Public Health - Doctoral Theses

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Adverse pregnancy outcomes and the long-term risk of maternal kidney disease
(University College Cork, 2021-01-06) Barrett, Peter M.; Khashan, Ali; McCarthy, Fergus; Kublickiene, Karolina; Wellcome Trust; Health Research Board
Background: Adverse pregnancy outcomes, including hypertensive disorders of pregnancy (HDP), preterm delivery, foetal growth restriction, gestational diabetes (GDM), and pregnancy loss, have been associated with the risk of maternal chronic disease, particularly cardiovascular disease. Less is known about the long-term risk of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) in women who have experienced pregnancy complications. This thesis aims to examine associations between adverse pregnancy outcomes and the risk of maternal CKD and ESKD in later life. Structure and methods: This thesis begins with an introductory chapter (Chapter 1) followed by a systematic review and meta-analysis of the published literature, based on a pre-specified protocol (Chapter 2). A detailed methods chapter outlines the data sources, study design, exposure and outcome variables, and statistical approach used in each of the original observational studies conducted for this research (Chapter 3). Four population-based cohort studies are presented, and they focus on the risk of maternal kidney disease following preterm delivery (Chapter 4), stillbirth (Chapter 5), HDP (preeclampsia and gestational hypertension) (Chapter 6) and GDM (Chapter 7) respectively. In each study, data from the Swedish national registers are used, and analyses are based on Cox proportional hazard regression models with time-dependent covariates, adjusted for a wide range of medical, obstetric, and socio-demographic factors. In Chapter 8, an updated systematic review and meta-analysis is presented to reflect newly published literature on this topic. This is followed by a discussion and interpretation of the key findings, including consideration of the public health implications arising from this work (Chapter 9). Finally, conclusions of the thesis are presented in Chapter 10. Results: (i) Updated systematic review and meta-analysis - Overall, the published literature on this topic was sparse and most meta-analyses were based on small numbers (<5) of original studies. HDP and preterm delivery were associated with higher risk of long-term kidney disease in parous women. Preeclampsia was associated with a strongly increased risk of ESKD (adjusted risk ratio (aRR) 4.90; 95% CI, 3.56-6.74) and a modest increased risk of CKD (aRR 1.73, 95% CI 1.42-2.12). Gestational hypertension was associated with a strongly increased risk of ESKD (aRR, 3.64, 95% CI, 2.34-5.66), and more modest increased risk of CKD (aRR 1.48, 95% CI 1.38-1.58). Preterm delivery was associated with an increased risk of ESKD (aRR 2.19, 95% CI 1.93-2.47), but there were too few studies to determine the risk of CKD, or to separate the effects of iatrogenic vs. spontaneous preterm deliveries. No significant association was observed between GDM and CKD (aRR 1.04, 95% CI 0.76-1.41), but this meta-analysis was based on pooled estimates from just two studies. (ii) Original population-based cohort studies - Preterm delivery was associated with increased risk of both CKD and ESKD in our study. This association was strongest in women who experienced iatrogenic preterm delivery (due to preeclampsia or small for gestational age (SGA)), but the risk persisted in women who only had spontaneous preterm deliveries compared to women who delivered at term (for CKD, aHR 1.32, 95% CI 1.25-1.39; for ESKD, aHR 1.99, 95% CI 1.67-2.38). Separately, stillbirth was alsoassociated with an increased risk of both CKD (aHR 1.26, 95% CI 1.09–1.45) and ESKD (aHR 2.25, 95% CI 1.55-3.25) compared to women who only experienced live births. These associations persisted independent of preeclampsia, SGA or congenital malformations. Preeclampsia was associated with a higher risk of CKD during follow-up (vs. no preeclampsia, aHR 1.92, 95% CI 1.83–2.03), but this risk differed by CKD subtype and was greater for hypertensive CKD, diabetic CKD, and glomerular/proteinuric CKD. Women who experienced preterm preeclampsia, recurrent preeclampsia, or preeclampsia complicated by antenatal obesity were at particularly high risk of CKD. There was also a modest risk of CKD among women who experienced gestational hypertension (vs. none, aHR 1.49, 95% CI 1.38–1.61). GDM-diagnosed women were at increased risk of CKD and ESKD overall. However, when GDM was stratified according to those who developed post-pregnancy type 2 diabetes (T2DM), the associations between GDM alone (without later T2DM) and maternal kidney disease were non-significant (for CKD, 1.11, 95% CI 0.89-1.38; for ESKD, aHR 1.58, 95% CI 0.70-3.60). By contrast, strong associations were observed with CKD and ESKD in those who had GDM followed by subsequent T2DM. Conclusion: Adverse pregnancy outcomes, specifically preeclampsia, gestational hypertension, preterm delivery and stillbirth, are associated with increased risk of maternal CKD and ESKD. These associations persisted in a nationwide cohort after controlling for a wide range of confounders. Although the relative risk of future kidney disease is highest for ESKD, associations with CKD are likely to be of greater importance from a population perspective, given the high prevalence of CKD. Women who experience adverse pregnancy outcomes may warrant systematic follow-up to prevent onset or progression of future kidney disease, but the optimal format and timing of this follow-up requires further research.
Aftercare and self-harm repetition following high-risk self-harm: a mixed methods study
(University College Cork, 2021-03-19) Cully, Grace; Arensman, Ella; Corcoran, Paul; Shiely, Frances; Health Research Board
Background: Existing research on individuals presenting to hospital with self-harm of high lethality or high suicidal intent indicates that they are a population with enduring mental health conditions (1-4) and a high risk of subsequent suicide (4-11). Despite this, there are gaps in the research relating to this subgroup of high-risk self-harm (HRSH) patients. Specifically, there is a paucity of prospective research examining rates and predictors of self-harm repetition following HRSH. Furthermore, knowledge of current approaches to aftercare following HRSH and the impact of these approaches on patient outcomes is limited. Aim: The aims of this research were to describe demographic, clinical and psychosocial factors associated with HRSH, to investigate the allocation and impact of aftercare for HRSH patients, and to examine predictors of self-harm repetition. Methods: The thesis used a mixed methods approach and is comprised of three quantitative studies (Studies 1-3) and one mixed-methods study (Study 4). Primary data collection was conducted as part of the Improving Prediction and Risk Assessment of Self-harm and Suicide (IMPRESS) study. This included: quantitative data collected from hospital records; qualitative and quantitative data collected via semi-structured interviews; and data linkage with the National Self-Harm Registry Ireland (NSHRI). The quantitative studies employed a prospective cohort design, and the mixed methods study used a sequential qualitatively led design. Results: Study 1 included hospital presented self-harm and found that intentional drug overdoses (IDOs) involving psychotropic drugs and multiple drug IDOs were associated with increased repetition risk. Study 2 demonstrated that one in nine self-harm patients attending the EDs during the study period presented with HRSH and factors associated with this were age (45-64 years), a history of recent self-harm presentations and alcohol involvement in the self-harm act. Individuals presenting with HRSH had a significantly lower risk of not receiving a biopsychosocial assessment, compared with individuals presenting with lower severity self-harm. Risk of non-assessment was highest among patients with a history of multiple recent self-harm presentations. HRSH patients showed the same risk of prospective non-fatal self-harm repetition as lower severity self-harm patients. Study 3 found that four out of five HRSH patients had a history of treatment for mental health issues. A high level of psychotropic drug prescribing was observed and most IDOs among HRSH patients involved multiple drugs, including drug(s) prescribed for the person. In a multivariable analysis using propensity score methods, HRSH patients admitted to a psychiatric inpatient setting following their self-harm act had similar risk of repeated self-harm as those who were not admitted. Factors that conferred greater risk of repeated self-harm following HRSH were recent self-harm history, particularly multiple recent presentations, young age (18-24 years) and a history of previous psychiatric admission. Study 4 identified considerable variation in satisfaction with aftercare following HRSH. Timely and comprehensive care involving supportive and compassionate relationships with healthcare professionals was considered essential following a HRSH episode by most participants. Individuals with a history of self-harm and mental health service engagement were more likely to report dissatisfaction with care provided. Those who described unsupportive relationships more frequently reported repeated self-harm, alcohol misuse and hopelessness at follow-up. Conclusions: HRSH patients are a vulnerable group with psychiatric conditions and psychosocial difficulties, many of whom feel unsupported in the current healthcare system. Throughout this research, the vulnerability of self-harm repeaters was highlighted; those with a history of self-harm were more likely to present with HRSH acts, receive substandard care, and engage in further repeated acts of self-harm. Conducting a biopsychosocial assessment needs to be prioritised among individuals with a history of self-harm and/or mental health treatment each time they present to the emergency department. The overall findings arising from this thesis underline the importance of ongoing skills training for healthcare professionals in optimising assessment and management of HRSH patients, and in safe prescribing practices.
