The cost-effectiveness of Australia's active after-school communities program

The objective of this study was to assess from a societal perspective the cost-effectiveness of the Active After-school Communities (AASC) program, a key plank of the former Australian Government's obesity prevention program. The intervention was modeled for a 1-year time horizon for Australian primary school children as part of the Assessing Cost-Effectiveness in Obesity (ACE-Obesity) project. Disability-adjusted life year (DALY) benefits (based on calculated effects on BMI post-intervention) and cost-offsets (consequent savings from reductions in obesity-related diseases) were tracked until the cohort reached the age of 100 years or death. The reference year was 2001, and a 3% discount rate was applied. Simulation-modeling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. An assessment of second-stage filter criteria ("equity," "strength of evidence," "acceptability to stakeholders," "feasibility of implementation," "sustainability," and "side-effects") was undertaken by a stakeholder Working Group to incorporate additional factors that impact on resource allocation decisions. The estimated number of children new to physical activity after-school and therefore receiving the intervention benefit was 69,300. For 1 year, the intervention cost is Australian dollars (AUD) 40.3 million (95% uncertainty interval AUD 28.6 million; AUD 56.2 million), and resulted in an incremental saving of 450 (250; 770) DALYs. The resultant cost-offsets were AUD 3.7 million, producing a net cost per DALY saved of AUD 82,000 (95% uncertainty interval AUD 40,000; AUD 165,000). Although the program has intuitive appeal, it was not cost-effective under base-case modeling assumptions. To improve its cost-effectiveness credentials as an obesity prevention measure, a reduction in costs needs to be coupled with increases in the number of participating children and the amount of physical activity undertaken.

Effectiveness of IT-based diabetes management interventions: a review of the literature

Background : Information technology (IT) is increasingly being used in general practice to manage health care including type 2 diabetes. However, there is conflicting evidence about whether IT improves diabetes outcomes. This review of the literature about IT-based diabetes management interventions explores whether methodological issues such as sample characteristics, outcome measures, and mechanisms causing change in the outcome measures could explain some of the inconsistent findings evident in IT-based diabetes management studies.

Methods : Databases were searched using terms related to IT and diabetes management. Articles eligible for review evaluated an IT-based diabetes management intervention in general practice and were published between 1999 and 2009 inclusive in English. Studies that did not include outcome measures were excluded.

Results : Four hundred and twenty-five articles were identified, sixteen met the inclusion criteria: eleven GP focussed and five patient focused interventions were evaluated. Nine were RCTs, five non-randomised control trials, and two single-sample before and after designs. Important sample characteristics such as diabetes type, familiarity with IT, and baseline diabetes knowledge were not addressed in any of the studies reviewed. All studies used HbA1c as a primary outcome measure, and nine reported a significant improvement in mean HbA1c over the study period; only two studies reported the HbA1c assay method. Five studies measured diabetes medications and two measured psychological outcomes. Patient lifestyle variables were not included in any of the studies reviewed. IT was the intervention method considered to effect changes in the outcome measures. Only two studies mentioned alternative possible causal mechanisms.

Conclusion : Several limitations could affect the outcomes of IT-based diabetes management interventions to an unknown degree. These limitations make it difficult to attribute changes solely to such interventions.

The cost-effectiveness of removing television advertising of high-fat and/or high-sugar food and beverages to Australian children

Objective: To model the health benefits and cost-effectiveness of banning television (TV) advertisements in Australia for energy-dense, nutrient-poor food and beverages during children's peak viewing times.

Methods: Benefits were modelled as changes in body mass index (BMI) and disability-adjusted life years (DALYs) saved. Intervention costs (AUD$) were compared with future health-care cost offsets from reduced prevalence of obesity-related health conditions. Changes in BMI were assumed to be maintained through to adulthood. The comparator was current practice, the reference year was 2001, and the discount rate for costs and benefits was 3%. The impact of the withdrawal of non-core food and beverage advertisements on children's actual food consumption was drawn from the best available evidence (a randomized controlled trial of advertisement exposure and food consumption). Supporting evidence was found in ecological relationships between TV advertising and childhood obesity, and from the effects of marketing bans on other products. A Working Group of stakeholders provided input into decisions surrounding the modelling assumptions and second-stage filters of 'strength of evidence', 'equity', 'acceptability to stakeholders', 'feasibility of implementation', 'sustainability' and 'side-effects'.

