Connecting Tax Time to Financial Security: Designing Public Policy with Evidence from the Field

The ability to accumulate and access savings is a fundamental determinant of economic security for many families, especially those with low incomes and limited resources. Since every family's circumstance is different, so too are their savings needs, which can range both in time horizon and flexibility of purpose. Current federal policy favors longer-term, targeted purposes, such as savings for retirement, leaving a void in policy supports for households whose savings needs are more immediate. This impedes a household's ability to build up a stock of flexible use savings that are accessible to buffer against financial shocks or to invest in ways that may improve their future, roles that serve as the underpinning for economic mobility. Policy solutions to fill this gap need to address both the lack of resources that lower-income households can dedicate to saving and the lack of products that facilitate saving for flexible purposes. In response, the Asset Building Program at the New America Foundation has developed a proposal, The Financial Security Credit, which offers lower- and middle-income households the option to open an account and an incentive to save in that account at a moment when they are receiving an influx of resources -- tax time

Person-centred therapy with a client experiencing social anxiety difficulties : a hermeneutic single case efficacy design

Social anxiety is a chronic, debilitating psychological condition. Hermeneutic Single Case Efficacy Design (HSCED) is a legalistic mixed-method case study method for evaluating therapy efficacy in single cases. Using a case of Person-Centred Therapy (PCT) with a client experiencing social anxiety difficulties, we addressed the standard HSCED research questions of pre-post client change, causal role of therapy, and change processes. In addition, we explored adaptations to HSCED for ambiguous outcomes. Based on a rich case record, affirmative and sceptic cases were constructed and adjudicated by three judges.The judges held that the client changed considerably (but not substantially) and that therapy contributed considerably to client change. Change processes central to PCT were held to be active, as were client resources. The new procedures enabled judges to make sense of the ambiguous outcome data and can be further extended and developed. PCT can bring about considerable change in socially anxious clients

Economic evaluation in intensive care: The case of SDD

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.The aim of this thesis was to examine the use of modelling techniques in the economic evaluation of selective decontamination of the digestive tract (SDD), used to prevent intensive care unit (ICU) acquired pneumonia. The need for evidence for the effectiveness and cost effectiveness of technologies used in intensive care was highlighted through an examination of the literature. The clinical and economic issues pertinent to ICU-acquired pneumonia and SDD were described. It was suggested that an economic evaluation of SDD was required. An evaluation using modelling techniques was proposed. A secondary economic evaluation of SDD was carried out, utilising a decision-analytic model and published clinical and economic evidence to derive cost/outcome ratios. This analysis showed that SDD could be a dominant therapy, but improved economic and long term outcome evidence was required to increase the robustness of conclusions. This thesis concentrated on improving the economic evidence. A national survey of SDD use provided information on clinical practice. A prospective observational study was carried out at two British ICUs to obtain evidence on the economic impact of ICU-acquired pneumonia. The impact of infection and confounding factors on resource use was handled quantitatively, using regression techniques. It was found that ICU-acquired pneumonia significantly increased length of ICU stay. These two sets of empirical data were used in a revised economic evaluation of SDD. SDD was found to be a dominant therapy at both centres. Uncertainty around cost/outcome ratios was considered to be decreased, or at least quantified, by this primary economic evidence. This thesis concludes that modelling has a place in economic evaluation in intensive care, if rigorous methods are used. It has also demonstrated that current, reliable and applicable economic evidence is a prerequisite to any economic evaluation, if it is to be included in the decision-making process.Financial support was obtained from the Office of the Chief Pharmacist, Department of Health

Supporting the emotional needs of young people in care: a qualitative study of foster carer perspectives

Young people who have been removed from their family home and placed in care have often experienced maltreatment and there is well-developed evidence of poor psychological outcomes. Once in care, foster carers often become the adult who provides day-to-day support, yet we know little about how they provide this support or the challenges to and facilitators of promoting better quality carer-child relationships. The aim of this study was to understand how carers support the emotional needs of the young people in their care and their views on barriers and opportunities for support. Participants were 21 UK foster carers, recruited from a local authority in England. They were predominantly female (86%), aged 42-65 years old and ranged from those who were relatively new to the profession (<12 months' experience) to those with over 30 years of experience as a carer. We ran three qualitative focus groups to gather in-depth information about their views on supporting their foster children's emotional well-being. Participants also completed short questionnaires about their training experiences and sense of competence. Only half of the sample strongly endorsed feeling competent in managing the emotional needs of their foster children. While all had completed extensive training, especially on attachment, diagnosis-specific training for mental health problems (eg, trauma-related distress, depression) was less common. Thematic analysis showed consistent themes around the significant barriers carers faced navigating social care and mental health systems, and mixed views around the best way to support young people, particularly those with complex mental health needs and in relation to reminders of their early experiences. Findings have important implications for practice and policy around carer training and support, as well as for how services support the mental health needs of young people in care

The Attitudes about Complex Therapy Scale (ACTS) in Type 2 Diabetes and Cardiovascular Disease: Development, Validity and Reliability

