in nucleoside-naive patients were considered to be uncertain because of concerns over its conduct and reporting. For the economic evaluation the manufacturer constructed two Markov state transition models, one in HBeAg-positive and one in HBeAg-negative patients. The modelling approach was considered reasonable subject to some uncertainties and concerns over some of the structural assumptions. In HBeAg-positive patients the base-case incremental cost-effectiveness ratios (ICER) for entecavir compared with lamivudine and pegylated interferon alpha-2a were 14,329 pounds and 8403 pounds per quality-adjusted life-year (QALY) respectively. Entecavir was dominated by telbivudine. In HBeAg-negative patients the base-case ICERs for entecavir compared with lamivudine, pegylated interferon alpha-2a and telbivudine were 13,208 pounds, 7511 pounds and 6907 pounds per QALY respectively. In HBeAg-positive lamivudine-refractory patients entecavir dominated adefovir added to lamivudine. In one-way deterministic sensitivity analysis on all key input parameters for entecavir compared with lamivudine in nucleoside-naive patients, ICERs generally remained under 30,000 pounds per QALY. In probabilistic sensitivity analysis in nucleoside-naive HBeAg-positive patients the probability of the ICER for entecavir being below 20,000 pounds per QALY was 57%, 82% and 45% compared with lamivudine, pegylated interferon alpha-2a and telbivudine respectively. In nucleoside-naive HBeAg-negative patients the probabilities were 90%, 100% and 96% respectively. The manufacturer's lifetime treatment scenario for HBeAg-negative patients and the ERG's 20-year treatment scenario for HBeAg-positive patients increased the ICERs, particularly in the latter case. Amending the HBeAg-negative model so that patients with compensated cirrhosis would also receive lifetime treatment gave probabilities of entecavir being cost-effective at a willingness to pay of 20,000 pounds and 30,000 pounds of 4% and 40% respectively. The NICE guidance issued in August 2008 as a result of the STA states that entecavir is recommended as an option for the treatment of people with chronic HBeAg-positive or HBeAg-negative hepatitis B in whom antiviral treatment is indicated.

Evaluation of community participation for the development of culture-based fisheries in village reservoirs of Sri Lanka

In this paper, an attempt is made to identify the socioeconomic characteristics of a community that influence the development and management of culture-based fisheries in village reservoirs of Sri Lanka. Socioeconomic data were collected from 46 agricultural farming communities associated with 47 village reservoirs in Sri Lanka. Principal component analysis indicated that scores of the first principal component were positively influenced by socioeconomic characteristics that are favorable for making collective decisions. These included leadership of the officers, age of the group, percentage of active members of the group, percentage of kinship of the group, percentage of common interest of the group, and percentage of participation of the group. The size of the group had a negative effect on the first principal component. The principal component scores of communities were positively related to willingness to pay (P < 0.001). The communities with socioeconomic characteristics favoring collective decision making were in favor of culture-based fisheries. Homogeneity of group characteristics facilitated successful development of culture-based fisheries.

Local population preferences toward restoring ecosystem services of a wetland in Thailand

This study reports the findings of a choice experiment designed to explore local population preferences toward wetland ecosystem restoration of Bung Khong Long Wetland in Thailand. By addressing ecological, socioeconomic and cultural dimensions of ecosystem services, the findings provide policy-makers with a richer insight into the interconnections among ecological, socioeconomic and cultural systems in explaining the value of ecosystem services. Gaining an understanding of the trade-offs associated with different interests in ecosystem uses in this community has the capacity to promote wetland management and enhance land use planning. The choice experiment application entails selecting attributes and their levels and developing an experimental design to create the choice sets or hypothetical scenarios for welfare assessment via the questionnaire. The study is based on household level data collected from 780 randomly drawn respondents living around the lake and the data are analysed using the Random Parameter Logit Model with interactions. The findings indicate that the local population derives positive and significant values from the restoration of wetland ecosystem services, indicating caution is needed in the decision-making processes involving sensitive environments faced with competing uses. Socioeconomic and attitudinal characteristics of respondents are important factors influencing willingness to pay, implying community preferences are important in the effectiveness of environmental conservation efforts in this community. The cultural values associated with the wetland are significant suggesting that incorporating culture preferences may be a key factor in supporting wetland conservation.