Results: The intervention had a gross incremental cost-effectiveness ratio of AUD$ 3.70 (95% uncertainty interval (UI) $2.40, $7.70) per DALY. Total DALYs saved were 37 000 (95% UI 16 000, 59 000). When the present value of potential savings in future health-care costs was considered (AUD$ 300m (95% UI $130m, $480m), the intervention was 'dominant', because it resulted in both a health gain and a cost offset compared with current practice.

Conclusions: Although recognizing the limitations of the available evidence, restricting TV food advertising to children would be one of the most cost-effective population-based interventions available to governments today. Despite its economic credentials from a public health perspective, the initiative is strongly opposed by food and advertising industries and is under review by the current Australian government.

Cost-effectiveness of adult circumcision in a resource-rich setting for HIV prevention among men who have sex with men

Background.  We examined the effects and cost‐effectiveness of 4 strategies of circumcision in a resource‐rich setting (Australia) in a population of men who have sex with men (MSM).

Method.  We created a dynamic mathematical transmission model and performed an economic analysis to estimate the costs, outcomes, and cost‐effectiveness of different strategies, compared with those of the status quo. Strategies included circumcision of all MSM at age 18 years, circumcision of all MSM aged 35–44 years, circumcision of all insertive MSM aged 18 years, and circumcision of all MSM aged 18 years . All costs are reported in US dollars, with a cost‐effectiveness threshold of $42,000 per quality‐adjusted life‐year.

Results.  We find that 2%–5% of human immunodeficiency virus (HIV) infections would be averted per year, with initial costs ranging from $3.6 million to $95.1 million, depending on the strategy. The number of circumcisions needed to prevent 1 HIV infection would range from 118 through 338. Circumcision of predominately insertive MSM would save $21.7 million over 25 years with a $62.2 million investment. Strategies to circumcise 100% of all MSM and to circumcise MSM aged 35–44 years would be cost‐effective; the latter would require a smaller investment. The least cost‐effective approach is circumcision of young MSM close to their sexual debut. Results are very sensitive to assumptions about the cost of circumcision, the efficacy of circumcision, sexual preferences, and behavioral disinhibition.

Conclusions.  Circumcision of adult MSM may be cost‐effective in this resource‐rich setting. However, the intervention costs are high relative to the costs spent on other HIV prevention programs.

Patterns of treatment of external genital warts in Australian sexual health clinics

Background: External genital warts are a common sexually transmitted viral disease. We describe the patterns of treatment for initial presentations of external genital warts (EGWs) in Australian sexual health centers.
Methods: This was a retrospective audit of 489 case notes from consecutive individuals who presented with a new diagnosis of EGWs to 1 of 5 major sexual health clinics in Australia. Eligibility criteria were consecutive patients aged 18 to 45 years inclusively, presenting with first ever episode of EGWs from January 1, 2004. Exclusion criteria were patients who were immunocompromised, including HIV infection, or enrollment in a treatment study for EGWs.
Results: The median age at presentation of women was 23.2 years and of men 26.8 years. One quarter (n = 127) of patients had another sexually transmitted infection diagnosed at presentation. Nearly half of the patients (n = 224) presented only once for treatment. Most often, patients were treated with a monotherapy (n = 382/489; 78%), usually cryotherapy (257; 53%). Staff applied treatment in 361 (74%) cases. There was wide variation across sites, possibly reflecting local policies and budgets. We found no difference in wart resolution (n = 292; 60%) by initial treatment chosen.
Conclusions: The diagnosis and treatment of genital warts constitute a sizable proportion of clinical visits to the audited sexual health services and require a large input of staff time to manage, including the application of topical treatments. Our results help complete the picture of the burden of EGWs on Australian sexual health centers before the introduction of the HPV vaccine.