Alcohol consumption and related harm among university students in Ireland
(University College Cork, 2015) Davoren, Martin P.; Perry, Ivan J.; Shiely, Frances; Cronin, Mary; Byrne, Michael
Aim: Alcohol consumption is a leading cause of global suffering. The harms caused by alcohol to the individual, their peers and the society in which they live provokes public health concern. Elevated levels of consumption and consequences have been noted in those aged 18-29 years. University students represent a unique subsection of society within this age group. University authorities have attempted to tackle this issue throughout the past decade. However, the issue persists. Thus, the aim of this study is to contribute to the evidence base for policy and practice in relation to alcohol harm reduction among third-level students in Ireland. Methods: A mixed methods approach was employed. A systematic review of the prevalence of hazardous alcohol consumption among university students in Ireland and the United Kingdom from 2002 to 2014 was conducted. In addition, a narrative synthesis of studies of drinking types evidenced among youths in western societies was undertaken. A cross-sectional study focused on university students’ health and lifestyle behaviours with particular reference to alcohol consumption was undertaken using previously validated instruments. Undergraduate students registered to one university in Ireland were recruited using two separate modes; classroom and online. Studies investigated the impact of mode of data collection, the prevalence of hazardous alcohol consumption and resultant adverse consequences for mental health and wellbeing. In addition a study using a Q-methodology approach was undertaken to gain a deeper understanding of the cultural factors influencing current patterns of alcohol consumption. Data were analysed using IBM SPPS statistics 20, Stata 12, MPLUS and PQ Method. Results: The literature review focusing on students’ alcohol consumption found that there has been both an increase in hazardous alcohol consumption among university students and a convergence of male and female drinking patterns throughout the past decade. Updating this research, the thesis found that two-thirds of university students consume alcohol at a hazardous level, detailing the range of adverse consequences reported by university students in Ireland. Finally, the heterogeneous nature of this drinking was described in a narrative synthesis exposing six types of consumption. The succeeding chapters develop this review further by describing three typologies of consumption, two quantitative and one quali-quantilogical. The quantitative typology describes three types of drinking for men (realistic hedonist, responsible conformer and guarded drinker) and four types for women (realistic hedonist, peer-influenced, responsible conformer and guarded drinker). The quali-quantilogical approach describes four types of consumption. These are defined as the ‘guarded drinker’, the ‘calculated hedonist’, the ‘peer-influenced drinker’ and the ‘inevitable binger’. Discussion: The findings of this thesis highlight the scale of the issue and provide up-to-date estimates of alcohol consumption among university students in Ireland. Hazardous alcohol consumption is associated with a range of harms to self and harms to others in proximity to the alcohol consumer. The classification of drinkers into types signal the necessity for university management, health promotion practitioners and public health policy makers to tackle this issue using a multi-faceted approach.
The association between hypertensive disorders of pregnancy and neurodevelopmental disorders in the offspring
(University College Cork, 2020-03) Maher, Gillian M.; Khashan, Ali; O'Keeffe, Gerard W.; Kearney, Patricia M.; Kenny, Louise C.; Health Research Board
Background and aims: Hypertensive disorders of pregnancy (HDP) are one of the most common gestational complications. HDP may be chronic (pre-dating pregnancy or diagnosed before 20 weeks’ gestation) or arise de novo (either preeclampsia or gestational hypertension). Of these, preeclampsia is one of the leading cause of maternal mortality and morbidity. Evidence suggests an association between HDP and neurodevelopmental outcomes; however, results are limited and inconsistent. The aim of the current thesis was to examine the association between HDP (in particular, preeclampsia) and neurodevelopmental disorders in the offspring, including autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), child development and behavioural outcomes. This would be achieved by systematically reviewing existing literature, and conducting a range of robust analyses using Swedish National Registry data, and data from a nationally representative study of children living in Ireland. Structure and methods: This thesis includes a brief introductory chapter (Chapter 1), and a detailed methods chapter describing study designs, data sources, exposure and outcome variables, statistical modelling, and the role of bias, confounding and chance in epidemiology (Chapter 2). Published literature on the relationship between HDP and neurodevelopmental disorders in the offspring were synthesised using a systematic review and meta-analysis, based on a pre-prepared protocol (Chapters 3 and 4). This was followed by a narrative literature review to provide a perspective on how maternal inflammation may lead to altered neurodevelopmental outcomes in preeclampsia-exposed offspring (Chapter 5). Data from Swedish National Registers were analysed to examine the association between preeclampsia and ASD and ADHD, using Cox proportional hazards regression analysis, adjusting for several perinatal and sociodemographic factors. Sibling-matched analysis was used to also control for shared genetic and familial confounding (Chapters 6 and 7). These associations were further explored by examining the intergenerational association between preeclampsia and ASD and ADHD (Chapter 8). Data from Growing Up in Ireland (GUI), a nationally representative study of children living in Ireland, were analysed to examine the association between preeclampsia and child development using the Ages and Stages Questionnaire (ASQ) at age 9-months, and behavioural outcomes using the Strengths and Difficulties Questionnaire (SDQ) at age 3 years, 5 years and 7-8 years. Multivariate logistic regression, linear regression and linear spline multilevel modelling were applied for this analysis (Chapter 9). Finally, the systematic review and meta-analysis was updated and included in this thesis (Chapter 10), along with discussion of findings, strengths and limitations of the thesis, and recommendations for future research (Chapter 11). Results: Updated systematic review and meta-analysis: Among ASD studies, adjusted pooled results indicated that exposure to HDP is associated with a 33% increased odds of ASD when compared to those unexposed (OR: 1.33, 95% CI: 1.17, 1.52). Results of a subgroup analysis, examining a preeclampsia-ASD relationship in isolation provided an OR of 1.36 (95% CI: 1.18, 1.58), while the other HDP-ASD relationship was statistically non-significant with an OR of 1.29 (95% CI: 0.97, 1.71). Among ADHD studies, adjusted pooled results suggested that offspring exposed to HDP are 26% more likely to have ADHD compared to those unexposed (OR: 1.26, 95% CI: 1.15, 1.38). For the subgroup analysis examining the preeclampsia-ADHD relationship, the OR was 1.23 (95% CI: 1.13, 1.35), and for other HDP-ADHD relationship, the OR was 1.80 (95% CI: 1.25, 2.59). Swedish National Registers: The adjusted Cox model suggested that preeclampsia was associated with 25% increased odds of ASD (Hazard ratio (HR): 1.25, (95% CI: 1.19, 1.30). The sibling-matched analysis reduced the HR to 1.17 (95% CI: 1.06, 1.28). The HR for preeclampsia and SGA combined (used as a crude proxy for preeclampsia with placental dysfunction) was 1.66 (95% CI: 1.49, 1.85) in the adjusted Cox model and 1.95 (95% CI: 1.53, 2.48) in the sibling-matched analysis. In the adjusted Cox model, preeclampsia was associated with a 15% increase in likelihood of ADHD (HR: 1.15, 95% CI: 1.12, 1.19), while the HR for preeclampsia and SGA combined was 1.43 (95% CI: 1.31, 1.55) in the adjusted model, compared to those unexposed to preeclampsia/SGA. The sibling-matched analysis did not materially change these associations. Similar to the findings outlined above, the intergenerational analysis suggested that exposure to preeclampsia was associated with an increased likelihood of ASD and ADHD in offspring. In addition to this, results suggested that preeclampsia in both the child’s mother and grandmother was associated with a 58% increased likelihood of ASD (HR: 1.58, 95% CI: 1.02, 2.46) and 34% increased likelihood of ADHD (HR: 1.34, 95% CI: 1.01, 1.80) in the child. GUI study: Multivariate logistic regression suggested that preeclampsia was not associated with failing any ASQ domain. Preeclampsia was associated with abnormal SDQ cut-off of Emotional (score of ≥5) and Hyperactivity (score of ≥7) domains at age 5 years only. In the linear spline model, mean SDQ score was higher at age 3, 5 and 7-8 years in exposed groups, however did not always reach statistical significance. Conclusions: This thesis rigorously investigates the association between HDP (in particular, preeclampsia) and neurodevelopmental disorders in offspring using a range of analytic approaches, and adjusting for a wide variety of potential confounders. Pooled estimates from previous literature suggested an association between HDP and ASD and ADHD. Furthermore, the data from Swedish National Registers indicate that exposure to preeclampsia or preeclampsia and SGA combined (i.e. SGA baby exposed to preeclampsia) was associated with ASD and ADHD. The stronger association with preeclampsia and SGA combined than preeclampsia alone suggests that placental pathology may be a mechanism for the increased likelihood of ASD and ADHD. Results of the current thesis also suggest that preeclampsia may be associated with adverse neurodevelopmental outcomes across generations. While we did not find strong evidence of associations between preeclampsia and child developmental and behavioural outcomes overall in the GUI study, exposure to preeclampsia was associated with an increased likelihood of subtle behavioural issues in the emotional and hyperactivity domain of the SDQ. The overall conclusion of this thesis suggests an association between HDP and neurodevelopmental outcomes in offspring. It is important to note however, that we cannot rule out the presence of residual confounding in observational studies.
