Deborah J Schofield

University of Sydney, Sydney, New South Wales, Australia

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Publications (102)225.47 Total impact

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    Emily J. Callander · Deborah J. Schofield
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    ABSTRACT: Purpose: It is known that strong feelings of self-efficacy are linked with better management of asthma. However, it is not known whether the experience of poverty can detrimentally impact the self-efficacy feelings of asthma patients. This paper aims to determine whether falling into income or multidimensional poverty lowers self-efficacy among people diagnosed with asthma. Methods: Longitudinal analysis of Waves 7 to 11 (2007 to 2011) of the nationally representative Household, Income and Labour Dynamics in Australia (HILDA) survey using generalized linear models. The analysis was limited to those who had been diagnosed with asthma. The Freedom Poverty Measure was used to identify those in multidimensional poverty. Results: People with asthma who fell into income poverty had significantly lower self-efficacy scores-23% lower (95% CI: -35.1 to -9.1), after falling into income poverty for 3 or 4 years between 2007 and 2011 compared to those who were never in income poverty. Those who fell into multidimensional poverty also had significantly lower self-efficacy scores-25% lower (95% CI: -42.8 to -2.0), after being in multidimensional poverty for 3 or 4 years between 2007 and 2011 compared to those who were never in poverty. Conclusions: Asthmatics who fall into poverty are likely to experience a decline in their feelings of self-efficacy. The findings of this study show that experiencing poverty should be a flag to identify those who may need extra assistance in managing their condition.
    Preview · Article · Jan 2016 · Allergy, asthma & immunology research
  • Emily J Callander · Deborah J Schofield
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    ABSTRACT: Aims: Self-efficacy has numerous benefits for active and healthy aging, including giving the people the ability to make positive changes to their living standards and lifestyles. The present study aims to determine whether falling into multidimensional poverty lowers self-efficacy. Methods: Longitudinal analysis of waves 7-11 (2007-2011) of the nationally representative Household, Income and Labor Dynamics in Australia survey using linear regression models. The analysis focused on the Australian population aged 65 years and older. The Freedom Poverty Measure was used to identify those in multidimensional poverty. Results: Those who fell into multidimensional poverty for 3 or 4 years between 2007 and 2011 had their self-efficacy scores decline by an average of 27 points (SD 21.2). Those who fell into poverty had significantly lower self-efficacy scores in 2011 - up to 57% lower (-66.6%, -45.7% P < 0.0001) after being in multidimensional poverty for 3 or 4 years between 2007 and 2011 than those who were never in poverty. Conclusions: Falling into multidimensional poverty lowers the self-efficacy scores of older people. In order to improve the chances of older people making long-term changes to improve their living standards, feelings of self-efficacy should first be assessed and improved. Geriatr Gerontol Int 2015; ●●: ●●-●●.
    No preview · Article · Dec 2015 · Geriatrics & Gerontology International
  • Emily J. Callander · Deborah J. Schofield
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    ABSTRACT: Fe deficiency anaemia (IDA) is more prevalent in lower socio-economic groups; however, little is known about who actually receives Fe supplements. This paper aims to determine whether the groups most likely to have IDA are the most likely to be taking Fe supplements. Logistic regression analysis was conducted using the cross-sectional, nationally representative National Nutrition and Physical Activity Survey and National Health Measures Survey. After adjusting for other factors, those whose main language spoken at home was not English had twice the odds of having IDA compared with those whose main language spoken at home was English (95 % CI 1·00, 4·32). Those who were not in the labour force also had twice the odds of having IDA as those who were employed (95 % CI 1·16, 3·41). Those in income quintile 1 had 3·7 times the odds of having IDA compared with those in income quintile 5 (95 % CI 1·42, 9·63). Those whose main language spoken at home was not English were significantly less likely to take Fe supplements ( P =0·002) than those whose main language spoken at home was English. There was no significant difference in the likelihood of taking Fe supplements between those who were not in the labour force and those who were employed ( P =0·618); between those who were in income quintile 1 and in higher income quintiles; and between males and females ( P =0·854), after adjusting for other factors. There is a mismatch between those who are most in need of Fe supplements and those who currently receive them.