Effectiveness of the development of internal auditing in the Victorian Public Service (1982-1987)

The selection of an inappropriate regime by policy makers can thwart the effective implementation of public policy and lead to implementation failure. Competing values in the implementation process have a significant impact on the results of implementation, and the regime selected for implementation implies the choice of one value over another. Stoker has argued that on the one hand central leadership is valued for consistency, benefits of scale, co-ordination and cost sharing (instrumental model); and on the other, diffuse authority is valued as knowledge is particular and situational, and the task of analysis is to understand the problems, perspectives and interactions of implementation participants at the contact point between public programs and their clients (accommodation model). This study examines the implementation regime chosen by the Victorian Government for the introduction of a modern internal auditing function into the Victorian Public Service, using the Bureau of Internal Audit within its Department of Management and Budget. The selection of the Department of Management and Budget for the introduction of Internal Audit as a managerial accountability mechanism indicates that the instrumental model was held by the Victorian Government to be the most important in implementation. It is argued that use of a top-down central agency leadership approach resulted in implementation failure. Three propositions suggesting the mechanisms by which this result is brought about are examined: that lack of co-ordinated planning at the outset will result in inadequate definition of client needs as part of policy formulation; that intraorganisational conflict during the implementation success, as individual participants are likely to exercise their veto; and the increasing the number of participants contributes to complexity, so that they should only be involved in implementation when their presence is absolutely required. It is argued that the essential task of implementation is to create an environment where participants are likely to co-operate to achieve predetermined public policy goals; and that the introduction of a modern internal auditing approach into the Victorian Public Service required a more participatory implementation regime in order to facilitate policy outcomes and prevent implementation failure. It is also argued that the dominance of economic reform over accountability in Victoria restricted the ability of the Bureau of Internal Audit to implement change to internal audit practices within Victorian Government departments. The selection of an instrumental model of implementation by the Department of Management and Budget is examined in the context of the environment that existed in Victoria between 1982-1987; and while some of the values which Stoker associates with the top-down approach to policy making were observed, an alternative view to the development of internal auditing in the Victorian Public Service can be sustained.

Effectiveness of recording in primary science : a study of the ability of junior primary school pupils to use drawing as an effective method of communication in science lessons

Drawing as a means of recording is a very common practice in junior primary science lessons. This is largely due to the availability of necessary materials. Also, most youg children have some degree of drawing skill and enjoy drawing activities. Since 1956 the science curriculum to be implemented in primary classrooms in Victoria has changed from one that was based largely on nature study (biological) to one that includes physical and technological aspects. Further, there have been changes in the teaching methodologies advocated for use in science lessons. A modified Interactive Teaching Approach was used for the studies. Drawing was the main means by which the children recorded information. The topic of 'shells' was used to enable collection of data about the children's enjoyment of the activity and satisfaction with their achievement. This study was replicated using the topic 'rocks'; again data were collected concerning satisfaction and enjoyment. During a series of lessons on 'snails' data were collected concerning the achievement of 'process' and 'objective' purposes that teachers might have in mind when setting a drawing activity. In addition to providing data about purposes the study stimulated some questions regarding the techniques the children had used in their drawings. Accordingly, data concerning the use of graphic techniques by the children were collected during a series of lessons on 'oils'. The data collected and analysed in the various studies highlighted the value of drawing in junior primary school science lessons. It also validated strategies developed by the author and designed to help teachers and children use drawing effectively in science activities.

