Cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children

Objective
 To assess from a societal perspective the incremental cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children. The intervention was modelled on the LEAP (live, eat and play) trial, a randomised controlled trial conducted by the Centre for Community Child Health, Melbourne, Australia in 2002–2003. This study was undertaken as part of the assessing cost-effectiveness (ACE) in obesity project which evaluated, using consistent methods, 13 interventions targeting unhealthy weight gain in children and adolescents.
Method
A logic pathway was used to model the effects of the intervention compared to no intervention on body mass index (BMI) and health outcomes (disability-adjusted life years—DALYs). Disease costs and health benefits were tracked until the cohort of eligible children reached the age of 100 years or death. Simulation-modelling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. The intervention was also assessed against a series of filters (‘equity’, ‘strength of evidence’, ‘acceptability’, ‘feasibility’, sustainability’ and ‘side-effects’) to incorporate additional factors that impact on resource allocation decisions.
Results
The intervention, as modelled, reached 9685 children aged 5–9 years with a BMI z-score of ≥3.0, and cost $AUD6.3M (or $AUD4.8M excluding time costs). It resulted in an incremental saving of 2300 BMI units which translated to 511 DALYs. The cost-offsets stemming from the intervention totalled $AUD3.6M, resulting in a net cost per DALY saved of $AUD4670 (dominated; $0.1M) (dominated means intervention costs more for less effect).
Conclusion
Compared to a ‘no intervention’ control group, the intervention was cost-effective under current assumptions, although the uncertainty intervals were wide. A key question related to the long-term sustainability of the small incremental weight loss reported, based on the 9-month follow-up results for LEAP.

Chronic illness and its impact : considerations for psychologists

A significant proportion of the population is affected by chronic illnesses, which have a marked impact on psychological adjustment at both the individual and family level. The nature of these illnesses and their impacts is complex, and has implications for psychological practice. This paper reviews these issues, and argues that more emphasis should be given to medical conditions in training programmes for psychologists.

The impact of childhood conditions and concurrent morbidities on child health and well-being

Background. Understanding the impact of illnesses and morbidities experienced by children and adolescents is essential to clinical and population health programme decision making and intervention research. This study sought to: (1) examine the population prevalence of physical and mental health conditions for children and quantify their impact on multiple dimensions of children's health and well-being; and (2) examine the cumulative effect of concurrent conditions.

Methods. We conducted a cross-sectional school-based epidemiological study of 5414 children and adolescents aged 5–18 years, and examined parental reports of child health and well-being using the parent-report Child Health Questionnaire (CHQ) PF50 13 scales are scored on a 0–100 pt scale with clinically meaningful differences of five points and the presence of childhood conditions (illnesses and health problems).

Results. Asthma, dental, vision and allergies are the most commonly identified health problems for children and adolescents, followed by attention- and behaviour-related problems (asthma 17.9–23.2%, dental 11.9–22.7%, vision 7.2–14.7%, chronic allergies 8.8–13.9%, attention problems 5.1–13.8% and behaviour problems 5.7–12.0%). As the number of concurrent health problems increase, overall health and well-being decreases substantively with mean differences in CHQ scale scores of 14 points (−7.69 to −21.51) for physical health conditions, and 28 points (−5.15 to −33.81) for mental health conditions.

Conclusions. Children's health and well-being decreases linearly with increasing presence and frequency of health problems. Having three or more conditions concurrently significantly burdens children's health and well-being, particularly for family-related CHQ domains, with a greater burden experienced for mental health conditions than physical health conditions.

Work choices : Increasing productivity, job creation and work-family balance? Not likely!

The introduction of the Workplace Relations (Work Choices) Amendment Act 2005 (Cth) has resulted in one of the most contentious changes to federal labour law in Australia’s history. There is considerable debate as to whether it has fulfilled the government’s expectations of giving ‘flexibility’ and ‘choice’ to both employees and employers or if there has been an overall deterioration in working conditions. In order to identify the impact of this legislation in the workplace, Deakin University surveyed 11,000 AHRI members throughout Australia. Preliminary results are reported in the paper but, even at this early stage, there is sufficient material to critically comment upon the changes to Australia’s industrial relations system. It appears that the vast majority of AHRI members felt that there had been no change in productivity, job creation or work-family balance and that only a few expected an improvement over the next 3 years.

Personal communities and lifestyle : the role of family, friends and neighbours

Exploration of the impact of personal communities abd its impact on individual lifestyle.