Attributable burden, life expectancy and income loss to non-communicable diseases in Ireland: from evidence to policy-making
(University College Cork, 2020-12-18) Chakraborty, Shelly; Kabir, Zubair; Perry, Ivan J.; Balanda, Kevin; Health Research Board
Introduction: This thesis is devoted, primarily, to the study of the burden of non-communicable diseases in the Republic of Ireland. Four major NCDs – cancer, cardiovascular disease (CVD), diabetes and Chronic Obstructive Pulmonary Disease (COPD) – are chosen and their risk factors as well as socio-economic impact is analysed. Burden of disease studies utilize the evidence base and quantify the health scenario and trends over time. Such estimates are relevant for a country’s policy makers to allocate the limited resources to the areas that require more attention. The Global Burden of Disease study was the most comprehensive study of its kind to draw attention to the diseases and risk factors in any country which require more attention than the others. We seek to do the same for Ireland with a special focus for NCDs. NCDs contributed to approximately 71% of deaths worldwide in 2016 (WHO). NCDs lead to early deaths, morbidities and long-term health effects. It was observed that life expectancies have increased in Ireland. It is critically important to determine whether people are living these additional years in good health or not. NCDs also contribute to considerable economic loss. These considerations form the motivating factors for this study, whose primary objectives are as follows: 1. To estimate NCD burden and attributable burden, including LE and HALE- 1990 to 2017 2. To investigate the main drivers of NCD burden changes in 1990-2017 3. To estimate the national economic loss to NCD burden 4. To estimate the future NCD burden- 2040 5. To carry out Internal validation exercises Methods: This work uses methods similar to that of the GBD study. The metrics used to quantify the burden are Disability Adjusted Life Years (DALYs), number of deaths, Years of Life Lost (YLLs) and Years Lived with Disability (YLDs). DALYs quantify the burden due to premature mortality and disability. They enable comparisons across nations, thus allowing benchmarking. Decomposition analysis is used to separate the effects of population ageing, population growth and changes in the risk factor scenario. We also quantified Gross Domestic Product (GDP) per capita lost to DALYs in Ireland in 2017 using the WHO model for projecting the Economic Costs of Ill-Health (WHO--EPIC model). Each DALY amounts to a loss of 1 to 3 units of GDP per capita (in international dollars). The burden of disease in 2030 was projected for Ireland using GBD’s forecasting methods, and the potential and avertable YLLs were calculated. The GBD study results were also validated against some national level estimates. This is done to ascertain whether, and to what extent, the data from GBD would be an appropriate evidence base to formulate national level policy decisions. The estimates were also validated using different standard populations by checking if the results varied significantly. Main Findings: This study analyzed data from GBD as well as some national level databases, and the following are some of the main findings of the analysis. Ireland ranks 11th best in the NCD related age-standardized DALYs, 2nd in the age-standardized deaths and 3rd in the age-standardized YLDs within the EU. This clearly shows that, while Ireland performs well in terms of number of deaths and YLDs, there is still a lot to be done when it comes to DALYs. Life Expectancy in the ROI has increased during 1990 and 2017, however the Healthy life expectancy (HALE) has not increased at the same pace. This means that the additional years are lived in less than ideal health. It was found that diabetes, ischemic heart disease (IHD) and stroke related death rate attributable to diets high in processed meat and sodium have increased during 1990 and 2017. Cancer and diabetes YLDs attributed to alcohol consumption have increased significantly (from 2.4 per 100,000 to 37.6 for diabetes and 15.9 per 100,000 to 25.4 for cancer). On disentangling the drivers of burden change, it was observed that except diabetes, the other three NCDs have shown more improvements in the risk factor scenario. We estimated that Ireland lost about 75.6 million international dollars (I$) in GDP per capita from all causes in 2017. An alarming result here is that, of the 75.6 million mention above, cancer alone contributed to 15 million I$. A part of this study also focused on forecasting the burden in 2040. The model predicts that IHD will be the leading cause of deaths in 2040, whereas smoking is on its way to becoming the leading cause for YLLs. In all the above-mentioned analyses, estimates based on national level data agreed with those obtained from the analysis of the GBD data. On using different standard populations the DALYs varied. Conclusion: To the best of our knowledge, this is the first comprehensive epidemiologic and economic profile of NCD burden in Ireland. It was observed that the YLDs are on the rise and diabetes is the most neglected NCD in terms of effective population interventions. In terms of the risk factors, alcohol was found to be the leading cause of NCD morbidity. It should also be mentioned that, even though estimates obtained from GBD were in agreement with the national burden estimates, this study cannot be a replacement for a sub-national BOD study.
Caesarean section and subsequent pregnancy outcome: a Danish register-based cohort study
(University College Cork, 2014) O'Neill, Sinéad M.; Agerbo, Esben; Kenny, Louise C.; Greene, Richard A.; Kearney, Patricia M.; Khashan, Ali S.; National Perinatal Epidemiology Centre, College of Medicine and Health, University College Cork; Health Research Board
Background and Aims: Caesarean section rates have increased in recent decades and the effects on subsequent pregnancy outcome are largely unknown. Prior research has hypothesised that Caesarean section delivery may lead to an increased risk of subsequent stillbirth, miscarriage, ectopic pregnancy and sub-fertility. Structure and Methods: Papers 1-3 are systematic reviews with meta-analyses. Papers 4-6 are findings from this thesis on the rate of subsequent stillbirth, miscarriage, ectopic pregnancy and live birth by mode of delivery. Results Systematic reviews and meta-analyses: A 23% increased odds of subsequent stillbirth; no increase in odds of subsequent ectopic pregnancy and a 10% reduction in the odds of subsequent live birth among women with a previous Caesarean section were found in the various meta-analyses. Danish cohorts: Results from the Danish Civil Registration System (CRS) cohort revealed a small increased rate of subsequent stillbirth and ectopic pregnancy among women with a primary Caesarean section, which remained in the analyses by type of Caesarean. No increased rate of miscarriage was found among women with a primary Caesarean section. In the CRS data, women with a primary Caesarean section had a significantly reduced rate of subsequent live birth particularly among women with primary elective and maternal-requested Caesarean sections. In the Aarhus Birth Cohort, overall the effect of mode of delivery on the rate and time to next live birth was minimal. Conclusions: Primary Caesarean section was associated with a small increased rate of stillbirth and ectopic pregnancy, which may be in part due to underlying medical conditions. No increased rate of miscarriage was found. A reduced rate of subsequent live birth was found among Caesarean section in the CRS data. In the smaller ABC cohort, a small reduction in rate of subsequent live birth was found among women with a primary Caesarean section and is most likely due to maternal choice rather than any ill effects of the Caesarean. The findings of this study, the largest and most comprehensive to date will be of significant interest to health care providers and women globally.
Can population-level variation in early childhood development be measured in a manner that supports service planning and intervention?
(University College Cork, 2014) Curtin, Margaret; Perry, Ivan J.; Staines, Anthony; Health Research Board
Background: The Early Development Instrument (EDI) is a population-level measure of five developmental domains at school-entry age. The overall aim of this thesis was to explore the potential of the EDI as an indicator of early development in Ireland. Methods: A cross-sectional study was conducted in 47 primary schools in 2011 using the EDI and a linked parental questionnaire. EDI (teacher completed) scores were calculated for 1,344 children in their first year of full-time education. Those scoring in the lowest 10% of the sample population in one or more domains were deemed to be 'developmentally vulnerable'. Scores were correlated with contextual data from the parental questionnaire and with indicators of area and school-level deprivation. Rasch analysis was used to determine the validity of the EDI. Results: Over one quarter (27.5%) of all children in the study were developmentally vulnerable. Individual characteristics associated with increased risk of vulnerability were being male; under 5 years old; and having English as a second language. Adjusted for these demographics, low birth weight, poor parent/child interaction and mother’s lower level of education showed the most significant odds ratios for developmental vulnerability. Vulnerability did not follow the area-level deprivation gradient as measured by a composite index of material deprivation. Children considered by the teacher to be in need of assessment also had lower scores, which were not significantly different from those of children with a clinical diagnosis of special needs. all domains showed at least reasonable fit to the Rasch model supporting the validity of the instrument. However, there was a need for further refinement of the instrument in the Irish context. Conclusion: This thesis provides a unique snapshot of early development in Ireland. The EDI and linked parental questionnaires are promising indicators of the extent, distribution and determinants of developmental vulnerability.