Studies in supervisory practice : the effectiveness of the practicum in teacher education in the Northern Territory

In this thesis we descend into the swampy lowlands to meet with student-teachers and their supervisors and observe them working together at different sites across the Top End of Australia. In the process we discover the multiple relationships that comprise the practicum text and the discomforting untidiness and unwieldiness, as well as the awkwardness of complexity, which surrounds research into supervisory practice. The thesis demonstrates the need to attend to the subjectivities of the participants and highlights the conflicting attitudes, beliefs, interests, and desires which are only partially realised or understood. It moves us beyond language to the sentient world of anger, love, disgust, hope, fear, despair, joy, anguish, and pain and we become immersed in a murky, incoherent, interior world of hints, shadows, and unfamiliar sounds, a world of lost innocence and conflict in which knowledge is truly embodied. Encompassing a view of supervision as moral praxis, particular attention was given to the care and protection of the self and a romanticist conception of the self was seen to predominate. The thesis demonstrates the part played by positioning and agency in the process of subjectification, the importance of emotional and relational bonding in the emergence of collegiality, the tactics of power employed by supervisors, the struggle for personal autonomy, the presence of anxiety induced by failure to pro vide feedback, the inculcation of guilt, and the complex interplay of age-related and gender effects. Attention is also given to the degree to which supervisors adopt reflective and constructivist approaches to their work. The stories reveal that supervision is much more than advising student-teachers on curriculum content, resource availability and lesson presentation. It is a process of interiority in which supervisors may need to provide emotional support in the face of displacement and disorientation, and assume the role of an abiding presence, someone capable of imaginative introjection, someone who ‘knows’. Particular attention is paid to the language of supervision which was marked by indirection, diffidence, imprecision, irony, and understatement. At the same time, the agonistic nature of language associated with the politics of the personal is made apparent. Whilst in the opinion of Liaison Lecturers, context-of-site did not appear to matter as far as acquiring teaching competence was concerned, the failure to attend to context-of-site affected how student-teachers engaged with difference and diversity. In spite of attempts to contest the myths of Aboriginal education and interrupt the discourse of impoverishment, colonialist attitudes and resistance to liberatory education persisted. The thesis ends with suggestions for alternatives to the traditional practicum and discusses the introduction of Field-Based Teacher Education into Northern Territory schools.

Use and cost effectiveness of computer based training in the insurance industry

Training is essential to the growth and economic well-being of a nation. This need for training pervades all levels of industry, from a national level where a country’s well being is enhanced by training, to each company where productivity is improved, down to the individual whose skills are enhanced and as a result improve their position in the employment marketplace. The Australian Bureau of Statistics report ‘Training and Education Experience –Australia’ (ABS 1993) indicates that training in Australia is undertaken at a significant level with some 86% of employers undertaking some form of training. This is slightly higher in the Finance industry at a little over 89%. On the job training is undertaken by 82% of employers and off the job training is used by 47% of employers. In 80% of the off the job cases these courses were conducted in a conventional manner using an instructor. The remaining 20% of cases were either self paced (14%) or instructor based (6%). These latter cases could involve Computer Based Training (CBT). The report, referred to in the last paragraph, also indicates that a significant aspect of business in Australia is that 95% of businesses have less than 20 staff. This poses significant problems in that the ability to deliver effective training is limited. With businesses as small as these their size does not permit them to carry specialist training personnel so this role falls to the senior staff. These people already have a full workload and their ability to be able to take on training duties is limited. In addition these people were employed for their technical skills, not training. It may be that their ability to fill the role of a trainer is not good and as a result the training may not be very effective. In addition, small business has difficulty in releasing staff for training, The difficulties faced by small business were recognised by the Australian National Training Authority in their 1995 report which indicated that there was a need to develop a ‘training culture’ among small business employers. The authority made a commitment to provide flexible delivery strategies. This includes Computer Based Training (CBT). CBT has existed since the 1970’s. It came on to the scene with a flourish and tended to provide ‘page turning’ programs or ‘drill and practice programs’. In limited areas this form of training became popular but its popularity waned in the 80’s. With the advent of better graphical displays, larger and faster memory, and improved programs in the 1990’s the quality of CBT today is superior to those offered in the 70’s and has greater appeal. Today, still photographs and video clips can be displayed and made interactive. Because of this CBT is making a comeback and starting to have a greater impact. The insurance industry covers a wide range of companies in Australia, these companies vary in size from companies with employees in the thousands to companies with less than five staff. While the needs of the employees of each are similar the ability of these companies to deliver the training varies significantly. Any training can be divided into two parts. Internal or on the job training and external. External training deals with those aspects that concern the industry as a whole whereas internal training affects the individual company. Internal training would deal with matters like company procedures, company products and the like. External training deals with matters such as legislation, products generally, and the like. In the insurance industry the major problem arises with the small companies. Insurance companies would tend to be large in size and able to cover their training costs but the insurance brokers who would make up, numerically, the major number of companies would have a significant number of companies that fall into the 20 staffer less category. In fact many would have a staff of less than 5. While CBT can benefit all companies it is these small companies that could benefit from it the most. This thesis examines: • The place of CBT in training, its cost and effectiveness. • The incidence of CBT in the insurance industry and how the industry determines its effectiveness. • If a program that meets an industry need is able to be produced at a realistic price?

