Medicine & Health

Publication Search Results

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  • (2022) McEniery, Julie
    Thesis
    Background: Queensland’s infant mortality rate (IMR) is higher than other Australian jurisdictions and the disparity is under-researched, particularly for Sudden Unexpected Deaths in Infancy (SUDI). Informed by Triple Risk and Adverse Childhood Events (ACEs) constructs, and with a focus on shared infant sleep, this thesis analyses risk factors to identify opportunities for prevention. Methods: Three analytical chapters include: extraction and reconfiguration of reported demographic data to compare international and Australian jurisdictions; multivariate analysis of linked administrative data (a six-year Queensland births cohort) to analyse pre-natal risk factors for infant death; and analysis of findings from a series of SUDI and post-neonatal deaths, incorporating reviews by the Queensland Paediatric Quality Council expert panel. Results: I confirmed that Queensland’s IMR was significantly higher than the rest of Australia for neonatal, post-neonatal, ill-defined, and non-Indigenous deaths, but not Indigenous deaths. Perinatal factors significantly associated with acquired cause of death after multivariate analysis (young motherhood, higher birth order, smoking in pregnancy, late antenatal care, preterm gestation, maternal obesity, Male infant), were identifiable but not modifiable by mid-pregnancy. Indigeneity and residence in low socio-economic areas were not associated with acquired cause of death after adjustment for other factors. Correcting for post-conceptional age at SUDI shifts the peak incidence to age less than 44-weeks post-conception. Death scene description, post-mortem investigation, and clinico-pathological correlation were inadequate in more than 30 percent of SUDI cases. After panel review, deaths attributed to suffocation and undetermined causes increased, acknowledging the contributory role of unsafe sleep in almost all SUDI, and the rarity of other sufficient causes. SUDI occurred in the setting of high levels of multigenerational social adversity. Conclusion: SUDI is an important contributor to Queensland’s excess infant mortality. The vulnerability to SUDI of infants born before 40-weeks gestation provides a new focus for prevention. The association of maternal pre-natal risk factors with maternal ACEs is consistent with the multifactorial genesis of SUDI and warrants further research. Opportunities for prevention are hampered by inadequate death investigation. SUDI occur in families experiencing multigenerational adversity, for whom engagement and support may help to mitigate highly prevalent risk factors including unsafe sleep.

  • (2021) Short, Katherine
    Thesis
    Children experiencing social and environmental adversity are at greater risk of language difficulties and the related long-term educational and social life challenges. Early years interventions such as home visiting are designed for this vulnerable group and target a range of factors that may influence language outcomes. Many fixed, less modifiable and more modifiable risk and protective factors are known to influence language development. However, it is not clear which factors influence language outcomes in children experiencing adversity nor how these factors combine, especially in the context of intervention. This thesis used qualitative and quantitative methods to investigate the influence of: i) 16 different risk and protective factors and ii) a home visiting intervention on the language outcomes of two groups of children experiencing adversity (n=234). Data were extracted from three longitudinal studies: the Gudaga birth cohort, the Bulundidi Gudaga study and the Maternal Early Childhood Sustained Home-visiting randomised control trial. Several factors influenced language outcomes in urban Aboriginal children. Receptive vocabulary at 3 years was predicted by the child’s gender, non-verbal cognition, number of children in the home and maternal education, and at 4 years by mothers’ emotional well-being, home visiting intervention and daily book reading. In a low socioeconomic status culturally and linguistically diverse cohort, multiple combinations of cumulative risk and protective factors resulted in ‘good’ and ‘poor’ language development, with and without home visiting intervention. While all factors explored, including toddler development, maternal education, early childhood education, number of children in the home and language spoken, impacted on children’s language outcomes, the pervasive influence of two modifiable factors – maternal psychological resources and responsivity – were key. This thesis details the impact of varying combinations of risk and protective factors and a home visiting intervention on language development in two cohorts of children experiencing adversity. Children’s environments made a difference to their learning. Maternal psychological resources, responsivity, home visiting, book reading, the number of children at home and early childhood education were all important, in varied combinations, in children’s language outcomes. These findings have the potential to inform more precise home visiting early interventions so they can respond to the individual characteristics of children and families.