Family circumstance and adolescent dietary behaviours

The available information on the contribution of family circumstance to adolescent dietary behaviours is inconsistent. Indicators of family circumstance may impact adolescent behaviours by influencing their daily home environment. This study examined cross-sectional and longitudinal relationships between indicators of family circumstance and (i) breakfast skipping and (ii) consumption of snack food, fast food, fruits and vegetables among adolescents. Dietary behaviour was assessed using a web-based survey completed by 1884 adolescents from years 7 and 9 of secondary schools in Victoria, Australia, at baseline and 2 years later. Five indicators of family circumstance (parental marital status, maternal education, maternal employment status, number of brothers and number of sisters) were assessed with a questionnaire completed by parents at baseline only. Logistic regression was used to examine cross-sectional associations between indicators of family circumstance and dietary behaviours. Multinomial logistic regression was used to examine associations between indicators of family circumstance and 2-year change in dietary behaviours. Individual indicators of family circumstance were differentially associated with adolescent dietary behaviours. Cross-sectional and longitudinal associations differed for adolescent boys and girls highlighting the importance of assessing specific dietary behaviours and food types individually by gender. This study highlights the complexity of the relationships between family circumstance and adolescent dietary behaviours. Future research needs to assess the efficacy of strategies promoting maternal nutritional knowledge on the dietary behaviours of adolescents.

Importance of assessing family dysfunction in conjunction with standardised measures when treating substance abuse

In this thesis, the link between substance abuse and family dysfunction is examined, and an argument is made for the assessment of family dysfunction when treating clients with substance abuse issues. Family dysfunction has been associated with a broad range of problems in children (e.g., low self esteem, increased risk of child abuse) through to adolescence and adulthood (e.g., increased risk of mental disorders such as depressive disorders, substance abuse disorders, and personality disorders) (Kaplan & Sadock, 1998). It is not the purpose of this thesis to suggest that family dysfunction causes substance abuse but rather to highlight that family dysfunction can in some cases place the individual at greater risk of substance abuse. Therefore, in order to understand the reasons why substance abuse developed and how it is maintained in the present requires the assessment of family dysfunction. Further, the importance of assessing the role and impact that family dysfunction may have had on the client, may help to better understand the nature and extent of substance abuse so that relevant and appropriate treatment goals for change may be set, progress monitored, and risk of relapse reduced. Chapter 1 provides a brief introduction to this thesis, and Chapter 2 is a review of the literature on the impact of family dysfunction including poor parental attachment and supervision, neglect, physical and sexual abuse, in adolescence and adulthood. Four case studies are presented to illustrate how family dysfunction and substance abuse may be related, thus highlighting the importance of assessing family dysfunction when treating substance abuse clients. All of the case studies include an individual with a substance abuse disorder (namely heroin) but they are diverse in terms of the types and extent of family dysfunction. The final chapter discusses the case studies in relation to the literature reviewed. Lastly, it gives consideration to the implication of a history of family dysfunction, and how it may impact negatively on treatment and therefore prognosis.

Fracturing the façade : exploring the impact of childhood sexual abuse

Examination of previous empirical literature illustrates how researchers have concentrated on documenting the impact of childhood sexual abuse (CSA) on the later psychological functioning of survivors, through comparisons with those who have not had such a history. Only more recently has there been a focus on assessing the relationship between aspects of the abuse and specific psychological difficulties. This thesis investigated the relationships between CSA characteristics and women’s later psychological adjustment. The role of attributions, coping methods, parenting competency and marital satisfaction were also investigated. Qualitative data on perception of benefit and general reflections of participants were used to explore participants’ self-esteem, locus of control, decisions relating to parenting, disclosure experiences, and attributions in relation to their abuse, including the search for meaning. Recruitment through newspapers and counselling services led to 118 women volunteering to complete a questionnaire evaluating the characteristics of their CSA and their current psychological adjustment. Of this group, 33 subsequently volunteered to participate in a telephone interview that explored in greater depth issues related to the long-term impact of their CSA. Both quantitative and qualitative analyses were conducted on the data. The women reported a high prevalence of dysfunction in their families of origin. Abuse had generally commenced by middle childhood, and lasted for a number of years and often involved a number of perpetrators. Perpetrators were most likely to be intrafamilial, with stepfathers being over-represented. Sexual activities generally involved physical contact, with participation often induced by the use of coercion. Participants demonstrated significant difficulties in psychological adjustment, but attributions regarding the abuse improved over time. Some concerns were expressed regarding parenting competency, and avoidant coping methods were favoured. In general, participants were satisfied with their current marital relationship. Significant associations were found between coping methods, attributional style, beliefs and various psychological adjustment measures. Participants, in general, demonstrated low self-esteem and displayed an external locus of control. As a consequence of their experience of CSA, many participants reported they had decided not to have children. For those who did have children, CSA was almost universally seen as having had an impact on their parenting. Disclosure of CSA was usually delayed for a number of years, with poor outcomes generally resulting from disclosure when it occurred. Women with current partners rated them as very caring and not controlling. Participants were generally still searching for meaning in their abuse, despite many having accepted it. Survivors outlined an extensive range of long-term effects of CSA, and nominated a number of strategies that would assist in reducing these effects. The results of the study indicated that there are a number of characteristics associated with CSA which signal a higher risk of difficulties in psychological adjustment. Concerns of survivors regarding parenting were confirmed according to those who undertook this role. Unfortunately, concerns expressed by survivors that disclosure of their CSA would have had negative consequences was usually the case when they did finally disclose. However, the accessing of social and family support appeared to have an important role in changing the attributions of survivors regarding their CSA. Furthermore, change of attributions in relation to abuse may provide the key to resilience in survivors against the negative impact of CSA on later psychological adjustment.