Childhood obesity in Ireland: recent trends and modifiable determinants
(University College Cork, 2014) Keane, Eimear; Harrington, Janas M.; Perry, Ivan J.; Kearney, Patricia M.; National Children’s Research Centre, Ireland
Background: Childhood obesity is a global epidemic posing a significant threat to the health and wellbeing of children. To reverse this epidemic, it is essential that we gain a deeper understanding of the complex array of driving factors at an individual, family and wider ecological level. Using a social-ecological framework, this thesis investigates the direction, magnitude and contribution of risk factors for childhood overweight and obesity at multiple levels of influence, with a particular focus on diet and physical activity. Methods: A systematic review was conducted to describe recent trends (from 2002-2012) in childhood overweight and obesity prevalence in Irish school children from the Republic of Ireland. Two datasets (Cork Children’s Lifestyle [CCLaS] Study and the Growing Up in Ireland [GUI] Study) were used to explore determinants of childhood overweight and obesity. Individual lifestyle factors examined were diet, physical activity and sedentary behaviour. The determinants of physical activity were also explored. Family factors examined were parental weight status and household socio-economic status. The impact of food access in the local area on diet quality and body mass index (BMI) was investigated as an environmental level risk factor. Results: Between 2002 and 2012, the prevalence of childhood overweight and obesity in Ireland remained stable. There was some evidence to suggest that childhood obesity rates may have decreased slightly though one in four Irish children remained either overweight or obese. In the CCLaS study, overweight and obese children consumed more unhealthy foods than normal weight children. A diet quality score was constructed based on a previously validated adult diet score. Each one unit increase in diet quality was significantly associated with a decreased risk of childhood overweight and obesity. Individual level factors (including gender, being a member of a sports team, weight status) were more strongly associated with physical activity levels than family or environmental factors. Overweight and obese children were more sedentary and less active than normal weight children. There was a dose response relationship between time spent at moderate to vigorous physical activity (MVPA) and the risk of childhood obesity independent of sedentary time. In contrast, total sedentary time was not associated with the risk of childhood obesity independent of MVPA though screen time was associated with childhood overweight and obesity. In the GUI Study, only one in five children had 2 normal weight parents (or one normal weight parent in the case of single parent families). Having overweight and obese parents was a significant risk factor for overweight and obesity regardless of socio-economic characteristics of the household. Family income was not associated with the odds of childhood obesity but social class and parental education were important risk factors for childhood obesity. Access to food stores in the local environment did not impact dietary quality or the BMI of Irish children. However, there was some evidence to suggest that the economic resources of the family influenced diet and BMI. Discussion: Though childhood overweight and obesity rates appear to have stabilised over the previous decade, prevalence rates are unacceptably high. As expected, overweight and obesity were associated with a high energy intake and poor dietary quality. The findings also highlight strong associations between physical inactivity and the risk of overweight and obesity, with effect sizes greater than what have been typically found in adults. Important family level determinants of childhood overweight and obesity were also identified. The findings highlight the need for a multifaceted approach, targeting a range of modifiable determinants to tackle the problem. In particular, policies and interventions at the shared family environment or community level may be an effective mean of tackling this current epidemic.
Childhood obesity treatment: integrating mobile health technology into a paediatric obesity service
(University College Cork, 2015) O'Malley, Grace Catherine; Burls, Amanda; Perry, Ivan J.; Clarke, Mike; Health Research Board
Background: The management of childhood obesity is challenging. Aims: Thesis, i) reviews the evidence for lifestyle treatment of obesity, ii) explores cardiometabolic burden in childhood obesity, iii) explores whether changes in body composition predicts change in insulin sensitivity (IS), iv) develops and evaluates a lifestyle obesity intervention; v) develops a mobile health application for obesity treatment and vi) tests the application in a clinical trial. Methods: In Study 1, systematic reviews and meta-analyses of the 12‐month effects of lifestyle and mHealth interventions were conducted. In Study 2, the prevalence of cardiometabolic burden was estimated in a consecutive series of 267 children. In Study 3, body composition was estimated with bioelectrical impedance analysis (BIA) and dual x-ray absorptiometry (DXA) and linear regression analyses were used to estimate the extent to which each methods predicted change in IS. Study 4 describes the development of the Temple Street W82GO Healthy Lifestyle intervention for clinical obesity in children and a controlled study of treatment effect in 276 children is reported. Study 5 describes the development and testing of the Reactivate Mobile Obesity Application. Study 6 outlines the development and preliminary report from a clinical effectiveness trial of Reactivate. Results: In Study 1, meta--‐analyses BMI SDS changed by -0.16 (-0.24,‐0.07, p<0.01) and -0.03 (-0.13, 0.06, p=0.48). In study 2, cardiometabolic comorbidities were common (e.g. hypertension in 49%) and prevalence increased as obesity level increased. In Study 3, BC changes significantly predicted changes in IS. In Study 4, BMI SDS was significantly reduced in W82GO compared to controls (p<0.001). In Study 5, the Reactivate application had good usability indices and preliminary 6‐month process report data from Study 6, revealed a promising effect for Reactivate. Conclusions: W82GO and Reactivate are promising forms of treatment.
A comparative evaluation of surrogate measures of adiposity as indictors of cardiometabolic disease
(University College Cork, 2016) Millar, Sean R.; Phillips, Catherine; Perry, Ivan J.; Health Research Board
This thesis contributes to the current evidence base regarding methods to detect patients with type 2 diabetes, and those at increased obesity-related cardiometabolic risk. In particular, it aimed to determine how useful surrogate measures of adiposity might be to identify high-risk patients within a clinical setting. Using a cross-sectional sample of 2,047 middle-aged men and women, the main objectives were: (1) to examine the rationale for adiposity assessment within clinical practice, and whether methods used for disease classification and anthropometric measurement procedure are important for diagnosing cardiometabolic risk and type 2 diabetes; (2) to compare adiposity variable relationships with a range of cardiometabolic disease features, biomarkers of chronic low-grade inflammation and type 2 diabetes; (3) to explore whether central adiposity indices provide additional information regarding disease and risk status, compared to general adiposity characterised by body mass index (BMI); (4) to investigate the clinical utility of a composite index using both general and central adiposity measures. The results suggest that surrogate measures of central adiposity provide information regarding disease status and cardiometabolic risk, independent of that provided by BMI, and that a composite index using both BMI and central adiposity measures may help refine body fat classification. Earlier identification of patients at increased cardiometabolic risk, and those with type 2 diabetes, could allow earlier targeted interventions to be implemented, thus reducing the incidence of related complications, premature mortality and financial costs associated with the obesity epidemic.