  • (2022) Ye, Pengpeng
    Thesis
    Introduction With rapid ageing of the population, falls have become a significant public health issue in China. Although falls prevention activities have been mandated in the National Essential Public Health Service Package since 2009, recommendations remain only as general advice and are not evidence-based. This thesis aims to generate an evidence base to support the integration of falls prevention programs for older people into the National Essential Public Health Service Package within the Chinese primary health care system. Methods This thesis contains five interrelated studies: an epidemiological study to understand the burden of falls among older people at the national and subnational level in mainland China from 1990 to 2019 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019; a scoping review to characterise existing evidence for fall-prevention interventions in community-dwelling older people in mainland China from 1990 to 2022; a policy review to document national healthy ageing-related policies from a health system perspective in mainland China from 2016 to 2020; a qualitative study to identify the perceptions of facilitators and barriers to implementation of falls prevention programs in primary health care settings in China; and a participatory design study to develop an implementation framework to support the integration of evidence-based falls prevention programs for older people into the National Essential Public Health Service Package. Results In mainland China, the incidence rate of falls in older adults increased substantially over the last three decades. Very few high-quality studies were identified to provide evidence on the effectiveness of existing interventions in China. The national policies on healthy ageing, including falls prevention, were fragmented and inadequate. At the primary health care level, major barriers, including the lack of confidence in delivering interventions, fragmentation in service delivery and limited multi-sectoral collaboration, posed challenges to the implementation of falls prevention in the National Essential Public Health Service Package. An implementation framework consisting of data, workforce, organisation, service and policy themes was jointly developed to support the integration of falls prevention into the National Essential Public Health Service Package. Conclusions In mainland China, falls remain as an ongoing health burden for older people. The challenges to preventing falls for older people primarily arise from low-quality evidence for intervention effectiveness, fragmented policy support and multiple barriers to implementation at the primary health care level. Establishing data-driven surveillance, generating high-quality evidence for the effectiveness of interventions, and creating a supportive environment are three key strategies to address these challenges and have the potential to integrate falls prevention into the National Essential Public Health Service Package within the Chinese primary health care system.

  • (2022) Adepoyibi, Temitope
    Thesis
    The levels of disease prevention provide a foundational framework for public health practitioners. This thesis presents the results of research projects related to three different public health challenges. Each chapter generates evidence to support interventions aligned with different levels of disease prevention. Active travel is important for the primordial and primary prevention of conditions related to physical inactivity, yet it has been in global decline for decades. Chapter 2 presents three cross-sectional studies to provide the first national data on trends and predictors of active school travel specifically among secondary students in Australia. Findings will inform advocacy activities and health promotion practice, including an innovation trial to increase active travel among secondary students. Rapid diagnosis and treatment enable primary prevention of tuberculosis by reducing the reservoir of disease, and secondary prevention of severe disease. Existing tests have several limitations related to use in low- and middle-income countries, hence new tests are needed. Test developers require guidance on the prioritisation of ideal test attributes. Chapter 3 contains the results of a survey of decision-makers ranking tuberculosis test attributes in order of importance, a stepped-wedge randomised controlled trial protocol for the evaluation of a new tuberculosis test in Papua New Guinea and the results of a prospective multicentre diagnostic accuracy study for a new tuberculosis test. The findings have informed test developers regarding market needs, and World Health Organization policy. Results will also inform future studies evaluating new diagnostic tests. Accurate diagnosis and treatment of gestational diabetes are important for the prevention of poor secondary outcomes, and appropriate tests and algorithms facilitate quaternary prevention of over-screening harms. Tests that are more appropriate for low- and middle-income countries are needed. Chapter 4 contains a review of gestational diabetes tests currently used in Melanesia and their appropriateness for use in this setting. The findings provide information for researchers, policymakers and test developers regarding market needs. Chapter 5 summarises the contributions of the thesis to public health practice, and provides recommendations and concluding remarks.