Family food environments as determinants of children's eating : implications for obesity prevention

The prevalence of childhood obesity is escalating rapidly and it considered to be a major public health problem. Diet is a recognised precursor of fatness, and current evidence supports the premise that in Westernised countries, the dietary intakes of children are likely to be important in obesity genesis. However, we have a relatively poor understanding of the environments in which a child’s eating is learnt and maintained. Much of the existing work in this area is based on small-scale or experimental studies, or has been derived from homogeneous populations within the USA. Despite these limitations, there is evidence that aspects of the child’s family environment are likely to be important in determining obesity risk in children. This thesis examines the impact of the family food environment on a child’s eating through two related studies. The first study, titled the Children and Family Eating (CAFÉ) study comprised three phases. Phase one involved qualitative interviews with 17 parents of 5-6 year-old children to explore parental perceptions regarding those factors in a child’s environment believed to influence the development of their child’s eating habits. These interviews were used to inform the development of quantitative measures of the family food environment. The second phase involved the development of a Food Frequency Questionnaire (FFQ) to assess dietary intake in 5-6 year-olds. The FFQ was informed by analysis of 1995 Australian National Nutrition Survey data. In the final phase the relationships between dietary intakes of 5-6 year-old children, and potential predictors of dietary intake were examined in a cross-sectional study of 560 families. Predictors included measures of: parental perceptions of the adequacy of their child’s diet; food availability and accessibility; child-feeding; the opportunities for parental modelling of food intake; a child’s television exposure; maternal Body Mass Index; and maternal education. Analysis of the CAFÉ data provides unique information regarding the relationships between a child’s family food environment and their food consumption. Models developed for a range of dietary outcomes considered to be predictive of increased risk for obesity, including total energy and fat intakes, vegetable variety, vegetable consumption, and high-energy (non-dairy) fluid consumption, explained between 11 and 20 percent of the variance in dietary intake. Two aspects of the family food environment, parental perception of a child’s dietary adequacy, and the total minutes of television viewed per day, were frequently found to be predictive of dietary outcomes likely to promote fatness in these children. The second study, titled the Parent Education and Support (PEAS) Feeding Intervention Study, was a prospective pre/post non-randomised intervention trial that assessed the impact of a feeding intervention to 240 first-time mothers of one-year-old children. This intervention focused on one aspect of the family food environment, child-feeding, which has been proposed as influential in the development of obesogenic eating behaviours. In this study, Maternal and Child Health Nurses (MCHNs), using a ‘Division of Responsibility’ model of feeding, taught parents to provide nutritious food at regular intervals and to let children decide if to eat and how much to eat. Thus parents were encourages to food their child without exerting pressure, or employing coercion or rewards (controlling behaviours). The aim was to influence parental attitudes and beliefs regarding child-feeding. Through the use of these feeding techniques, this intervention also aimed to increase the variety of fruits and vegetables a child consumed by teaching parents to persist with offering these foods, over the year of the intervention, in non-emotive environments. Fruits and vegetables were chosen in this intervention because they are likely to be protective in the development of obesity. Analysis of the PEAS data suggests that this low-level feeding intervention, delivered through existing Maternal and Child Health services, was modestly effective in changing parental attitudes and beliefs regarding the feeding of young children. Further, the validity of fruits offered to intervention group children increased. This thesis expands the existing knowledge base by providing a comprehensive analysis of the relative impact of aspects of the family environment on dietary intakes of 5-6 year-olds. Further, the analysis of a feeding intervention in first-time parents provides important insights regarding the potential to influence child-feeding and the impact this may have on the promotion of eating behaviours protective against obesity.