Evaluation of the effectiveness of marine protected areas in temperate waters of Australasia

An evaluation of the effectiveness of Marine Protected Areas (MPAs) in temperate waters of Australasia has been conducted for this thesis. The aim was to identify key elements needed in a strategy for establishment and management of MPA’s in temperate waters of Australasia. This aim was achieved by assessing how effective a sample of MPA’s has been in meeting the conservation objectives for their establishment and by identifying factors that have contributed to success or failure of the MPA’s in meeting these objectives. Particular attention was paid to the objectives of ecological sustainability and biodiversity preservation. A MPA for the purposes of this research was defined as an area of coastal or marine environment, with a substantial subtidal component, set aside by law primarily for conservation purposes. The study region encompassed the coastal zones of Victoria, Tasmania and South Australia (Australia) and New Zealand. The questions posed in order to address the aim of this thesis were; a) Have existing MPA’s been effective in achieving conservation objectives? b) What have been the important influences on effectiveness of existing MPA’s? c) What are the key elements required for implementation of effective MPA’s? The thesis is divided into three parts. Part I is a review of the literature on implementation and effectiveness of MPA’s. Part II presents a detailed evaluation of one MPA: Point Lonsdale Marine Reserve (PLMR), Victoria, Australia. Part in is an evaluation of a number of Australasian temperate MPA’s based on information provided in a survey of people involved in management of MPA’s, and from a variety of published and unpublished documents. The MPA’s are described, evidence about ecological effectiveness is presented and factors that have enhanced and limited the ability of these MPA’s to achieve conservation objectives are derived. A substantial amount of scientific evidence was found for increases in abundance, mean size and size range of fish and invertebrate populations within the boundaries of ‘no-take’ MPA’s, Some evidence was found for ‘spillover’ of adults and juveniles into adjacent fishing grounds. Ecological effects detected within ‘no-take’ MPA’s in Australasia matched those described in the literature. The abundance and mean size of a number of previously exploited species have increased, migration into adjacent fishing grounds has been documented, and species richness has increased in at least one MPA. The PLMR was established primarily to protect the scientifically significant intertidal rock platforms. The results of the case study suggest that this objective has been achieved. Opinions about effectiveness were obtained for 28 MPA’s. Of these 19 were considered to be achieving some objectives and 10 were considered to be performing well in terms of overall ecological effectiveness. Positive effects on biodiversity were generally assumed as a result of reduction of damaging anthropogenic effects on habitat. Many questionnaire respondents noted an increase in community awareness about and support for marine conservation as a result of proclamation of MPA’s, Overall, the results support the value of MPA’s for sustainability of fish stocks and preservation of biodiversity, but there is substantial doubt over whether some of the MPA’s are too small to maintain benefits in the long-term. ‘No-take’ MPA’s, particularly those more remote from the impacts of human activities, have been the most effective in achieving objectives. A number of interacting factors important to eventual success of MPA’s were identified. The most important enhancing factors identified for the PLMR were physical attributes that limit the extent of human use and a strong conservation ethic amongst many of the visitors to this marine reserve. Limiting factors were far more numerous. Of most concern is the inadequacy of at-site management. Almost half of visitors to the area were not aware of its marine reserve status, despite the fact many were frequent visitors. The need for better educational and interpretative material on-site is highlighted by the results of the PLMR visitor survey. A total of 56 factors that have enhanced effectiveness and 46 factors that have limited effectiveness of Australasian temperate MPA’s were identified. A number of factors were important in more than one MPA and this was used to derive a set of critical, or key, factors. For example, a conclusion of all three approaches used in this study is that failure to implement day-to-day management through lack of resources was a major constraint on effectiveness. The importance of MPA’s to marine conservation depends, in part, on how well they are managed. The key factors that influence MPA effectiveness were used as the basis for derivation of the main requirements for implementation of MPA’s that will be capable of meeting the objectives for their establishment. The most important needs are: • that ‘no-take’ areas surrounded by buffer zones form the basis for a system of MPA’s; • that a high level of protection is bestowed by legislation and regulations; • that a minimum size be set for the ‘no-take’ core areas; • that the selection of sites for MPA’s takes into account land-based impacts; • that institutional arrangements are developed specifically for MPA’s; • that funding for MPA’s is increased to enable effective management; • that day-to-day management is implemented in all MPA’s, with enforcement and education programs as priority areas; • that a monitoring program for one or more MPA in each 'State' is established to provide evidence of ecological effects of reservation; • that public and stakeholder involvement in development and implementation of MPA’s is encouraged as this will influence the degree of public support and compliance; • that community-based programs to educate the general public, stakeholders, the media and decision-makers about the value of MPA’s are essential; and • that measures to reduce financial impact on affected stakeholders be implemented.