  • (2023) Sparrow, Erin
    Thesis
    Monoclonal antibodies (mAbs) have been used extensively for treatment of some cancers and chronic diseases for over three decades. However, their use in infectious diseases has been limited, partially due to their high production costs and limited duration of protection. Nonetheless, mAbs may have niche applications in the control of infectious diseases in the absence of or in conjunction with vaccines to address unmet public health needs. The research I conducted for this thesis began with a review of infectious disease mAbs in clinical development, before seeking to evaluate how mAbs could be used in the control of infectious diseases, focusing on replacing blood-derived immunoglobulins, pandemic preparedness and addressing gaps in prevention where vaccine development has been challenging. These areas were explored in the context of prevention and control of rabies, influenza, and RSV. For rabies, I undertook a review of mAb candidates in clinical development to inform decisions at WHO on inclusion of mAbs in global policy recommendations for rabies post-exposure prophylaxis (PEP). These findings supported decisions to include mAbs in rabies PEP recommendations and the Essential Medicines Lists as alternatives to blood-derived immunoglobulins. For influenza, I looked at both global vaccine production and development of influenza mAbs, in the context of pandemic preparedness. New estimates of global vaccine production were produced through a survey administered to manufacturers, supplemented by a review. I estimated that initial production capacity would be insufficient for global needs and, given delays in initial availability, alternative interventions will be required early in a pandemic. I also reviewed the development of influenza mAbs leading to their inclusion as a research target in the Global Influenza Strategy. For RSV, a disease where vaccine development has been challenging, this research sought to estimate whether long-acting mAbs could potentially be a cost-effective strategy for RSV prevention in Australian infants. The study estimated that, depending on the assumed price, RSV mAbs could be cost-effective. The research also contributed to the development of WHO preferred product characteristics for RSV mAbs. Collectively these studies demonstrate the potential for an expanded role of mAbs in the prevention and control of infectious diseases.

  • (2023) Obol, James
    Thesis
    Cervical cancer, despite being a preventable and curable disease, is the most commonly diagnosed female cancer in Uganda. Previous studies have sought to understand the challenges to the delivery and uptake of cervical cancer screening services in Uganda, but these studies were conducted in tertiary hospitals in cities and are not representative of the health facilities in which the majority of Ugandan women receive care. Therefore, the aims of my research were to understand the factors that contribute to the low provision of cervical cancer screening services in rural Northern Uganda, to establish the knowledge, attitudes, and practices of cervical cancer prevention among rural health workers in Northern Uganda, to understand the policy environment that contributes to low service provision, and to identify strategies that can be used to develop and deliver a robust and sustainable cervical cancer policy that can address the barriers to cervical cancer screening. The thesis is a series of published peer-reviewed articles that form Chapters Two to Five. The first article, which comprises Chapter Two, reported that most health workers were not screening women due to structural barriers, including a lack of training and equipment/consumables. The second paper reported that health workers had gaps in knowledge of the specific cervical cancer risk factors, signs and symptoms, and prevention methods. The third article was about the key informants’ belief that the absence of a cervical cancer policy in Uganda has affected the implementation of a cervical cancer prevention programme. The fourth paper reported that the policy context is lacking a policy to support cervical cancer screening, but importantly, lacks fundamental contextual requirements for a policy to be developed and successfully implemented. Therefore, the government of Uganda should develop a comprehensive cervical cancer policy that will address the healthcare system barriers to cervical cancer screening and provide for a cervical cancer screening programme to be run concurrently with a public health education programme to address myths about cervical cancer screening to improve screening utilisation and coverage. Improving coverage and utilisation of cervical cancer screening among age-eligible women will contribute towards the reduction of the cervical cancer burden in Uganda.

