This paper aims to illustrate the interdependencies between key epidemiological and economic factors that influence the control of many livestock infectious diseases. The factors considered here are (i) farmer heterogeneity (i.e., differences in how farmers respond to a perceived disease risk), (ii) off-farm effects of farmers' actions to control a disease (i.e., costs and benefits borne by agents that are external to the farm), and (iii) misalignment between privately and socially optimal control efforts (i.e., privately optimal behavior not conducive to a socially optimal outcome). Endemic chronic diseases cause a wide range of adverse social and economic impacts, particularly in low-income countries. The actions taken by farmers to control livestock diseases minimize some of these impacts, and heterogeneity in those actions leads to variation in prevalence at the farm level. While some farmers respond to perceived disease risks, others free-ride on the actions of these individuals, thereby compromising the potential benefits of collective, coordinated behavior. When evaluating a plausible range of disease cost to price of control ratios and assuming that farmers choose their privately optimal control effort, we demonstrate that achievement of a socially optimal disease control target is unlikely, occurring in <25% of all price-cost combinations. To achieve a socially optimal disease control outcome (reliant on farmers' voluntary actions), control policies must consider farmer heterogeneity, off-farm effects, and the predicted uptake of control measures under the assumption of optimized behavior.
Abstract Background Preliminary evidence suggests that a ketogenic diet may be effective for bipolar disorder. Aims To assess the impact of a ketogenic diet in bipolar disorder on clinical, metabolic and brain magnetic resonance spectroscopy (MRS) outcomes. Method Euthymic individuals with bipolar disorder (N=27) were recruited to a 6-8 week single-arm open pilot study of a modified ketogenic diet. Clinical, metabolic and MRS measures were assessed before and after the intervention. Results Of 27 recruited participants, 26 began and 20 completed the ketogenic diet for 6-8 weeks. For participants completing the intervention, mean body weight fell by 4.2kg (p<0.001), mean BMI fell by 1.5kg/m 2 (p<0.001) and mean systolic blood pressure fell by 7.4 mmHg (p<0.041). All participants had baseline and follow up assessments consistent with them being in the euthymic range with no statistically significant changes in symptoms (assessed by the Affective Lability Scale-18, Beck’s Depression Inventory and Young Mania Rating Scale). In some participants (those providing reliable daily ecological momentary assessment data; n=14) there was a positive correlation between daily ketone levels and self-rated mood (r=0.21, p<0.001) and energy (r=0.19 p<0.001), and an inverse correlation between ketone levels and both impulsivity (r =-.30, p<0.001) and anxiety (r=-0.19, p<0.001). From the MRS measurements, brain Glx (glutamate plus glutamine concentration) decreased by 11.6% in the anterior cingulate cortex ACC (p=0.025) and fell by 13.6% in the posterior cingulate cortex (PCC) (p=<0.001). Conclusions These preliminary findings suggest that a ketogenic diet may be clinically useful in bipolar disorder, for both mental health and metabolic outcomes. Replication and randomised controlled trials are now warranted. Study Registration Number ISRCTN61613198
Equally Safe at School (ESAS) is a whole-school intervention to reduce gender-based violence (GBV) in secondary school. ESAS comprises self-assessment, student-led action group, two-tier staff training, curriculum enhancement and policy review. Schools set up key activities in Year 1 and embed them in Year 2. GBV, including sexual harassment, is common in secondary schools and disproportionately affects young women and lesbian, gay, bisexual, transgender and queer youth. We will evaluate the effectiveness, cost-effectiveness, mechanisms of action and implementation of ESAS. We will recruit 36 schools across Scotland. The evaluation comprises three linked studies:Study 1: Pragmatic cluster randomised trial with 1:1 school allocation to either immediate ESAS intervention start (intervention schools) or 12-month delayed intervention start (control schools). Our primary outcome of student experience of sexual harassment will be measured at 12 months post-randomisation. Analysis of primary and secondary outcomes (student and school level) will be conducted on an intention to treat (ITT) basis comparing schools according to their original allocation.Study 2: Mixed-methods evaluation. Study 2A: Longitudinal follow-up will assess primary, secondary and intermediate outcomes at baseline, 12 months and 24 months of follow-up. Study 2B: Systems and realist-informed process evaluation will assess intervention and control school context, fidelity, dose and reach, acceptability and actor response, and how this varies by school and students. We will also assess implementation processes and mechanisms of action (beneficial or harmful), including if and how change is embedded over time, and if and how ESAS helps schools leverage other assets and resources.Study 3: Economic evaluation to assess the within-trial and longer term cost-effectiveness of ESAS.The methods include surveys in three out of six year groups (Years 2, 4 and 6) in all schools (baseline, 12 months and 24 months of follow-up); interviews with staff, students and other stakeholders; activity observations; brief surveys with key actors and analysis of trial documentation. Ethical approval by University of Glasgow MVLS Ethics Committee (200220268). Findings will be disseminated via multiple channels to researchers, GBV and education sector stakeholders, study participants and the public. ISRCTN29792495.