    No preview · Article · Dec 2015 · British Journal Of Nutrition
  • Emily J. Callander · Deborah J. Schofield
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    ABSTRACT: Background: Diabetes is known to be associated with low income, however no longitudinal studies have documented whether developing T2DM is a risk factor for later falling into poverty. This paper aims to determine whether Australians who are diagnosed with type 2 diabetes have an elevated risk of falling into income poverty or multidimensional poverty. Methods: Data from a nationally representative, longitudinal survey conducted annually since 2001 is utilised. It identifies adults aged 21 years and over who were diagnosed with type 2 diabetes between 2007 and 2009 and compares their risk of falling into income poverty and multidimensional poverty between 2007 and 2012 relative to those who had never been diagnosed with type 2 diabetes using survival analysis with Cox regression models. Results: After adjusting for confounding factors, for males who were diagnosed with T2DM the hazard ratio for falling into income poverty was 1.89 (95% CI: 1.03 - 3.44) and 2.52 (95% CI: 1.24 - 5.12) for falling into multidimensional poverty, relative males who had never been diagnosed with T2DM. There was no significant difference in the hazard ratio for falling into income poverty (p=0.6554) or multidimensional poverty (p=0.9382) for females who were diagnosed with T2DM compared to females who had never been diagnosed with T2DM. Conclusion: Being diagnosed with type 2 diabetes increases the risk of males falling into poverty. The risk is higher for multidimensional poverty than income poverty. This article is protected by copyright. All rights reserved.
    No preview · Article · Dec 2015 · Diabetes/Metabolism Research and Reviews
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    ABSTRACT: Objectives: To estimate (1) productive life years (PLYs) lost because of chronic conditions in Australians aged 45-64 years from 2010 to 2030, and (2) the impact of this loss on gross domestic product (GDP) over the same period. Design, setting and participants: A microsimulation model, Health&WealthMOD2030, was used to project lost PLYs caused by chronic conditions from 2010 to 2030. The base population consisted of respondents aged 45-64 years to the Australian Bureau of Statistics Survey of Disability, Ageing and Carers 2003 and 2009. The national impact of lost PLYs was assessed with Treasury's GDP equation. Main outcome measures: Lost PLYs due to chronic disease at 2010, 2015, 2020, 2025 and 2030 (ie, whole life years lost because of chronic disease); the national impact of lost PLYs at the same time points (GDP loss caused by PLYs); the effects of population growth, labour force trends and chronic disease trends on lost PLYs and GDP at each time point. Results: Using Health&WealthMOD2030, we estimated a loss of 347 000 PLYs in 2010; this was projected to increase to 459 000 in 2030 (32.28% increase over 20 years). The leading chronic conditions associated with premature exits from the labour force were back problems, arthritis and mental and behavioural problems. The percentage increase in the number of PLYs lost by those aged 45-64 years was greater than that of population growth for this age group (32.28% v 27.80%). The strongest driver of the increase in lost PLYs was population growth (accounting for 89.18% of the increase), followed by chronic condition trends (8.28%). Conclusion: Our study estimates an increase of 112 000 lost PLYs caused by chronic illness in older workers in Australia between 2010 and 2030, with the most rapid growth projected to occur in men aged 55-59 years and in women aged 60-64 years. The national impact of this lost labour force participation on GDP was estimated to be $37.79 billion in 2010, increasing to $63.73 billion in 2030.
    Preview · Article · Sep 2015 · The Medical journal of Australia
  • Emily J. Callander · Deborah J. Schofield
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    ABSTRACT: Objective Low income is known to be associated with having arthritis. However, no longitudinal studies have documented the relationship between developing arthritis and falling into poverty. This paper focuses upon Australians who develop arthritis to determine if they have an elevated risk of falling into poverty.Methods Survival analysis using Cox regression models applied to nationally representative, longitudinal survey data between the years 2007 and 2012 for Australian adults aged 21 years and over.ResultsThe hazard ratio for falling into income poverty for females who develop arthritis is 1.51 (95% CI: 1.50 – 1.53), and for males the hazard ratio for falling into income poverty is 1.22 (95% CI: 1.21 – 1.23), relative those who never developed arthritis. The hazard ratio for falling into multidimensional poverty for females who develop arthritis is 1.87 (95% CI: 1.84 – 1.90) and for males the hazard ratio is 1.29 (95% CI: 1.29 – 1.30).Conclusion Developing arthritis increases the risk of falling into income poverty and multidimensional poverty. The risk for income and multidimensional poverty is higher for females. Given the high prevalence of arthritis, the condition is an overlooked driver of poverty. This article is protected by copyright. All rights reserved.