  • (2023) Albanese, Bianca
    Thesis
    The incorrect use of child car restraint systems is a longstanding and widespread problem. While child restraints offer good protection, incorrect use increases the risk of death and injury to child occupants in a crash. Strategies to address incorrect use continue to be developed and implemented. However, no strategy has successfully addressed the complexity of interactions between the users i.e., the adult, the child, and the restraint. There is a need to engineer design-based solutions that target the ergonomics of child restraints from a user-centred approach. This thesis presents four interrelated studies evaluating the potential of targeted restraint design to reduce incorrect use. A multimethod, user-centred approach was used to identify restraint design features or clusters of design features with the lowest propensity for misuse by both adult and child users. A diverse range of methods were used to capture the breadth of interactions that occur between the child, the adult and the restraint. Methods include in-depth observation studies, a laboratory trial, a driving trial and the retrospective analysis of naturalistic driving data. Descriptive and complex multilevel statistical analysis techniques were used, including those that allow for the control of potential confounders and clustering of data, as well as content analysis for qualitative data. Results from this body of work demonstrate the substantial scope for reducing incorrect use of child restraints through attention to their design. To realise this reduction, there is a need to shift to user-centred design that recognises the usability of a restraint as a precedent to its utility. Design that incorporates features with a low propensity for misuse by both the adult and child users will ensure a system offers the level of crash protection for which it was designed. There is a need to further investigate different restraint systems, with different features, across all tasks of restraint use from a user-centred approach.

  • (2022) Kabir, A Y M Alamgir
    Thesis
    Risk-based recommendations for pneumococcal vaccines are common, but little is known about their uptake and vaccine effectiveness (VE) in high-risk children. In Australia, a primary course of pneumococcal conjugate vaccine (PCV) with booster doses was recommended and funded for Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Indigenous) and medically at-risk (MAR) children in 2001. Vaccination with the primary PCV course was extended to all children in 2005. As a result, pneumococcal disease burden has declined substantially, but the burden remains disproportionately high in MAR and Indigenous children compared to their counter parts. The overarching objective was to evaluate the pneumococcal vaccination program in these high-risk children using a previously assembled linked data asset. The specific aims were to measure: (a) vaccine coverage of the full primary PCV course (dose 3) and booster doses by risk group for children born in the pre (2001-2004) and post (2005-2012) universal vaccination periods, (b) VE of the primary PCV course against invasive pneumococcal disease (IPD) notification by 5 years of age in MAR children, and (c) VE of the 23-valent pneumococcal polysaccharide vaccine (PPV23) booster against pneumonia hospitalisation in Indigenous children aged 18-60 months who had received PCV dose 3. MAR conditions were ascertained using linked ICD-coded hospitalisations and perinatal data. Coverage of PCV dose 3 was suboptimal in the pre-universal period but increased substantially in the post-universal period (from 37% to 83% for Indigenous and 15% to 91% for MAR children). PCV7 was estimated to be effective in MAR children (86%), and similar to previously reported VE estimates for the general population (94%). Booster dose coverage in MAR children was unacceptably low (<10%), so effectiveness of the booster doses was unable to be evaluated in this group. Coverage of the PPV23 booster in Indigenous children was modest (~50%), and we did not find a protective effect of PPV23 against all-case pneumonia (HR: 1.11; 95% CI: 0.87-1.43).   This research suggests that the inequality in IPD incidence between children with and without MAR conditions is not due to low PCV uptake or suboptimal PCV VE. It also found no evidence that a PPV23 booster is effective at preventing cases of pneumonia in high-risk children, which supports the World Health Organization’s position not to recommend PPV23 vaccination.