Background. Responding to rising oncology therapy costs, multiple value frameworks are emerging. However, input from economists in their design and conceptualization has been limited, and no existing framework has been developed using preference weightings as legitimate indicators of value. This article outlines use of the nominal group technique to identify valued treatment attributes (such as treatment inconvenience) and contextual considerations (such as current life expectancy) to inform the design of a discrete choice experiment to develop a preference weighted value framework for future decision makers. Methods. Three focus groups were conducted in 2017 with cancer patients, oncology physicians, and nurses. Using the nominal group technique, participants identified and prioritized cancer therapy treatment and delivery attributes as well as contextual issues considered when choosing treatment options. Results. Focus groups with patients ( n = 8), physicians ( n = 6), and nurses ( n = 10) identified 30 treatment attributes and contextual considerations. Therapy health gains was the first priority across all groups. Treatment burden/inconvenience to patients and their families and quality of evidence were prioritized treatment attributes alongside preferences for resource use and cost (to patients and society) attributes. The groups also demonstrated that contextual considerations when choosing treatment varied across the stakeholders. Patients prioritized existence of alternative treatments and oncologist/center reputation while nurses focused on administration harms, communication, and treatment innovation. The physicians did not prioritize any contextual issues in their top rankings. Conclusions. The study demonstrates that beyond health gains, there are treatment attributes and contextual considerations that are highly prioritized across stakeholder groups. These represent important candidates for inclusion in a discrete choice experiment seeking to provide weighted preferences for a value framework for oncology treatment that goes beyond health outcomes.
Abstract Background/Aims Musculoskeletal disorders (MSKD) are an important global health problem, but we know little about how it is understood and explained in Tanzanian communities. This understanding is crucial for developing culturally competent interventions and services for MSKD which avoid unintended impacts. This study aims to examine how joint pain is understood, explained, and responded to in rural and peri-urban communities in northern Tanzania. Methods We conducted rapid ethnographic assessment (REA) in two communities in Kilimanjaro region (one peri-urban, one rural) to document the language used to describe joint pain, ideas about causes, understandings of who experiences such pain, the impacts the pain has and how people respond to it. The REA included 60 short interviews with community leaders, traditional healers, community members, and pharmacists. The research team also wrote detailed field notes and, with written consent, took photographs which were used to develop ‘thick descriptions’ of the phenomena in each community. Thematic analysis of interview notes, thick descriptions and photographs was conducted using QDA Miner (v5.0) software. Results The dominant concepts of joint pain and its cause were named as Ugonjwa wa baridi - cold disease; Ugonjwa wa uzee - old age disease; rimatizim - disease of the joints and gauti - gout. Causes mentioned included exposure to the cold - walking bare foot, working in cold conditions - old age, alcohol and red meat consumption, witchcraft, demons, settling in one position, sex, injuries/falls. Age, gender and occupation were seen as important factors for developing joint pain. The impacts of joint pain included loss of mobility, economic and family problems, death, reduction in sexual functioning, and negative self-perceptions. Responses to joint pain blend biomedical treatments, exercise, herbal remedies, consultations with traditional healers and religious ritual. Conclusion Understandings of and responses to joint pain in the two communities are ‘syncretic’ - mixing folk and biomedical practices. Narratives about who is affected by joint pain mirror emerging epidemiological findings, suggesting a strong ‘lay epidemiology’ in these communities. The impacts of joint pain are wide ranging, extending beyond the individual affected, and suggest that there are unmet needs which can be targeted by future interventions and services. Disclosure E.F. Msoka: None. C. Bunn: None. P. Msoka: None. N.M. Yongolo: None. E. Laurie: None. S. Wyke: None. E. McIntosh: None. B. Mmbaga: None.
Bronchiolitis is a common infection of the lower respiratory tract in infants,with costly hospital admissions rising across Europe. Management is inconsistent;the American Academy of Pediatrics advocates oxygen support up to ≥90% saturation, while the Scottish Intercollegiate Guideline Network advise ≥94%.There is no evidence to support either recommendation. Aim: To explore the cost-effectiveness of oxygen saturation target ≥90% compared to ≥94% in the management of infants with bronchiolitis. Method: A cost-effectiveness analysis(CEA) was undertaken alongside an equivalence RCT, from the perspective of the UK NHS. The RCT recruited 615 infants from 6 weeks and 12 months old with a clinical diagnosis of bronchiolitis. Infants were randomised to an oxygen saturation monitor to target supplementation at a standard level(308 infants) or to a modified level (307 infants) and were followed up at 7, 14,28 days & 6 months post discharge.Patient level resource use and outcome data were collected alongside the RCT.The primary outcome was time to cough resolution.The CEA reports the incremental cost per reduced day to cough resolution. Result: The modified arm (≥90%) was cost saving, reducing NHS costs by £274(€356) per infant (95% CI:-£648, £130)(-€842, €169)in comparison to standard oxygen(<94%), with no difference in time to cough resolution(-1.58 days).Probabilistic sensitivity analysis showed some uncertainty. Inclusion of societal costs in the analysis favoured the modified arm. Conclusion: Management of infants to an oxygen saturation of ≥90% v9s≥94% produces significant healthcare cost savings,without detrimental effects on health, and is a cost-effective strategy.
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