The contribution of population-based cancer registries to the current knowledge on cancer epidemiology: the example of skin melanoma
(University College Cork, 2018) Crocetti, Emanuele; Clough-Gorr, Kerri
Introduction The activity of cancer registries represents a multistep process that starts by gathering information from a variety of sources. Such information is checked, linked, enriched and handled to produce high-quality original data capable of being informative enough to prove useful in answering specific epidemiological and clinical questions. This thesis is part of a PhD by Prior Publication grounded in six published papers. These papers deal with different steps in the production of cancer registry data, enhancing the contribution of registries to cancer epidemiology. Skin melanoma has been used as an example, but all the presented methods and concepts apply to any cancer type. Materials and methods 1. The first paper (related to cancer registry data quality) tests the hypothesis whether the distribution of the first digit (from one to nine) of crude incidence rates obeys Benford law. Pearson’s coefficient of correlation and different distance measures were applied to compare the theoretical distribution to the observed one in a sample of 43 population-based cancer registry populations randomly drawn from the volume X of Cancer Incidence in 5 Continents. 2. In the second paper, an innovative index for measuring the amount of internal variability among the sub-areas underlying an overall incidence rate is presented. The measure is a ratio, where the numerator is the difference between the highest and the lowest age-adjusted standardised rate in sub-areas. The denominator is the overall area age-adjusted standardised rate. Such measure was applied to age-standardised incidence rates for ‘all cancer sites excluding non-melanoma skin cancer’, for men, in 2014, for Nordic countries as a whole, for each country (Denmark, Faroe Islands, Finland, Greenland, Iceland, Sweden and Norway) and their regions. 3. In paper three, to make cancer registry data useful in the clinical setting, melanoma incidence during 1985–2004 in the Tuscan cancer registry (Italy) was analysed including both standard (site, morphology, sex, age, calendar period) and clinically relevant variables, as in situ melanoma and Breslow’s thickness. For the time trend analysis, the annual percent change (APC) of the rates was computed. 4. Paper 4 presents the results of an age-period-cohort model applied to 1977 skin melanomas, incident in the Tuscan cancer registry. Such a method allows us to understand the time trend better and to forecast future change. Moreover, a non-linear regression model was applied to estimate the expected number of new cases in a more recent period. 5. Paper 5 shows a skin melanoma survival analysis based on 1403 patients from two Italian registries (Tuscan and Reggio-Emilia). The focus was on two different approaches: the multivariate Cox proportional hazard model and the Classification And Regression Trees analysis. The latter is an automatic method that splits data through a recursive process creating a ‘tree’ of groups with different profiles of risk of death. Both ways were applied to the following variables: age, sex, Breslow thickness, Clark level, Registry, sub-site and morphologic type. 6. In Paper 6, the quality of melanoma diagnosis and care in the Tuscan region is measured based on 13 newly realised process indicators, which encompassed early diagnosis, pathology reporting and surgical treatment. We evaluated the clinical adherence to these indicators in two years: 2004 and 2008, using a population-based series of incident skin melanomas, measuring the possible changes in the indexes following the implementation of specific regional recommendations. Results 1. The distribution of the first significant digits of cancer incidence rates was shown to belong to numbers that abide by Benford law, in the whole dataset (146,590 rates) by sex and cancer registries. The correlation coefficient between observed and expected distributions was extremely high (0.999), and the distance measures very small. 2. The index for internal variability highlighted a quite relevant heterogeneity among Nordic countries (index 57.1% = the difference between the Nordic country with the highest and the one with the lowest rate is 57.1% of the Nordic overall age-adjusted rate). Within countries, the variability was negligible in Iceland (9.6%), and high in Sweden (37.1%). 3. During the four analysed periods standardized melanoma incidence rose significantly, for both invasive (APC = + 5.1%) and in situ lesions (APC = + 11.1). Over time, the median value of thickness decreased from 1.68 to 0.8 mm (P < 0.001), but only for <=1.00 mm melanomas. Although the rates of thin melanoma have increased, rates for thick ones did not decrease. 4. The model that best fitted the data included age and ‘drift’. The linear effect (‘drift’) showed, in each age group, an increase of the risk of malignant melanoma diagnosis of about 36.6% every five years of period or cohort. For the period 2002–2006, 1112 new cases were predicted with a standardised rate (age 15–84 years) of 19.2 × 100.000. In the Tuscany Cancer Registry area, no clues for malignant melanoma incidence rates levelling off were documented. Growing rates and numbers of malignant melanoma are expected soon. 5. The Cox proportional hazard model found sex, age, Breslow thickness, Clark and morphologic type to have a significant independent prognostic value. The Classification And Regression Trees analysis identified six groups of different risks based on Breslow thickness, age and sex. The best prognostic group (5-year observed survival, 98.1%) included those subjects with Breslow less than 0.94 mm and age 19–44 years. The same thickness but an older age (50–69 years) was associated with a statistically significant different prognosis (5-year observed survival, 92.8%). 6. As regards the quality of care, there were statistically significant increases in the percentage of thin (<= 1 mm) melanomas from 2004 to 2008 (from 50.7 to 61.3%) and in the number of pathology reports that mentioned ulceration (from 61.4 to 84.6%) and margin statuses (from 76.8 to 84.3%). The percentage of patients staged by sentinel lymph node biopsy was stable (63%) and was higher for patients younger than 75 years of age (74%). The number of lymph nodes almost invariably exceeded the proposed site-specific cut-off reference, and, in 2008, the number of nodes removed was always reported for lymphadenectomy. From 2004 to 2008, surgical and pathological waiting times increased. Conclusions The six presented papers cope cohesively with consecutive steps in the procedure of cancer registration. 1. The check for Benford law abidance may become a preliminary test in the process of data quality. 2. The heterogeneity index offers a new, simple (to be produced and to be understood) and noteworthy information. 3. The analysis of some clinically crucial variables raises the interest of clinicians and makes cancer registries closer to the real world. 4. The use of methods with higher statistical involvement, e.g., the age-period-cohort model, provided further information on melanoma time trends in the area. Moreover, estimates were projected to a more recent period bridging the Registry’s timeliness gap. 5. Prognosis is a piece of vital information for both patients and clinicians. Hazard ratios and patients grouping showed almost the same risk patterns but conveyed by a different message (relative vs absolute), with a different understandability. 6. Population-based quality indexes allow to check the practical application of guidelines and recommendations, highlighting critical situations to be improved. Cancer registration is a unique process made by different but connected steps. The improvement of each of them positively affects others. It is a sort of virtuous circle in which new methods, new uses and new users are all involved in a common aim: exploiting cancer registries’ activity. Registries can have a real informative power only if the whole process, from the collection of raw data to the provision of relevant information for various stakeholders, is accomplished.
Cyberbullying and young people: behaviours, experiences and resolutions
(University College Cork, 2019-11-07) Dennehy, Rebecca; Arensman, Ella; Cronin, Mary; Meaney, Sarah; Health Research Board
Introduction: Cyberbullying is a complex and multifaceted public health issue among young people. Research indicates deleterious effect on the mental health and wellbeing of victims which warrants action to address this issue. Adults do not have first-hand experience of cyberbullying in their youth and so the development of prevention and intervention strategies can benefit from the engagement of young people’s perspectives. However, young people’s voices are largely absent from the current discourse. This thesis aims to explore the nature, causes, and consequences of cyberbullying from the perspective of young people with a view to informing the development of evidence-based prevention and intervention strategies. Methods: The research was framed by the Medical Research Council guidelines for intervention development. Qualitative and participatory research methods were employed. In the first instance a systematic review and meta-ethnographic synthesis of qualitative studies related to young people’s conceptualisations of cyberbullying was conducted. Secondly, a rights-based model was developed to facilitate the active involvement of young people in the research process. A Young Person’s Advisory Group was purposefully formed to collaborate in the design, conduct, and interpretation of a qualitative study of young people’s perspectives on cyberbullying as well as in priority setting for intervention development. Young People’s involvement in the Advisory Group was evaluated to determine the effectiveness off the model in facilitating young people’s participation in the research process and the acceptability of the approach. The co-designed qualitative study comprised focus groups with secondary school students which were conducted in the school setting. Findings:The meta-ethnography highlighted that the fundamental role of cyber technology in young people’s lives and the complexity and ambiguity of the cyber world in which they connect are inherent to young people’s conceptualisations of cyberbullying. The participatory evaluation of young people’s involvement in the research process indicated that the elements necessary for the effective realisation of young people’s participation rights were present in this study. Based on their interpretation of preliminary findings from the qualitative study, Advisory Group Members identified the non-consensual distribution of nude images and the mental health impact of cybervictimisation as serious concerns for young people and priorities for intervention development. Findings indicate that non-consensual distribution involves a complex process that is produced by, and reinforces, gender power dynamics. Young males, under pressure to conform to societal constructs of masculinity, coerce females to send explicit images which are screenshot and intentionally distributed, without consent, to male peers in exchange for social kudos. Regarding the mental health impact, cyberbullying was described as more psychological in nature and impact than traditional bullying with increased deleterious effect on the mental health and wellbeing of victims. Analysis identified several barriers which prevent victims from seeking social support and participants’ perception that suicide is a viable escape route for young victims defeated and entrapped by cybervictimisation. Conclusion:This research makes a valuable contribution to the existing knowledge base in that it privileges youth voice on the nature, causes, and consequences of the phenomenon and highlights young people’s priorities with regard to intervention development. In response to research findings and suggestions from the Young Person’s Advisory Group a number of recommendations are made in relation to research, policy, and practice which are grounded in young people’s experiences, values, and norms.