    No preview · Article · Jul 2015 · Arthritis and Rheumatology
  • Emily J Callander · Deborah J Schofield
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    ABSTRACT: To identify whether psychological distress is associated with an increased risk of falling into poverty, giving a more complete picture of how psychological distress affects living standards. Longitudinal analysis of the nationally representative Household Income and Labour Dynamics in Australian (HILDA) survey using Poisson regression models to estimate relative risk of falling into income poverty and multidimensional poverty between 2007 and 2012. The sample was limited to those who were not already in income poverty in 2007. Psychological distress was identified using the Kessler-10 (K10) scale. After adjusting for confounding factors, having moderate psychological distress increased the risk of falling into income poverty by 1.62 (95 % CI 1.31-2.01, p < 0.0001) and the risk of falling into multidimensional poverty by 1.85 (95 % CI 1.37-2.48, p < 0.0001); having very high psychological distress increased the risk of falling into income poverty by 2.40 (95 % CI 1.80-3.20, p < 0.0001) and the risk of falling into multidimensional poverty by 3.68 (95 % CI 2.63-5.15, p < 0.0001), compared to those with low psychological distress. Those who did experience income poverty (RR: 1.29, 95 % CI 1.04-1.61, p = 0.0210) and those who experienced multidimensional poverty (RR: 1.69, 95 % CI 1.32-2.17, p < 0.0001) had an increased risk of having their level of psychological distress increase further compared to those who did not experience poverty. To date, the increased risk of falling into poverty that is associated with elevated levels of psychological distress has been an overlooked burden of the condition.
    No preview · Article · May 2015 · Social Psychiatry
  • Emily J Callander · Deborah J Schofield
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    ABSTRACT: Studies on the indirect costs of asthma have taken a narrow view of how the condition affects the living standards of patients by examining only the association with employment and income. To build on the current cost-of-illness literature and identify whether having asthma is associated with an increased risk of poverty, thus giving a more complete picture of the costs of asthma to individuals and society. Longitudinal analysis of the nationally representative Household Income and Labour Dynamics in Australian survey to estimate the relative risk of income poverty, multidimensional poverty, and long-term multidimensional poverty between 2007 and 2012 and population attributable risk method to estimate the proportion of poverty between 2007 and 2012 directly attributable to asthma. No significant difference was found in the risk of falling into income poverty between those with and without asthma (P = .07). Having asthma increased the risk of falling into multidimensional poverty by 1.35 (95% confidence interval [CI], 1.01-1.83) and the risk of falling into chronic multidimensional poverty by 2.22 (95% CI, 1.20-4.10). Between 2007 and 2012, a total of 5.2% of income poverty cases (95% CI, 5.1%-5.4%), 7.8% of multidimensional poverty cases (95% CI, 7.7%-8.0%), and 19.6% of chronic multidimensional poverty cases (95% CI, 19.2%-20.0%) can be attributed to asthma. Asthma is associated with an increased risk of falling into poverty. This should be taken into consideration when considering the suitability of different treatment options for patients with asthma. Copyright © 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Mar 2015 · Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology
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    ABSTRACT: Diabetes is a debilitating and costly condition. The costs of reduced labour force participation due to diabetes can have severe economic impacts on individuals by reducing their living standards during working and retirement years. A purpose-built microsimulation model of Australians aged 45-64 years in 2010, Health&WealthMOD2030, was used to estimate the lost savings at age 65 due to premature exit from the labour force because of diabetes. Regression models were used to examine the differences between the projected savings and retirement incomes of people at age 65 for those currently working full or part time with no chronic health condition, full or part time with diabetes, and people not in the labour force due to diabetes. All Australians aged 45-65 years who are employed full time in 2010 will have accumulated some savings at age 65; whereas only 90.5% of those who are out of the labour force due to diabetes will have done so. By the time they reach age 65, those who retire from the labour force early due to diabetes have a median projected savings of less than $35,000. This is far lower than the median value of total savings for those who remained in the labour force full time with no chronic condition, projected to have $638,000 at age 65. Not only does premature retirement due to diabetes limit the immediate income available to individuals with this condition, but it also reduces their long-term financial capacity by reducing their accumulated savings and the income these savings could generate in retirement. Policies designed to support the labour force participation of those with diabetes, or interventions to prevent the onset of the disease itself, should be a priority to preserve living standards comparable with others who do not suffer from this condition.
