Dr Jonathan Briody, UCD 2015
Shocks and the Understudied: Three Essays on the Economics of Health
Institution: UCD, 2015 cohort
Supervisors: Professor Cecily Kelleher (UCD), Dr Orla Doyle (UCD)
The common definition of a shock is a sudden, unexpected, and usually unpleasant event or experience. Evidently, most definitions of a shock quantify this term in the context of the subsequent reaction to such a change. Human beings are biological organisms, and, like all complex living things, unique outcomes are expected for different population groups. Despite this, much of the existing literature focuses on narrow portions of society. For example, studies on economic decline typically consider the importance of direct job loss, thus often removing women, and particularly new mothers, from the evidence base on this topic. In addition, studies of weight typically focus on adulthood or late adolescence due to disagreement on the appropriate classification of excess and unhealthy weight, coupled with insufficient surveillance data, in the critical first five years of life. While it is agreed that parents play a crucial role in children’s development, until recently, appropriate longitudinal data has not been available to assess the consequences of caregiver shocks on children’s early socio-emotional outcomes.
To address these limitations, this thesis incorporates rich longitudinal data on population groups for whom answering these questions was historically complex, and who were thus previously understudied in the literature. Chapter 2 and 3 examine the role of economic shocks in engendering health outcomes and behaviours. Both chapters focus on understudied members of society, recognising the economic vulnerability of new mothers and young children.
Chapter 2 uses longitudinal data, prospectively gathered during the Great Recession in Ireland, matched with Census data to investigate the impact of unemployment on health regardless of actual labour force participation. This allows me to capture the health consequences of employment declines for mothers, individuals who traditionally have a limited degree of exposure to the labour market, and hence provides a useful complement to the prevailing literature which is predominantly restricted to working men.
Excess weight in infants and young children is a significant health problem facing many industrialised countries, yet little is known about the impact of parental employment shocks on childhood adiposity. In chapter 3, I derive anthropometric indices from objective height and weight data compared with reference charts for children in the first five years of life. Studying repeated anthropometric measures in household-level panel data before, during and after the peak of the Great Recession in Ireland allows me to present the first estimates of the impact of direct parental unemployment shocks on children’s weight.
Similarly, the relationship between parental health and child socio-emotional development is not well understood, although the role played by parents in children’s development is increasingly recognised. In chapter 4, I use health shocks as an exogenous source of variation to identify the impact of parental health on child outcomes. I contribute new economic knowledge on the practical significance of developmental scores by placing the importance of parental health shocks in the clinical context for children’s development.
Chapters 2 and 3 study economic changes and changes in health and health behaviours, thereby focusing on economic shocks specifically. In contrast, chapter 4 concerns the consequences that a health shock, once experienced, may hold for well-being in offspring, consequently adding to the literature on the intergenerational repercussions of health shocks.
Keywords: Shocks; Health; Behaviours; Panel Data
Dr Katarzyna Gajewska, RCSI 2015
Dr Aoife Gallagher, UL 2015
Dr Marita Hennessy, NUIG 2015
Background: Childhood obesity is a global public health challenge. Research priorities have not been established for obesity prevention research across childhood, however. Coproduction of research priorities leads to research which may be more translatable to policy and practice. Childhood obesity prevention is advocated, particularly during the first 1,000 days – the period between conception and a child’s second birthday. This is a critical window of opportunity to promote healthy growth and associated behaviours. Health professionals can play an important role in part due to the large number of routine contacts they have with parents. While there is some evidence of the effectiveness of health professional delivered interventions in impacting on obesity-related outcomes, reviews have not examined the impact of provider type, and the active ingredients of interventions have not been explored. The extent to which interventions are generalisable to populations or settings beyond those in the original study is also unclear. Furthermore, there is an absence of research on parental views and experiences of early life health professional-delivered obesity prevention interventions.
Aims: The aim of this research is to examine opportunities for, and the effectiveness of, interventions delivered by health professionals during the first 1,000 days which aim to prevent childhood obesity. This will provide a basis for the development, adaptation and/or scale-up of future interventions.
Methods: A mixed methods approach was taken. In study 1, a nominal group technique was used to co-produce research priorities, and generate information on facilitators and barriers to knowledge translation, in childhood obesity prevention. In study 2a, a systematic review was conducted to examine the effectiveness of health professional-delivered early life obesity prevention interventions, and what behaviour change theories and/or techniques were associated with more effective intervention outcomes. In study 2b, included studies within the systematic review were further examined to determine the extent to which they reported on elements that can be used to inform generalizability across settings and populations. Finally, in study 3, qualitative interviews with parents were conducted to examine their views and experiences of early life interventions to promote healthy growth, particularly those delivered by health professionals. Data were analysed using reflexive thematic analysis.
Findings: Key themes identified during the research prioritization exercise were the importance of funding and resources, coproduction of research, and a focus on both implementation research and social determinants within the field of childhood obesity prevention. The systematic review identified 39 trials involving 46 intervention arms. There was some evidence of intervention effectiveness: only four interventions were effective on a primary (adiposity/weight) and secondary (behavioural) outcome measure, while twenty‐two were effective on a behavioural outcome only. Several methodological limitations were noted, impacting on efforts to establish the active ingredients of interventions. Reporting of external validity dimensions varied; elements that were poorly described included: representativeness of individuals and settings, treatment receipt, intervention mechanisms and moderators, cost effectiveness, and intervention sustainability and acceptability. Two central themes were generated from the qualitative data: (1) navigating the uncertainty, stress, worries, and challenges of parenting whilst under scrutiny and (2) accessing support in the broader system. Becoming a parent brings challenges relating to lack of knowledge and/or confidence in this role, and feeling judged for parenting/feeding decisions. Parents require support and face barriers to accessing and engaging with supports and services. They are often in the receiving end of uninformed, conflicting, confusing, changing and/or unsolicited advice. Relationships and relatability are key, and tailored information and support is required.
Conclusion: The findings of this research contribute important insights into early life obesity prevention interventions, with implications for the conduct and reporting of research, and knowledge translation efforts. The identified research priorities may help to shape the agendas of funders and researchers, and aid in the conduct of policy-relevant research and the translation of research into practice in childhood obesity prevention. Health professional-delivered early life obesity prevention interventions show some evidence of effectiveness and there is some evidence that more active engagement strategies—such as problem solving, review behavioural goal(s), feedback on behaviour, feedback on outcome(s) of behaviour, and social support (unspecified) — should be incorporated into practice. More emphasis is needed on research designs that consider generalisability, and the reporting of external validity elements. Parents are receptive to, and would welcome, support during this critical time period, particularly around feeding. Such support, however, needs to be practical, realistic, evidence-based, timely, accessible, non-judgemental, and from trusted sources, including both health professionals and peers. Various levels of support and intervention are required, at individual, inter-personal, organisational, community, and policy levels. Interventions to promote healthy growth and related behaviours need to be developed/adapted and implemented in a way that supports parents, their views and circumstances.