The design, implementation and evaluation of a laboratory based intervention to optimise serum immunoglobulin use in primary care
(University College Cork, 2016) Cadogan, Sharon L.; Browne, John P.; Bradley, Colin P.; Cahill, Mary; Health Research Board
Background Laboratory testing plays a fundamental role in the screening, diagnoses and monitoring of many conditions. Given the increased pressures on the Irish health service, improving inefficiencies and reducing waste, while maintaining the quality of care is at the forefront of healthcare planning. Promoting optimal laboratory service utilisation could play a key role in reducing health expenditure, in particular by preventing the unnecessary use of costly downstream services that often arise as a result of testing. Aims and objectives The overall aim of this thesis was to design, implement and evaluate a behaviour change intervention for optimising serum immunoglobulin test use in primary care. The thesis objectives were as follows: 1. To conduct a systematic review of the existing literature on the effectiveness of previous interventions targeting primary care test use. 2. Identify the barriers and enablers of improving test ordering for serum immunoglobulins among General Practitioners (GPs), using semi-structured interviews. 3. Identify the intervention components (behaviour change techniques and mode(s) of delivery) that could overcome the modifiable barriers and enhance the enablers. 4. Determine which GP and practice characteristics are associated with higher serum immunoglobulin test ordering patterns in the South of Ireland. 5. To implement and evaluate a behaviour change intervention targeting GP serum immunoglobulin test use in the Cork-Kerry region. Structure and Methods The published literature to date was synthesised in a systematic review (Chapter 3). This review was conducted in accordance with the Effective Practice and Organisation of Care (EPOC) guidelines and quality appraised using the Cochrane Collaboration risk of bias tool. A theory-based paper identifying the modifiable barriers and enablers to test ordering behaviour change and the selection of intervention components to overcome these is presented in Chapter 4. This involved using a combination of behaviour change models including the Theoretical Domains Framework (TDF), the behaviour change wheel constructs; capabilities, opportunities, motivations of behaviour (COM-B) and Behaviour Change Techniques (BCTs) to identify intervention functions best suited to targeting GP test ordering behaviour. The GP and practice characteristics associated with higher test ordering patterns are described in Chapter 5. These were identified by performing a multi-level analysis of all GP test orders in the studied region for a one-year time period, using routine laboratory data. The design of the intervention material and details on the implementation plans are provided in Chapter 6. Results of the effect of the intervention using nine-month follow up data are described in Chapter 7. This was performed using interrupted time-series with segmented Poisson regression models to assess the pre-and xxi post-intervention trend for serum immunoglobulin testing among GPs in the Cork-Kerry region of Ireland. Finally, a discussion of the key findings, strengths and limitations of the thesis and recommendations for future research are addressed (Chapter 8). Key Findings A number of different interventions were of variable efficacy at changing GP test ordering behaviour. However, generalisability across tests and methodological weakness were identified in these studies (Chapter 3). GP factors contributing to higher immunoglobulin test ordering in our sample included female gender and fewer years of clinical experience (Chapter 5). The lack of clear guidelines and knowledge on how to interpret the test results posed greatest problems for GPs. Four key intervention functions were identified for overcoming these modifiable barriers to effective test use; education, persuasion, enablement and environmental restructuring (Chapter 4). Following the introduction of a guideline and education-based strategy targeting the two key issues (by incorporating the four functions), test orders for serum immunoglobulins dropped significantly. A nine-month evaluation of the effectiveness of this intervention found a statistically significant 1.5% reduction in the fortnight-to-fortnight test ordering trend for serum immunoglobulins (Chapter 7). Conclusions This research provides an important overview of the behavioural factors influencing laboratory testing among GPs. The incorporation of behavioural theory, specifically the COM-B, TDF and BCT taxonomy, has supported the identification of factors such as xxii knowledge and the social and environmental context, which are key for understanding testing behaviours. Combining these context specific "mechanisms of change" with international evidence on what has previously worked, assisted in the development of an effective behaviour change intervention targeting serum immunoglobulin test use in primary care.
Dietary phosphorus in chronic kidney disease
(University College Cork, 2020) Byrne, Fiona Nora; Eustace, Joe; Kiely, Mairead; Shiely, Frances; Kearney, Patricia M.
Hyperphosphataemia is common in the later stages of chronic kidney disease and is a universal problem in end stage kidney disease, where it is associated with increased morbidity and mortality. Treatment includes a low phosphorus diet, that imposes numerous dietary restrictions, lacks a robust evidence base and in current practice fails to distinguish between phytate and non phytate bound phosphorus. The overall aim of this PhD was to provide the evidence basis for a revised low phosphorus diet, and to assess its effectiveness, safety and tolerability. Specific aims were 1) to define revised dietary recommendations for phosphorus in chronic kidney disease and to translate these recommendations into food based advice, 2) to conduct a proof of concept acute feeding study in prevalent haemodialysis patients using the modified diet and 3) to investigate the effectiveness of the modified diet in a multicentre randomised controlled trial in prevalent haemodialysis patients. To update the traditional low phosphorus diet, as chair of a national working group of Irish renal dietitians, I undertook a narrative review of the available renal nutrition literature. We combined the evidence with clinical experience and expertise to update the traditional low phosphorus diet. The modified diet, agreed by consensus, relaxed the restrictions of phytate bound phosphorus, and introduced previously disallowed foods such as pulses, peas, nuts and more whole grains. To ensure adequate but not excessive protein intake, we introduced guidance on bread and cereal intakes and included some advice based on phosphorus to protein ratios. Finally we increased the focus on avoiding phosphate additives. These changes were incorporated into a modified renal diet. The modified diet was initially evaluated against the standard low phosphorus diet in an in-centre, directly observed, one day, cross-over feeding study in order to examine the immediate postprandial effects of the modified diet. We demonstrated that the modified diet blunted post-prandial hyperphosphataemia, was not associated with increased hyperkalaemia and was well tolerated. Given the results of the acute feeding study, we conducted a national multicentre randomised controlled trial, comparing the modified low phosphorus diet with the standard low phosphorus diet in 74 prevalent patients treated with maintenance haemodialysis. The modified renal diet, with its broader food choice, achieved a significantly higher fibre intake, was well tolerated and provided comparable serum phosphate and potassium control as the standard renal diet. Based on the evidence from this project, a decision was taken by the Irish Renal Interest Group of the Irish and Dietetic Institute in January 2019, to endorse the modified low phosphorus diet and to implement it nationally.
Disrupting routines, facilitating control: exploring a change towards healthier food purchasing behaviour using a health app
(University College Cork, 2019) Flaherty, Sarah Jane; Mccarthy, Mary; Collins, Alan; Health Research Board
Background: Unhealthier food consumption patterns constitute a leading risk factor for ill health. As an important step in the food consumption process, changing food purchasing may improve the healthfulness of dietary patterns. Changing behaviour towards healthier food purchasing may be viewed as effortful by consumers due to inadequate nutrition knowledge and skills which may inhibit their ability to make healthy choices within the supermarket. A dominance of routines and habits further impedes the use of deliberative decision-making, which makes information provision and goal-setting less effective. Behaviour change may be supported by disrupting undesirable behavioural patterns, building of personal resources, and reframing behavioural outcomes. This should prompt a greater use of reflective cognitive processes during food purchasing and aid healthier behaviour. However, there is limited evidence in relation to food purchasing. Given recent technological advances, apps offer a potential tool to facilitate such change. The high use of apps across social groups suggests that they may be appropriate for supporting behaviour change in lower socioeconomic groups. It is unclear if existing apps are appropriately designed or acceptable for use for the necessary time period, particularly for individuals from a lower socioeconomic background. Such knowledge gaps must be addressed to inform intervention design. This thesis aims to contribute to the theoretical understanding of the interplay between mobile app technology and behaviour change with food purchasing as the behaviour of interest, and a particular focus on women from a lower socioeconomic background. Methods: This thesis was grounded in a pragmatic philosophical perspective and consisted of four phases. In phase one, structural equation modelling was undertaken to examine the individual-level determinants of a healthy eating habit and the extent to which personal goals and self-control are linked to a healthy eating habit. A content analysis of existing apps was undertaken in phase two to examine their capacity to support healthier food purchasing behaviour. A structured analytical matrix was employed where relevant literature and theory was drawn upon. A phenomological methodology was used for the remaining two research phases. In phase three, the researcher explored the experience of using a health app to support healthier food purchasing behaviour. Women from a lower socioeconomic background were recruited and asked to use two, of three possible, apps over a two-week period. Subsequent semi-structured interviews explored the experience of using an app including those personal and app-related factors of importance. Inductive thematic analysis was conducted to explore common patterns across participants’ experiences. In the fourth research phase, the lived experience of changing purchasing behaviour was explored in women from a lower socioeconomic background using a health app over an 8-11 week period. Participants were asked to use one, of two possible, apps. Multiple data collection methods were employed to capture the lived experience of behaviour change and app use. At baseline, an accompanied shop, incorporating the use of think-aloud protocol and researcher observations, was conducted, followed by an in-depth interview and questionnaire completion. At the midway point, participants were asked to complete a reflective account of their experience thus far. They were also asked to share their till receipts for the study duration. At follow-up, an accompanied shop, in-depth interview, and questionnaire completion was again employed. Interpretative phenomenological analysis was conducted to gain insight into the behaviour change experience. Theoretical thematic analysis was employed to examine app use through the lens of engagement theory. Findings: Self-control and deliberative cognitive processes were central to maintaining a healthy eating habit. This challenges the current conceptualisation and suggests the need to view complex food behaviours as highly routinised; this is an important consideration for behaviour change. Food purchasing behaviour was not a primary focus of existing apps with behavioural outcomes, such as weight-loss, as their main goal. While existing apps have the potential to support healthier purchasing behaviour, there is an opportunity to broaden their capacity. Health apps, through the process of self-monitoring, problem solving, and behavioural prompts, disrupted existing purchasing patterns. This prompted the use of reflective cognitive processes such that purchasing behaviour was directed by personal resources and healthy food goals. However, the extent to which reflective cognition continued to be employed during behaviour change was influenced by the broader goal system in which healthy food goals resided. The importance of user engagement was highlighted through this exploratory research. Engagement was expressed at an intrinsic level as a sense of personal autonomy, an increased perceived capacity to change, and viewing the app as a confidential and empathetic ally. App features that facilitated their expression were considered to result in optimal engagement. Findings suggest that an individual’s involvement, in relation to healthy food, may act as a trigger for different phases of engagement as variations in goal saliency lead to flux in involvement levels. The importance of individual characteristics on app engagement was evident which emphasises the need to integrate tailored features into health apps to ensure that it is congruent with personal goals. Conclusions The present findings add to the existing understanding of the interplay between app technology and behaviour change. If appropriately designed health apps may facilitate a more conscious approach to food purchasing and support healthier purchasing behaviour. An individual’s goal system architecture may influence the extent to which the reflective cognitive system is employed during behaviour change, which progresses existing knowledge of the influence of goal systems on behaviour change. The present research contributes to the extant literature in relation to user engagement. The intrinsic expressions of engagement are proposed to result from different configurations of engagement dimensions which suggests an interaction between these dimensions rather than an isolated existence. The potential role of involvement as a trigger of engagement phases further challenges the current conceptualisation of engagement. Such findings add to the call for the use of alternative non-quantitative, context-specific means of measurement to adequately capture the engagement process. In conclusion, findings suggest the potential to expand existing behaviour change theory, to integrate components of engagement, for improved relevance in the app technology space. Future health app design must consider the individual user and incorporate tailored features to ensure user self-congruence and support continued engagement to facilitate change. Health apps may be an effective tool to support healthier food behaviours in women from a lower socioeconomic background but they may be most effective when implemented as part of a range of individual, community, and broader structural measures.