  • (2023) Thapa, Poshan
    Thesis
    India accounts for an estimated 26% of total global Tuberculosis (TB) cases, the highest among the 30 high TB burden countries. The importance of engaging the private sector in TB care has long been endorsed in global TB policies and guidelines. However, the engagement gap is wide, particularly in relation to Informal Healthcare Providers (IPs), who are reported to be the first providers in care pathways for a significant proportion of TB patients. When compared to formal private providers (such as qualified private doctors and pharmacists), there is a non-prioritization of IPs in the National TB Elimination Program (NTEP) of India, a situation that could result from a lack of clarity concerning IPs’ roles in the National TB policies and guidelines. Such a gap with regards to IPs also prevails at the level of evidence, as limited studies have been conducted focusing on this group of providers. Therefore, this PhD project aims to achieve two primary research goals: 1) To examine IPs’ roles in TB care and 2) To explore factors influencing IPs’ engagement in the NTEP. The thesis includes five studies in a multimethod design; a scoping review on IPs’ role in TB care; two quantitative studies, the first focusing on IPs’ knowledge and the second on practices in TB care; and two qualitative studies exploring in-depth IPs’ roles in TB care, as well as the factors influencing their engagement in the NTEP of India. New empirical findings from this research include 1) Though information on IPs’ roles included in India’s TB policies and guidelines lacks clarity, IPs were found to be undertaking various TB care roles at the community level; 2) a number of potential roles for IPs in TB care were also discovered; and 3) finally, this study identifies various barriers and facilitators, including policy and system-level factors and some related to IPs’ service characteristics that can significantly influence this cadre’s engagement in the NTEP. The evidence generated through this research provides critical insight to clarify and effectively address IPs in India’s TB policies and programs. The findings provide clarity on IPs’ current roles in TB care and shed light on potential roles for IPs within the framework of NTEP. Furthermore, this study identifies various factors which can significantly influence the engagement of this cadre of workforce who are ubiquitously present in India’s health system and are highly accepted and trusted as primary care providers in the community.

  • (2023) Fagerlind, Helen
    Thesis
    Road safety is acknowledged by the United Nations as critical for peoples’ prosperity and well-being. Historically, global road safety targets have focussed on reducing fatal injuries but recently there has been a shift to also include targets for reduction of nonfatal injuries. Hence, road safety needs to be evaluated in terms of both mortality and long-term outcomes. This thesis aimed to develop a tool to quantify injury in a way that captures a broader spectrum of outcomes than just mortality, thereby providing a new method to support the prioritisation of road crash countermeasures. An iterative process was used to construct an injury taxonomy. The literature was reviewed to identify existing categorisations of injuries and outcome severity metrics. A 4-step process identified a set of injury categories (ICs) where inferential statistics supported decisions to preserve the homogeneity of severity within ICs. Swedish road trauma data was used to investigate the occurrence of injury patterns. Using a Market Basket Analysis approach, novel to injury analyses, Individual-Based Injury Patterns (IBIPs) were identified in people with multiple injuries. Severity ranking values based on mortality (MR) and disability (DR) were computed from existing trauma outcomes. Ultimately, the taxonomy was named SAID where Survival/Mortality and Disability outcomes were considered. The SAID Taxonomy was applied to Australian road trauma data to test the correlation between road user outcomes and computed MR and DR values. To demonstrate the utility of the tool, a fused SAID severity value between MR and DR was proposed and used in regression modelling to compare pedestrian outcomes in 40 km/h and 60 km/h speed zones. The development process resulted in the SAID Taxonomy founded on 54 ICs and 77 IBIPs and of MR, DR and SAID severity values. Road trauma outcomes had higher correlation to MR and DR values in road users with IBIPs assigned than those with a single IC. Univariate analysis showed a shift to higher SAID severity for pedestrians injured in the 60-zone. This tendency remained in the multiple regression model but with less evidence for this effect. The SAID Taxonomy is a tool that considers all recorded injuries a person sustained and classifies them into ICs and IBIPs, including predefined MR, DR and SAID severity. Further analyses can evaluate crash consequences so that road and vehicle safety experts can make informed decisions about necessary countermeasures.