Medicine & Health

Publication Search Results

Now showing 1 - 10 of 77
  • (2021) Hailemariam, Tewodros
    Thesis
    Couples HIV Testing and Counselling (CHTC) is recommended by the World Health Organisation to increase uptake of testing in Sub-Saharan Africa (SSA). There is limited evidence about whether people in heterosexual relationships consider CHTC to be a viable HIV testing option compared to other approaches, or the perceived risks and benefits of CHTC. This thesis examined the uptake, beliefs, intentions, and experiences associated with CHTC in SSA, and in Ethiopia specifically. The thesis includes four studies in a mixed methods design: a systematic review and meta-analysis of CHTC uptake in SSA (n=14 peer-reviewed studies); a qualitative elicitation study (n=21 people in heterosexual relationships and n=11 key informants) of beliefs and intentions; a qualitative experience study (n=19 in-depth interviews) of people who had used CHTC; and the development and pilot of a survey informed by the elicitation study (n=100 individuals). New empirical findings from this research include 1) a modest (24%) uptake of CHTC among heterosexual couples in SSA, with variability by country and population sub-groups; 2) that although CHTC was regarded as important to prevent HIV transmission, some participants stated they preferred to first ‘test alone, then together’ to avoid the perceived risks of being diagnosed with HIV in the presence of their partner — including accusations of infidelity and relationship break-up; 3) key reasons for undertaking CHTC included requests by third parties, such as religious institutions, before marriage, frequent sickness, as part of antenatal care, visa application, or mistrust between partners; 4) for some couples, consequences following an HIV-positive result included ongoing disputes, abuse, and relationship breakdown. Lastly, the elicitation study findings informed the development of a new survey tool for population-level use. Pilot psychometric testing found acceptable internal constancy, discriminant validity, and predictive ability of individuals’ behavioural intentions towards CHTC. The collective findings in this thesis provide evidence that individuals are cautious of undertaking CHTC because of fears about confidentiality and potential risks to their relationships. Testing programs should monitor and assure adherence to the principles of confidentiality and voluntary testing. For individuals who decide to undertake CHTC, individual-based pre-test counselling is important to ensure informed decisions about HIV testing options.

  • (2021) Thompson, Kelly
    Thesis
    Sepsis is life threatening organ failure due to a dysregulated host response to infection. It is a leading cause of death and disability worldwide. Priorities of management include early detection and treatment with appropriate antimicrobials, along with organ support therapies administered in the intensive care unit (ICU). Corticosteroids are an adjunctive therapy used to treat patients with septic shock. They modulate the immune and cardiovascular response to infection, reducing the duration of mechanical ventilation and ICU stay. The longer-term health and economic impacts of corticosteroid treatment are unknown. There is also a paucity of data describing the longer-term health and economic burden of sepsis for patients treated in Australian ICUs. This thesis contributes novel data to describe sepsis survivorship in Australia, including the longer-term health and economic burden of sepsis and septic shock, and the longer-term health and economic implications of adjunctive corticosteroid treatment in women and men with septic shock. The main findings are: 1. In a propensity score matched analysis of ICU patients with and without sepsis: 1. Patients with sepsis had increased healthcare resource use and costs, compared to other critically ill patients. 2. In a cost-effectiveness analysis of a clinical trial assessing the impact of hydrocortisone treatment compared to placebo on mortality due to septic shock: 1. Hydrocortisone treatment in the ICU did not significantly impact longer-term mortality, health-related quality-of-life, healthcare resource use or costs. 2. Hydrocortisone treatment was unlikely to be cost-effective overall, but more likely to be cost-effective in women, compared to men. 3. In a follow-up sex-disaggregated analysis of the trial: 1. Women treated with hydrocortisone had a higher risk of shock recurrence, compared to men. 2. Hydrocortisone treatment significantly reduced the time to ICU discharge and cessation of mechanical ventilation in men, but not in women. Sepsis survivors experience ongoing disease sequelae, resulting in increased healthcare resource use and costs. Hydrocortisone treatment, administered in the ICU, does not mitigate the longer-term sequelae of sepsis and is unlikely to be cost-effective. Strategies to reduce the sequelae of sepsis, including understanding sex differences and other health inequalities, is an important direction for future research.

  • (2021) Lujic, Sanja
    Thesis
    The growing number of individuals living with multimorbidity – the presence of two or more chronic conditions – is a challenge facing many healthcare systems internationally. Multimorbidity has been hailed a priority for research and practice, but Australian studies of multimorbidity are impeded by the lack of national primary care data, data silos, researcher access to data, and limited information contained within the data that are available. This thesis demonstrates how data linkage can be used to enhance the understanding of multimorbidity and its outcomes via a series of studies using Australian linked data sources, including claims-based, cohort study and clinical registry datasets for residents of NSW, Australia's most populous state. Thesis studies found variations in the recording of common health conditions between hospitals, under ascertainment of multimorbidity in administrative data, and differences in the estimates of multimorbidity dependent on the data used. Thesis studies also showed we can enhance our understanding of multimorbidity by exploring related concepts of patient risk and complexity. Within administrative hospital inpatient data, one-third of hospitalised patients had both multimorbidity and elevated risks of frailty – and these patients had worse outcomes than those with one or neither factor. The addition of clinical registry data also improved risk adjustment for hospital readmission performance indicators for total knee and hip replacement over and above models including multimorbidity measured using administrative hospital inpatient data. The research presented here highlights the benefits of the use of linked data in Australian multimorbidity research in three ways. Firstly, it underlines the need for incorporation of chronic disease information from multiple databases, including self-reported, inpatient, and claims-based data to accurately capture the extent of chronic disease and to identify people with multimorbidity. Secondly, it emphasises the need to examine complexities in the interplay between drivers of adverse outcomes – including multimorbidity, frailty and clinical assessment of a patient's overall health – in identifying patients with increased risk of complications and informing future hospital resource planning. And thirdly, it demonstrates the value of integrating new data sources, such as clinical registries with linked administrative data for improving risk-adjustment of hospital performance measures.