Burden of epilepsy: a prevalence-based cost of illness study of direct, indirect and intangible costs for epilepsy

OBJECTIVES: We aimed to gauge the burden of epilepsy in China from a societal perspective by estimating the direct, indirect and intangible costs. METHODS: Patients with epilepsy and controls were enrolled from two tertiary hospitals in China. Patients were asked to complete a Cost-of-Illness (COI), Willingness-to-Pay (WTP) questionnaires, two utility elicitation instruments and Mini Mental State Examination (MMSE). Healthy controls only completed WTP questionnaire, and utility instruments. Univariate analyses were performed to investigate the differences in cost on the basis of different variables, while multivariate analysis was undertaken to explore the predictors of cost/cost component. RESULTS: In total, 141 epilepsy patients and 323 healthy controls were recruited. The median total cost, direct cost and indirect cost due to epilepsy were US$949.29, 501.34 and 276.72, respectively. Particularly, cost of anti-epileptic drugs (AEDs) (US$394.53) followed by cost of investigations (US$59.34), cost of inpatient and outpatient care (US$9.62) accounted for the majority of the direct medical costs. While patients' (US$103.77) and caregivers' productivity costs (US$103.77) constituted the major component of indirect cost. The intangible costs in terms of WTP value (US$266.07 vs. 88.22) and utility (EQ-5D, 0.828 vs. 0.923; QWB-SA, 0.657 vs. 0.802) were both substantially higher compared to the healthy subjects. CONCLUSIONS: Epilepsy is a cost intensive disease in China. According to the prognostic groups, drug-resistant epilepsy generated the highest total cost whereas patients in seizure remission had the lowest cost. AED is the most costly component of direct medical cost probably due to 83% of patients being treated by new generation of AEDs.

Super Blooper? Time to halt the superannuation juggernaut?

The superannuation industry has increased almost exponentially in Australia over the past decade. The main reason for this is because government  regulation compels employers to pay a fixed portion of employees’ salary  towards superannuation. In this article we suggest that the unremitting  government policy of coercing money towards superannuation is flawed. Superannuation is wrong at two levels. First, on an economic analysis, the evidence does not suggest that (i) individuals who invest in superannuation are necessarily better off than those who apply their income elsewhere; and (ii) there is no evidence that absent a coercive superannuation scheme the government will be unable to sustain people into their old age. Second, at the human and societal level, studies of human well-being show that coercing people to make spending decisions is inimical to human happiness. People flourish best when they are in control of their activities, including their finances. Left to their own devices, many people will not save for a rainy day; however, on balance it is probably better off to be a bit poorer in retirement than to have been deprived of the opportunity to spend 9% of one’s income over the period of one’s working life – when one’s needs are the greatest. Compulsory superannuation should be abolished. Money currently paid as a compulsory superannuation contribution should instead be paid to the employee as a salary.

Institutional economics approach to irrigation management with special reference to developing countries

Neoclassical economics has failed to address irrigation management issues in developing countries successfully. Institutions are at the heart some of these failures. Many academics in various disciplines in the social sciences now emphasize the need to pay attention to the multitude of informal institutions such as rotational irrigation in developing countries and not to treat them as irrelevant for development. Water user associations have been initiated for irrigation management in many countries. These have shown much promise although many problems still constrain the full adoption of this institutional mode. Water pricing is still at its infancy and significant problems remain in the use of the market system for improved management of irrigation water.

Follow your heart and something will come : subjective factors in the sustainability of early to mid career contemporary dance artists

This project comes out of a desire to investigate the subjective factors that influence how and why people become and stay dance artists. When dance artists in Australia earn, on average, $27,000 per year, and only $16,700 of that income is dance-related, according to David Throsby’s (2003) recent study for the Australia Council, one has to start to think that maybe sustainability, that is, artists’ ability and willingness to stay within the industry, is not solely governed by economic factors. One has to also start to think that subjective factors, things to do with the value, satisfaction and quality of life dance artists get from what they do, might be as significant, if not more significant, drivers of sustainability than pure economics.

What help do young women want in their efforts to control their weight? Implications for program development

The aim of this study was to examine women's views on the usefulness of various types of information and practical sessions on weight control, their preferences for program delivery, and likelihood of participation. Cross-sectional survey of 462 women aged 18–33 years randomly selected from the community was conducted. We examined the perceived usefulness of various types of information and practical classes on weight control; preferred mode of delivery; willingness to participate. Among the women 82% were interested in trying to lose or control weight. Information on weight control was considered to be more useful than practical sessions. Information about meal planning, cooking and low-fat recipes and how to manage stress was considered most useful. Fifty-eight per cent of women reported they would prefer to participate in an individual face-to-face program delivered by a health professional. Thirty-one per cent of women reported it was very likely that they would participate in a program if it included the sort of things they considered useful and was offered in the way they preferred; a further 35% felt it 'likely'. It appears that health professional-delivered, individual, information-based programs appear most popular among this target group. Tailoring the content and delivery mode of weight management programs to young women's preferences may enhance program participation.

Listening to students' voices in mathematics education

In many tertiary institutions, mathematics education staff teach courses from early childhood education through to professional development courses at Masters level. Similarly, research into teacher education processes spans these contexts. Common principles that underpin this work include staff willingness to be responsive to students’ needs. This symposium focuses on the importance of listening to students’ voices in mathematics teaching and research – no matter how old students are.