HRB Centre for Health and Diet Research - Doctoral Theses

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    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.
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    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.