The economic burden of diabetes in Ireland
(University College Cork, 2018) O'Neill, Kate N.; Kearney, Patricia M.; Fitzgerald, Tony; Mchugh, Sheena; Health Research Board
Background and Aims: As a leading cause of morbidity and mortality, diabetes places a significant burden on society and presents a growing challenge for national economies. The economic burden of diabetes is forecast to grow in coming years, driven by increasing diabetes prevalence and rising medical expenditure. Worldwide, there is a lack of robust, comprehensive and comparable estimates of costs attributable to diabetes. Cost-effective interventions are required to efficiently manage and treat diabetes and curb increasing trends in incidence. Three effective interventions spanning the prevention continuum have recently been recommended in Irish health policy and can potentially influence the burden of diabetes; a sugar-sweetened beverage (SSB) levy, financial remuneration for the provision of structured diabetes care in primary care through the ‘cycle of care’ initiative and bariatric surgery. The overarching aims of this thesis were to estimate the economic burden of diabetes in Ireland and to explore the potential for current policy approaches to impact on the burden of diabetes. Methods: The economic burden of diabetes was estimated from a societal perspective employing an incremental costing approach where possible. Nationally representative data from The Irish LongituDinal study of Ageing (TILDA) and the national pharmacy claims database, Health Service Executive – Primary Care Reimbursement Service (PCRS), were utilised. Direct costs included health service utilisation costs and medication costs while indirect costs included productivity losses from reduced labour force participation and premature mortality. The impact of diabetes on health service utilisation and productivity were explored using multivariable regression models. Trends in pharmaceutical expenditure on diabetes between 2011 and 2015 were explored. Total expenditure associated with diabetes was calculated by extracting data on all diabetes-related items dispensed. A comparative risk assessment was conducted to robustly estimate the potential impact of a reduction in population-level SSB consumption on type 2 diabetes incidence. Using data from the Survey of Lifestyle, Attitudes and Nutrition (SLAN), the potential impact of a 10% levy on SSBs was explored. An assessment of the potential impact of the ‘cycle of care’ and bariatric surgery provision on the burden of diabetes was conducted using a cross-sectional analysis of TILDA. Results: Diabetes was associated with excess health service use across the entire health system and was also adversely associated with productivity. Compared to those without diabetes, people with diabetes have on average 1.49 (95% CI: 1.10, 1.88) additional GP visits annually. Diabetes was associated with an 87% increase in out-patient visits, 52% increase in hospital admissions and 33% increase in A&E attendances (p<0.001). People with diabetes were 41% less likely to be employed than those without diabetes (p<0.001). The total costs of diabetes in those aged over 50 years in Ireland was estimated at €545,787,911 (95% CI: 365,597,451 – 766,782,103) in 2013; €238,155,072 (95% CI: 192,023,954 – 278,959,992) in direct costs and €307,632,839 (95% CI: 173,573,497 – 487,822,111) in indirect costs. Over the five-year period from 2011 to 2015, the cost of prescription items used specifically in the treatment and management of diabetes increased by 18%, reaching €153,621,477 in 2015, with blood glucose-lowering medications accounting for 73% of this increase. The introduction of a 10% SSB levy is estimated to prevent 0.25% (95% UI: 0.01%,0.5%) of incident type 2 diabetes cases in a ten-year period. While the majority of people with type 2 diabetes are covered by the ‘cycle of care’ initiative, 31.6% (95% CI: 27.8, 35.6) are not eligible. Current eligibility criteria do not identity people on the basis of clinical need but rather on income. With fewer than 50 publicly funded bariatric surgeries taking place annually, current service provision meets less than 0.1% of the need. Conclusion: Diabetes places a substantial burden on the Irish health system as well as the national economy. The estimates provide useful information to inform policy-level responses to tackle the burden of diabetes. With findings demonstrating increasing pharmaceutical expenditure on diabetes in recent years, combined with the increasing prevalence of diabetes in Ireland, the economic burden of diabetes is likely to increase. Population-level interventions targeting SSB consumption can play a role in the primary prevention of type 2 diabetes. The potential impact of effective tertiary prevention interventions, as recommended and supported by Irish health policy, are limited by inequitable and inadequate investment.
The effect of complex workplace dietary interventions on employees dietary behaviours, nutrition knowledge and health status
(University College Cork, 2015) Geaney, Fiona; Harrington, Janas; Perry, Ivan J.; Greiner, Birgit; McKenzie, Kenneth; Health Research Board; Irish Heart Foundation; Department of Agriculture, Fisheries and Food, Ireland
Background The growing prevalence and associated burden of diet-related non-communicable diseases is a global public health concern. The environments in which people live and work influences their dietary behaviours. Aim The focus of this thesis was on the effectiveness of complex workplace dietary interventions. The comparative effectiveness of a complex workplace environmental dietary modification intervention and an educational intervention were assessed both alone and in combination relative to a control workplace setting. Methods The systematic review was guided by the PRISMA statement. In a cluster controlled trial, four workplaces were purposively allocated to control, nutrition education alone (Education), environmental dietary modification alone (Environment) and nutrition education and environmental dietary modification (Combined intervention). The interventions were guided by the MRC framework. In the control workplace, data were collected at baseline and follow-up. In the intervention related sub-study, the relationships between nutrition knowledge, diet quality and hypertension were examined. Results The systematic review provided limited evidence. In the FCW study, 850 employees aged 18-64 years were recruited at baseline with N(response rate %) in each workplace as follows: Control: 111(72%), Education: 226(71%), Environment: 113(91%), Combined intervention: 400(61%). Complete follow-up data was obtained for 517 employees (61%). There were significant positive changes in dietary intakes of saturated fat(p=0.013), salt(p=0.010) and nutrition knowledge(p=0.034) between baseline and follow-up at 7-9 months in the combined intervention versus the control workplace in the fully adjusted multivariate analysis. Small but significant changes in BMI(-1.2kg/m2 (p=0.047) were also observed in the combined intervention. In the sub-study, nutrition knowledge was positively significantly associated with diet quality and blood pressure but no evidence of a mediation effect of the DASH score was detected between nutrition knowledge and blood pressure. Conclusion This thesis provides critical evidence on the effectiveness of complex workplace dietary interventions in a manufacturing working population.
The effectiveness of using patient-reported outcome measures as quality improvement tools
(University College Cork, 2014) Boyce, Maria B.; Browne, John P.; Health Research Board
Aim: To investigate the value of using PROMs as quality improvement tools. Methods: Two systematic reviews were undertaken. The first reviewed the quantitative literature on the impact of PROMs feedback and the second reviewed the qualitative literature on the use of PROMs in practice. These reviews informed the focus of the primary research. A cluster randomised controlled trial (PROFILE) examined the impact of providing peer benchmarked PROMs feedback to consultant orthopaedic surgeons on improving outcomes for hip replacement surgery. Qualitative interviews with surgeons in the intervention arm of the trial examined the view of and reactions to the feedback. Results: The quantitative review of 17 studies found weak evidence to suggest that providing PROMs feedback to professionals improves patient outcomes. The qualitative review of 16 studies identified the barriers and facilitators to the use of PROMs based on four themes: practical considerations, attitudes towards the data, methodological concerns and the impact of feedback on care. The PROFILE trial included 11 surgeons and 215 patients in the intervention arm, and 10 surgeons and 217 patients in the control arm. The trial found no significant difference in the Oxford Hip Score between the arms (-0.7, 95% CI -1.9-0.5, p=0.2). Interviews with surgeons revealed mixed opinions about the value of the PROMs feedback and the information did not promote explicit changes to their practice. Conclusion: It is important to use PROMs which have been validated for the specific purpose of performance measurement, consult with professionals when developing a PROMs feedback intervention, communicate with professionals about the objectives of the data collection, educate professionals on the properties and interpretation of the data, and support professionals in using the information to improve care. It is also imperative that the burden of data collection and dissemination of the information is minimised.