Study of the dimensions that relate to the effectiveness of training systems : a systems approach

The purpose of this thesis is to explore dimensions that relate to the training systems effectiveness in a number of industry categories. The training system is taken as part of the reproducer boundary subsystem within the organisation (Miller 1978). The research has been developed on the assumption that no single criterion is appropriate as a measure of effectiveness of a training system (Campbell et al 1970). An index of criteria based on the different organisational variables that interact within an organisation is employed in the development of the study. In this research the structural variables (independent variables) including industry category, size and formalisation factors of the sample organisations will be related to the effectiveness of training systems in their organisations. This research attempts to formulate hypotheses in the field of training system research to contribute to a theory of training system impact studies. The popular areas of research in the field of training have mainly tended to focus separately on the effectiveness of training programmes, the economics of training, the social impact of training and the dynamics of training. To my knowledge there is no research work that tests the relationship between structure and the effectiveness of training systems.

Effectiveness of a community-based osteoporosis education and self-management course : a wait list controlled trial

Summary : Osteoporosis is an increasing burden on individuals and health resources. The Osteoporosis Prevention and Self-Management Course (OPSMC) was designed to assist individuals to prevent and manage osteoporosis; however, it had not been evaluated in an Australian setting. This randomised controlled trial showed that the course increased osteoporosis knowledge.
Introduction and hypothesis : Osteoporosis is a major and growing public health concern. An OPSMC was designed to provide individuals with information and skills to prevent or manage osteoporosis, but its effectiveness has not previously been evaluated. This study aimed to determine whether OPSMC attendance improved osteoporosis knowledge, self-efficacy, self-management skills or behaviour.
Materials and methods : Using a wait list randomised controlled trial design, 198 people (92% female) recruited from the community and aged over 40 (mean age = 63) were randomised into control (n = 95) and intervention (n = 103) groups. The OPSMC consists of four weekly sessions which run for 2 h and are led by two facilitators. The primary outcome were osteoporosis knowledge, health-directed behaviour, self-monitoring and insight and self-efficacy.
Results : The groups were comparable at baseline. At 6-week follow-up, the intervention group showed a significant increase in osteoporosis knowledge compared with the control group; mean change 3.5 (p < 0.001) on a measure of 0–20. The intervention group also demonstrated a larger increase in health-directed behaviour, mean change 0.16 (p < 0.05), on a measure of 0–6.
Conclusion : The results indicate that the OPSMC is an effective intervention for improving understanding of osteoporosis and some aspects of behaviour in the short term.