    Full-text · Article · Feb 2015 · PLoS ONE
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    ABSTRACT: The objective of this study was to quantify the impact that having arthritis has on income poverty status and accumulated wealth in Australia. Cross-sectional analysis of Health&WealthMOD, a microsimulation model built on data from the Australian Bureau of Statistics' Survey of Disability, Ageing and Carers and STINMOD, an income and savings microsimulation model. Across all categories of labour force participation status (employed full time, part time or not in the labour force at all), those with arthritis were significantly more likely to be in poverty. Those employed full time with no health condition had 0.82 times the odds of being in income poverty (95 % CI 0.80-0.84) compared with those employed full time with arthritis. Those not in the labour force with no chronic health conditions had 0.36 times the odds of being in income poverty compared with those not in the labour force due to arthritis (95 % CI 0.36-0.37). For people not in the labour force with no long-term health condition, the total value of their wealth was 211 % higher (95 % CI 38-618 %) than the amount of wealth accumulated by those not in the labour force due to arthritis. Similarly, those employed part time with no chronic health condition had 50 % more wealth than those employed part time with arthritis (95 % CI 3-116 %). Arthritis has a profound impact upon the economic circumstances of individuals, which adds a further dimension to the detrimental living standards of older individuals suffering from the condition.
    No preview · Article · Jan 2015 · Rheumatology International
  • Emily Callander · Deborah Schofield · Rupendra Shrestha · Simon Kelly
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    ABSTRACT: This paper explores which measures of health accurately reflect the functional capabilities of individuals – that is, in what measures of health do those classified as having poorer health actually have poorer functional outcomes. Using the 2003 Survey of Disability, Ageing and Carers, cross-tabulations, chi-squared analysis, and logistic regression models were used to identify the relationship between functional outcomes (core activity limitations and employment and education participation) and various measures of health and disability (composite disability measure, health utility scores and general health assessment). Both the composite disability measure and the health utility score accurately capture individual functional capacity – with both measures being related to employment participation, employment and education restrictions, and core activity imitations. The health utility scores can also be divided into a categorical measure and still reflect this functional capacity. The general health assessment measure is also related to functional capacity and can potentially be used in the place of both the composite disability measure and the health utility score.
    No preview · Article · Dec 2014 · Health Sociology Review
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    ABSTRACT: Depression has economic consequences not only for the health system, but also for individuals and society. This study aims to quantify the potential economic impact of five-yearly screening for sub-syndromal depression in general practice among Australians aged 45-64 years, followed by a group-based psychological intervention to prevent progression to depression. We used an epidemiological simulation model to estimate reductions in prevalence of depression, and a microsimulation model, Health&WealthMOD2030, to estimate the impact on labour force participation, personal income, savings, taxation revenue and welfare expenditure. Group therapy is estimated to prevent around 5,200 prevalent cases of depression (2.2%) and add about 520 people to the labour force. Private incomes are projected to increase by $19 million per year, tax revenues by $2.4 million, and transfer payments are reduced by $2.6 million. Group-based psychological intervention to prevent depression could result in considerable economic benefits in addition to its clinical effects. © The Royal Australian and New Zealand College of Psychiatrists 2014.
    No preview · Article · Nov 2014 · Australian and New Zealand Journal of Psychiatry
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    ABSTRACT: IntroductionThe study aim was to develop a generic framework to derive the parameters to populate health-economic models for the rapid evaluation of new techniques and technologies in radiation oncology.MethodsA draft framework was developed through horizon scanning for relevant technologies, literature review to identify framework models, and a workshop program with radiation oncology professionals, biostatisticians, health economists and consumers to establish the Framework's structure. It was tested using four clinical protocols, comparing intensity modulated with 3D conformal therapy (post-prostatectomy, anal canal and nasopharynx) and image-guided radiation therapy techniques with off-line review of portal imaging (in the intact prostate).ResultsThe draft generic research framework consisted of five sequential stages, each with a number of components, and was assessed as to its suitability for deriving the evidence needed to populate the decision-analytic models required for the health-economic evaluations. A final Framework was established from this experience for use by future researchers to provide evidence of clinical efficacy and cost-utility for other novel techniques. The four clinical treatment sites tested during the project were considered suitable to use in future evaluations.Conclusions Development of a generic research framework to predict early and long-term clinical outcomes, combined with health-economic data, produced a generally applicable method for the rapid evaluation of new techniques and technologies in radiation oncology. Its application to further health technology assessments in the radiation oncology sector will allow further refinement and support its generalisability.