The effects of copayment policies on adherence to prescription medicines in publicly insured populations
(University College Cork, 2014) Sinnott, Sarah-Jo; Whelton, Helen; Byrne, Stephen; Woods, Noel; Normand, Charles; Health Research Board
Introduction: Copayments for prescriptions are associated with decreased adherence to medicines resulting in increased health service utilisation, morbidity and mortality. In October 2010 a 50c copayment per prescription item was introduced on the General Medical Services (GMS) scheme in Ireland, the national public health insurance programme for low-income and older people. The copayment was increased to €1.50 per prescription item in January 2013. To date, the impact of these copayments on adherence to prescription medicines on the GMS scheme has not been assessed. Given that the GMS population comprises more than 40% of the Irish population, this presents an important public health problem. The aim of this thesis was to assess the impact of two prescription copayments, 50c and €1.50, on adherence to medicines.Methods: In Chapter 2 the published literature was systematically reviewed with meta-analysis to a) develop evidence on cost-sharing for prescriptions and adherence to medicines and b) develop evidence for an alternative policy option; removal of copayments. The core research question of this thesis was addressed by a large before and after longitudinal study, with comparator group, using the national pharmacy claims database. New users of essential and less-essential medicines were included in the study with sample sizes ranging from 7,007 to 136,111 individuals in different medication groups. Segmented regression was used with generalised estimating equations to allow for correlations between repeated monthly measurements of adherence. A qualitative study involving 24 individuals was conducted to assess patient attitudes towards the 50c copayment policy. The qualitative and quantitative findings were integrated in the discussion chapter of the thesis. The vast majority of the literature on this topic area is generated in North America, therefore a test of generalisability was carried out in Chapter 5 by comparing the impact of two similar copayment interventions on adherence, one in the U.S. and one in Ireland. The method used to measure adherence in Chapters 3 and 5 was validated in Chapter 6. Results: The systematic review with meta-analysis demonstrated an 11% (95% CI 1.09 to 1.14) increased odds of non-adherence when publicly insured populations were exposed to copayments. The second systematic review found moderate but variable improvements in adherence after removal/reduction of copayments in a general population. The core paper of this thesis found that both the 50c and €1.50 copayments on the GMS scheme were associated with larger reductions in adherence to less-essential medicines than essential medicines directly after the implementation of policies. An important exception to this pattern was observed; adherence to anti-depressant medications declined by a larger extent than adherence to other essential medicines after both copayments. The cross country comparison indicated that North American evidence on cost-sharing for prescriptions is not automatically generalisable to the Irish setting. Irish patients had greater immediate decreases of -5.3% (95% CI -6.9 to -3.7) and -2.8% (95% CI -4.9 to -0.7) in adherence to anti-hypertensives and anti-hyperlipidaemic medicines, respectively, directly after the policy changes, relative to their U.S. counterparts. In the long term, however, the U.S. and Irish populations had similar behaviours. The concordance study highlighted the possibility of a measurement bias occurring for the measurement of adherence to non-steroidal anti-inflammatory drugs in Chapter 3. Conclusions: This thesis has presented two reviews of international cost-sharing policies, an assessment of the generalisability of international evidence and both qualitative and quantitative examinations of cost-sharing policies for prescription medicines on the GMS scheme in Ireland. It was found that the introduction of a 50c copayment and its subsequent increase to €1.50 on the GMS scheme had a larger impact on adherence to less-essential medicines relative to essential medicines, with the exception of anti-depressant medications. This is in line with policy objectives to reduce moral hazard and is therefore demonstrative of the value of such policies. There are however some caveats. The copayment now stands at €2.50 per prescription item. The impact of this increase in copayment has yet to be assessed which is an obvious point for future research. Careful monitoring for adverse effects in socio-economically disadvantaged groups within the GMS population is also warranted. International evidence can be applied to the Irish setting to aid in future decision making in this area, but not without placing it in the local context first. Patients accepted the introduction of the 50c charge, however did voice concerns over a rising price. The challenge for policymakers is to find the ‘optimal copayment’ – whereby moral hazard is decreased, but access to essential chronic disease medicines that provide advantages at the population level is not deterred. This evidence presented in this thesis will be utilisable for future policy-making in Ireland.
Evaluation of complex workplace dietary interventions
(University College Cork, 2016) Fitzgerald, Sarah; Perry, Ivan J.; Kirby, Ann; Murphy, Aileen; Geaney, Fiona; Health Research Board
Background and aim The workplace has been identified as an ideal setting in which to promote healthy dietary behaviours. However, uncertainty surrounds both the effectiveness and costeffectiveness of workplace dietary interventions and a dearth of evidence exists with regards to evaluating the implementation process of such interventions. The core aim of this thesis was to conduct both a process evaluation and an economic evaluation of the Food Choice at Work (FCW) complex workplace dietary intervention. Methods The FCW study was a pragmatic trial which measured the effectiveness of a complex workplace dietary intervention in ideal settings. Firstly, a cross-sectional analysis which employed a zero-inflated negative binomial (zinb) regression model to examine associations between objective health status outcomes, lifestyle characteristics and absenteeism was conducted. Secondly, a detailed process evaluation addressed the implementation of the complex workplace intervention. Interviews were conducted at baseline (27 interviews) and at 7-9 months follow-up (27 interviews) with a purposive sample of workplace stakeholders (managers, caterers and employees). Data were analysed using a thematic framework. Thirdly, micro-costing methods were employed to estimate the cost of implementing and delivering the complex workplace dietary intervention from an employer’s perspective. Finally, an economic evaluation of the complex workplace intervention was conducted. This consisted of 1) a baseline costutility analysis (CUA) which measured the cost-effectiveness of the interventions in terms of quality-adjusted life-years (QALYs), 2) sensitivity analyses to test the robustness of the QALYs which involved performing cost-effectiveness analyses (CEA) using clinical measures to measure health outcomes and 3) a cost-benefit analysis (CBA) where the monetary value of absenteeism was employed so as to report the net benefit of the interventions relative to the control. Results Central obesity was positively associated with absenteeism and increased the expected rate of absence by 72% (mean number of absences was 2.5 days). Consuming a highquality diet and engaging in moderate levels of physical activity were negatively associated with absenteeism and reduced the expected frequency by 50% and 36% respectively. The process evaluation revealed that managers’ desire to improve company image, stakeholder buy-in, organisational support and stakeholder cohesiveness facilitated the implementation of the interventions. Anticipation of employee resistance towards menu changes, workplace restructuring and target-driven workplace cultures were found to impede intervention implementation. With regards to the cost-analysis, 3 main cost categories were identified 1) set-up costs 2) maintenance costs and 3) physical assessment costs. The combined intervention xvi reported the highest total costs (€47,305), followed by nutrition education (€44,726), environmental modification (€24,474) and the control (€21,412). In the economic evaluation, the baseline CUA indicated that each intervention (education (€970/QALY) environment (€98/QALY) and combined (€2,156/QALY)) can be considered costeffective when compared to the control. The CEACs demonstrated that the uncertainty in the incremental costs and effects translated into decision uncertainty for the environment intervention (50% probability of being cost-effective at €45,000/QALY threshold). However, at no point between a ceiling ratio of €0 to €100,000/QALY did the education and combined interventions have a higher probability of being cost-effective than the control. The results of the secondary CEA confirm the baseline CUA results for each intervention. The environment intervention reported the lowest ICERs for: BMI (€14/kg/m2 ), midway waist circumference (€3/cm) and weight (€7/kg). Furthermore, the environment intervention offers the highest net benefit for employers with a positive net benefit of €145.82 per employee reported. Conclusion This thesis provides critical evidence on the relationship between obesity, adverse lifestyle factors and absenteeism. Furthermore, findings also indicate that environmental modification strategies have the potential to offer a cost-effective approach for improving employee health outcomes, depending on the perspective taken. This thesis also highlights the importance of considering contextual factors such as workplace structures and cultures in the development and implementation of future workplace dietary interventions.

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