Displaced self : the impact of language-migration on self-identity

In this dissertation I explore the impact that language-migration has on Self-Identity. The thesis consists of two parts: a memoir The Strangeness of Freedom, and an exegesis. Each is intended to stand alone, but also to complement the other. In the memoir I draw on my personal recollections of my family's migrations across five countries (Czechoslovakia, West Germany, USA and Australia) and into three languages (Czech, German and English) in order to convey my particular experience of language migration. In the exegesis I analyse several memoirs written by other language migrants and examine what impact they believe migrating into a new language and culture had on their own Self-identity. I draw on postmodern and psychoanalytic theory to explore the nature of Self-Identity formation and why migrants, as well as non-migrants might experience a change in their Self-identity during the course of their lives. I attempt to tease out to what extent the change in Self-identity is a universal experience that results from living across time and moving from a known past into an unknown future, regardless of whether one physically migrates or not. I found that while language-migrants tend to describe a more intense disruption of their Self-Identity, non-migrants also experience such a disruption in their sense of Self, simply by living in a rapidly changing world. I propose that while changing locations and languages clearly disrupts the continuity we presume life entails, it is in fact the passage of time that distances us from our known past, including our familiar Self, even if we never physically or linguistically migrate.

Mental health and life satisfaction of young Australians : the role of family background

This paper uses the Household, Income and Labour Dynamics in Australia Survey to investigate the factors that influence young Australians’ mental health and life satisfaction, with an emphasis upon the role of family background. It also explores male and female differences concerning those background effects. The results indicate a particularly significant negative association between parental divorce and well-being, and suggest that the timing of divorce matters. Distinguishing the samples by gender shows that this relationship remains significant only for females. Past living arrangements consistently turn out to be statistically insignificant whether the sample used is the total, males or females. The current living arrangements, however, appear to be significantly associated with both mental health and life satisfaction of males. Adding potentially confounding characteristics to our basic regression, which includes only the family background variables, suggests that some of the ‘aggregate’ effects of family background might work indirectly through the mediating variables such as education or lifestyles, though most of them remain direct. Among those, marital status, education, labour market experience and lifestyles seem to be the major factors explaining the dispersion in well-being of young Australians. Income and wealth, on the other hand, have only a minor impact.

The impact of caring for a child with cerebral palsy : quality of life for mothers and fathers

Background:  Although it is expected that caring for a child with cerebral palsy (CP) can impact on the quality of life (QOL) of caregivers, the QOL of carers' has yet to be adequately examined. The aims of this study are to: (1) explore the QOL of mothers and fathers of children with CP aged 3–18 years; and (2) examine whether the impact of caring for a child with CP changes from childhood to adolescence.

Method: A qualitative study was conducted utilizing a grounded theory framework. Twenty-four mothers and 13 fathers of children and adolescents with CP aged 3–7 years (n = 15), 8–12 years (n = 10) and 13–18 years (n = 12) and with varying levels of impairment (GMFCS Level I = 1, II = 4, II = 3, IV = 5, V = 12) participated in semi-structured interviews about their QOL. The transcripts were analysed to identify issues affecting parental QOL.

Results: There were no differences in parental QOL among subgroups (i.e. mothers and fathers, age groups, GMFCS levels). Parental QOL ranged across a wide spectrum. Caring for a child with CP affects a parent's physical well-being, social well-being, freedom and independence, family well-being and financial stability. Parents indicated that they often feel unsupported by the services they access.

Conclusions: Caring for a child with CP can both positively and negatively impact on a parent's life. There is value for both parents and children if parental concerns and determinants of QOL are considered in overall programme planning and service delivery for children and their families.

Psychological impact of breast and prostate cancer on patients and partners

Aims to identify and describe the psychological experiences of breast and prostate cancer patients and their partners, in terms of adjustment, coping and support issues.

Exploring jockey and family life through a social health lens

Workplace practices form an overarching social determinant of health for Victorian jockeys and their families. This research highlights the importance of riding opportunity, coping with risk and danger, and the gratification associated with the lifestyle to be key characteristics that impact on jockey family health for the better or worse.

The impact of parental multiple sclerosis on the adjustment of children and adolescents.

Thirty-one parents with multiple sclerosis (MS) participated in a study to investigate the adjustment of their children, 24 boys and 24 girls aged 4 to 16 years. The majority of parents believed that their illness had an effect on their children. The perception of parents regarding their children's problems in the areas of emotions, concentration, behavior, or social interactions indicated that the children were at three times greater risk than the general community of developing psychological problems. In contrast, actual symptom scores reported by parents revealed that, although these children were at greater risk than the general community of developing peer problems, little difference was found on hyperactivity, emotional symptoms, conduct problems, or total difficulties. Parental negative affect predicted both parental reports of peer problems and perceptions that the parents' illness had an effect on their children. Parental relationship satisfaction and family income did not predict parental reports of children's level of adjustment. These results indicate that children of parents with MS demonstrate more difficulties in how they relate to others, the distress they experience, and how they manage their lives, rather than revealing higher levels of symptoms. Since the data were based on parental reports of their children's problems, the results may also be due to negative affect among the parents.