    No preview · Article · Nov 2014 · Journal of Medical Imaging and Radiation Oncology
  • Emily J. Callander · Deborah J. Schofield
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    ABSTRACT: Longitudinal analysis of Wave 5 to 10 of the nationally representative Household, Income and Labour Dynamics in Australia dataset was undertaken to assess whether multidimensional poverty status can predict chronic income poverty. Of those who were multidimensionally poor (low income plus poor health or poor health and insufficient education attainment) in 2007, and those who were in income poverty only (no other forms of disadvantage) in 2007, a greater proportion of those in multidimensional poverty continued to be in income poverty for the subsequent 5 years through to 2012. People who were multidimensionally poor in 2007 had 2.17 times the odds of being in income poverty each year through to 2012 than those who were in income poverty only in 2005 (95% CI: 1.23–3.83). Multidimensional poverty measures are a useful tool for policymakers to identify target populations for policies aiming to improve equity and reduce chronic disadvantage. Copyright © 2014 John Wiley & Sons, Ltd.
    No preview · Article · Oct 2014 · Health Economics
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    ABSTRACT: Background: There has been little research on the economic status of those with multiple health conditions, particularly on the relationship between multiple health conditions and wealth. This paper will assess the difference in the value and type of wealth assets held by Australians who have multiple chronic health conditions. Methods: Using Health&WealthMOD, a microsimulation model of the 45-64-year-old Australian population in 2009, a counterfactual analysis was undertaken. The actual proportion of people with different numbers of chronic health conditions with any wealth, and the value of this wealth was estimated. This was compared with the counterfactual values had the individuals had no chronic health conditions. Results: There was no change in the proportion of people with one health condition who actually had any wealth, compared to the counterfactual proportion had they had no chronic health conditions. Ninety-four percent of those with four or more health conditions had some accumulated wealth; however, under the counterfactual, 100% would have had some accumulated wealth. There was little change in the value of non-income-producing assets under the counterfactual, regardless of number of health conditions. Those with four or more chronic health conditions had a mean value of $17 000 in income-producing assets; under the counterfactual, the average would have been $78 000. Conclusion: This study has highlighted the variation in the value of wealth according to number of chronic health conditions, and hence the importance of considering multiple morbidities when discussing the relationship between health and wealth.
    No preview · Article · Sep 2014 · The European Journal of Public Health
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    Deborah Schofield · Michelle M Cunich · Lucio Naccarella
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    ABSTRACT: Objective There is a paucity of research on the quality of evidence relating to primary care workforce models. Thus, the aim of the present study was to evaluate the quality of evidence on diabetes primary care workforce models in Australia.
    Preview · Article · Aug 2014 · Australian health review: a publication of the Australian Hospital Association
  • Deborah J Schofield

    No preview · Article · Jul 2014 · Pain
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    ABSTRACT: Background context: Studies assessing the economic burden of back problems have given little consideration to the presence of comorbidities. Purpose: To assess the difference in the value of wealth held by Australians who have back problems and varying numbers of chronic comorbidities. Study design: A cross-sectional study. Patient sample: Individuals aged 45 to 64 years in 2009: 4,388 with no chronic health conditions, 1,405 with back problems, and 3,018 with other health conditions. Outcome measure: Total wealth (cash, shares, superannuation, investment property, and owner occupied home). Methods: Using a microsimulation model (Health&WealthMOD), logistic regression models were used to assess the odds of having any wealth. Linear regression models were used to assess the difference in the value of this wealth. Results: Those with back problems and two comorbidities had 0.16 (95% confidence interval [CI]: 0.06-0.42) times the odds and those with back problems and three or more comorbidities had 0.20 (95% CI: 0.11-0.38) times the odds of having accumulated some wealth than those with no chronic health conditions. Those with back problems and three or more comorbidities had a median value of total wealth of around $150,000, whereas those with back problems only and back problems and one comorbidity had a median value of total wealth of around $250,500. There was no significant difference in the amount of wealth accumulated by those with back problems and at least one comorbidity and those with other health conditions and the same number of comorbidities. However, those with only one health condition (excluding back problems) had 65% more wealth than those with back problems only (95% CI: 5.1-161.2). Conclusions: This study highlights the importance of considering multiple morbidities when discussing the relationship between back problems and economic circumstances.