Background: Type 2 diabetes is associated with cardiovascular disease, and patients with both conditions are prescribed complex medication regimens. Aim: The aim was to develop a reliable and valid measure of attitudes associated with the prescription and management of multiple medicines in patients with Type 2 diabetes and cardiovascular disease. Methods: Principal component analysis (PCA) and Cronbach alpha assessed the reliability of the Attitudes about Complex Therapy Scale (ACTS). Examinations of relationships with related measures inform concurrent validity. Questionnaires were sent to a cross-sectional sample of 480 people prescribed multiple medicines for co-morbid Type 2 diabetes. Results: Cronbach alpha was 0.76, indicating the scale had good internal reliability. PCA rotated a four factor model accounting for 37% of the variance. Four subscales identified; 1. Concerns about multiple medicines and increasing numbers of medicines; 2.Anxiety over missed medicines; 3. Desires to substitute medicines and reduce the number of medicines prescribed and; 4. Perceptions related to organising and managing complex therapy. The ACTS showed significant relationships with measures of anxiety, depression, general beliefs about medicines and self-efficacy. Also, the ACTS significantly correlated with adherence to medicines, showing good predictive validity. Conclusion: The ACTS was designed to assess negative attitudes towards complex therapy and multiple medication management. This tool could aid prescribing decisions and may identify people who are intentionally non-adherent to all or some of their medicines

Clinical and economic implications of therapeutic switching of Angiotensin receptor blockers to Angiotensin-converting enzyme inhibitors : a population-based study

OBJECTIVE: To evaluate the clinical and cost impact of switching angiotensin receptor blockers (ARBs) to angiotensin-converting enzyme inhibitors (ACEIs) in patients with hypertension. METHODS: This study used the UK Clinical Practice Research Datalink, linking with the Hospital Episode Statistics (April 2006 to March 2012). Adults with hypertension (n = 470) were followed from the first ARB prescription date to the switching date (preswitching period); then from the switching date to the date when study ended, patient left the dataset or died (postswitching period). Patients were divided into ACEIs-combined (n = 369) and ACEIs-monotherapy (n = 101) groups by whether additional antihypertensive drugs were prescribed with ACEIs in the postswitching period. Proportion of days covered (PDC), clinical outcomes and costs were compared between the preswitching and postswitching periods using a multilevel regression. RESULTS: Overall, in the postswitching period, there was a significant increase in the proportion of nonadherence (PDC < 80%) (OR: 2.4; 95% CI: 1.6-3.7), but a significant reduction in mean SBP (mean difference: -2.3; 95 CI: -3.4 to 1.2 mmHg) and mean DBP (mean difference: -1.9; 95% CI: -2.6 to -1.2 mmHg). However, these results were only observed in the ACEIs-combined group. There was no postswitching significant difference in either the incidence of individual or composite hypertension-related complications (OR: 0.9; 95% CI: 0.4-2.0). There was a significant reduction in the overall annual medical cost per patient by £329 (95% CI: -534 to -205). CONCLUSION: Switching of ARBs to ACEIs monotherapy appeared to be clinically effective and a cost-saving strategy. The observed changes in the ACEIs-combined group are assumed to be related to factors other than the ARBs switching

Unwrapping school lunch: Examining the social dynamics and caring relationships that play out during school lunch

Students are important stakeholders in school food programs. Yet children’s daily experiences and voices are often overlooked in advocacy around school food. In Canada, where the federal government recently expressed interest in creating a National School Food Program, nearly no research has documented the first-hand experiences of children during lunch. This ethnographic study draws on data collected during 36 lunchtimes in three Canadian schools during a transitional period in a school district’s lunch program. The findings unwrap the powerful role of students’ perceptions of and relationships to food in shaping their social interactions, and their sense of care, connection, and identity. Classroom observations coupled with photos of school lunches demonstrate the wide diversity of foods eaten at school and the nuanced, complex, and sometimes divergent meanings children give to food, school lunch and the people involved in preparing, serving, supervising, and sharing lunchtime experiences. Students demonstrated in-depth knowledge of the food choices and attitudes of their peers and actively marked out their identities vis-à-vis food. Students frequently talked about food as a site of care and support, and both the social relationships and care work that played out were a major part of school lunch experiences. Understanding the intricacies of children’s school lunch experiences, including the relationships, meanings, and values that shape school lunch, will be critical for creating robust school food programs and policies in Canada that better serve the needs of children and reduce rather than reproduce existing health and social inequalities.Peer reviewe

The impact of the ‘Better Care Better Value’ prescribing policy on the utilisation of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for treating hypertension in the UK primary care setting: longitudinal quasi-experimental design

In April/2009, the UK National Health Service initiated four Better Care Better Value (BCBV) prescribing indicators, one of which encouraged the prescribing of cheaper angiotensin-converting enzyme inhibitors (ACEIs) instead of expensive angiotensin receptor blockers (ARBs), with 80 % ACEIs/20 % ARBs as a proposed, and achievable target. The policy was intended to save costs without affecting patient outcomes. However, little is known about the actual impact of the BCBV indicator on ACEIs/ARBs utilisation and cost-savings. Therefore, this study aimed to evaluate the impact of BCBV policy on ACEIs/ARBs utilisation and cost-savings, including exploration of regional variations of the policy’s impact