    No preview · Article · Jul 2014 · The spine journal: official journal of the North American Spine Society
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    ABSTRACT: Background: Intensity modulated radiation therapy (IMRT) is a radiation therapy technology that facilitates the delivery of an improved dose distribution with less dose to surrounding critical structures. This study estimates the longer term effectiveness and cost-effectiveness of IMRT in patients post radical prostatectomy. Methods: A Markov decision model was developed to calculate the incremental quality adjusted life years (QALYs) and costs of IMRT compared with three dimensional conformal radiation therapy (3DCRT). Costs were estimated from the perspective of the Australian health care system. Results: IMRT was both more effective and less costly than 3DCRT over 20 years, with an additional 20 QALYs gained and over $1.1 million saved per 1000 patients treated. This result was robust to plausible levels of uncertainty. Conclusions: IMRT was estimated to have a modest long term advantage over 3DCRT in terms of both improved effectiveness and reduced cost. This result was reliant on clinical judgement and interpretation of the existing literature, but provides quantitative guidance on the cost effectiveness of IMRT whilst long term trial evidence is awaited.
    Full-text · Article · Jun 2014 · Radiotherapy and Oncology
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    ABSTRACT: Background Little is known about the effects of personal and other characteristics of care recipients on the behaviour of carers. The aim of this study is to examine the association between the main chronic (disabling) condition of care recipients and the likelihood of their (matched) primary carers aged 15–64 years being out of the labour force. Methods We conducted a retrospective analysis of cross-sectional data from the Australian Bureau of Statistics 2009 Survey of Disability, Ageing and Carers (SDAC) for people aged 15–64 years. We estimated the rates of exit from the labour force for primary carers and non-carers; rates of chronic disease occurrence for care recipients living with their main carers; odds ratios of primary carers being out of the labour force associated with the main chronic condition of their care recipient who lives with them. Results From the 2009 SDAC, we identified 1,268 out of 37,186 eligible participants who were primary carers of a care recipient who lived with them. Of these, 628 (49.5%) were out of the labour force. Most common diseases of care recipients were: back problems (12%); arthritis and related disorders (10%); diseases of the nervous system (such as multiple sclerosis, epilepsy, cerebral palsy) (7.4%); and conditions originating in the perinatal period or congenital malformations, deformations and chromosomal abnormalities (5.1%). When adjusted for age, sex, education and whether have a long term chronic condition of informal carers, the five conditions of care recipients associated with the highest odds of their carers being out of the labour force were: head injury/acquired brain damage; neoplasms, blood diseases, disorders of the immune system; leg/knee/foot/hip damage from injury/accident; dementia, Parkinson’s disease, Alzheimer’s disease; and diseases of the musculoskeletal system and connective tissue (osteoporosis). Conclusions This study identifies the type of conditions that have the greatest impact on the labour force participation of informal carers – previously unavailable information for Australia. Australia, like most developed countries, is facing several skills shortages and an ageing population. These governments will need to adopt novel and more wholistic approaches to increase the labour force participation of diverse groups. Informal carers are one such group.
    Full-text · Article · Jun 2014 · BMC Public Health

Publication Stats

708 Citations
225.47 Total Impact Points

Institutions

  • 2005-2015
    • University of Sydney
      • • School of Public Health
      • • NHMRC Clinical Trials Centre (CTC)
      • • Faculty of Health Sciences
      Sydney, New South Wales, Australia
  • 2013
    • Sydney Cancer Centre
      Camperdown, New South Wales, Australia
  • 2002-2012
    • University of Canberra
      • The National Centre for Social and Economic Modelling (NATSEM)
      Canberra, Australian Capital Territory, Australia
  • 2008
    • Thompson Rivers University
      Kamloops, British Columbia, Canada