  • (2021) Byrne, Bonita
    Thesis
    Background: Aboriginal and Torres Strait Islander people are more likely to abstain from alcohol than non-Indigenous Australians, however, they are more likely to experience harms related to their own or others’ alcohol use. Factors such as lower socioeconomic status and poorer access to appropriate services have been identified as potential risk factors for increased alcohol-related harms. Another potential factor that has not yet been explored in the published literature is lateral violence as a result of conflict in Aboriginal communities, and how that conflict contributes to alcohol-related harms. Aims: This research investigates the reasons why conflict exists in Aboriginal communities. It explores how conflict is associated with alcohol-related harms experienced by Aboriginal Australians. Methods: A narrative literature review using systematic search strategies was conducted to identify published literature on the association between conflict and substance misuse in Aboriginal communities in Australia. This review searched 14 databases. Abstracts were systematically screened against inclusion criteria. Next, qualitative interviews were conducted with nine Aboriginal Elders and community members to explore their lived experiences with conflict and alcohol-related harms in their communities and potential healing approaches to address this. Interviews were conducted using a yarning method in one-on-one interviews to elicit participants’ stories. A thematic analysis was conducted using inductive and deductive coding. Results: The literature review identified nine studies which considered conflict and its association with substance misuse in Aboriginal communities in Australia. The main factors that contribute to alcohol use, conflict and the association between the two were colonisation, lower socioeconomic status, remoteness and social identity. Key themes from participants’ lived experience with conflict and alcohol-related harms identified in the interviews were: breakdown of family and community due to colonisation and displacement, alcohol use in the community, and experience of racism. Key recommended strategies for healing included cultural programs and increasing respect for Elders. Conclusion: This study furthered our understanding of the effects of colonisation on Aboriginal communities today. It identified how the breakdown of family and kinship ties have contributed to conflict and alcohol-related harms experienced by Aboriginal communities. It points to potential ways to build resilience among Aboriginal communities and prevent alcohol misuse and conflict.

  • (2021) Ouyang, Menglu
    Thesis
    Introduction: Although clinical guidelines recommend various care processes to improve outcomes of patients with stroke, evidence to support many of them, such as the management of post-stroke infections and the monitoring of abnormal physiological variables, are scarce. While for those care processes with more evidence, very few studies have quantified their variations across regions and what factors influence their implementation in clinical practice. This thesis aims to determine the utilisation of guideline-recommended care processes for patients with acute stroke, and explore various strategies that may improve their implementation. Methods: I conducted secondary analyses of a large clinical trial to explore the associations of care processes and clinical outcomes, using data of 11,093 patients with acute stroke from nine countries. These care processes included dysphagia screening, indwelling urinary catheterisation (IUC), and early detection of low blood pressure (BP) and oxygen saturation (SaO2) levels. To explore variations in the utilisation of care processes, I compared the evidence-based recommendations for stroke unit care across Australia/UK, China, India/Sri Lanka and South America. I also conducted a process evaluation of a ‘quality improvement’ intervention within an ongoing trial involving the management of patients with acute intracerebral haemorrhage in China, to explore what factors could improve the implementation of systems to improve the quality of care. Results: Patients who failed a dysphagia screen, had an IUC, had SBP <120mmHg or SaO2 <93% during the acute phase (up to 7 days after stroke onset) had increased odds of poor outcome. The utilisation of care processes varied across regions, with lower probabilities of reperfusion therapy and allied health care in low- and middle-income countries (LMICs) than high-income countries. Constant training with the clinicians, case reviews, optimisation of workflow within available resources, and having a dedicated team, may facilitate the implementation of evidence-based care. Conclusions: The utilisations of guideline-recommended care processes are associated with patient outcomes and vary across regions. Timely assessment and appropriate management should be provided to those with dysphagia, IUC, low BP, and low SaO2 levels, in an effort to improve their recovery after stroke. Future studies are needed to confirm the causality of these associations and to examine opportunities to promote the delivery of evidence-based stroke care, especially in LMICs.

  • (2021) Bhandari Bhattarai, Buna
    Thesis
    The burden of hypertension is increasing worldwide, with higher rates in Low- and Middle-Income Countries (LMICs), like Nepal. Despite the availability of effective interventions, uncontrolled blood pressure remains a major challenge contributing to significant morbidity and mortality. Nonadherence to treatment and improper understanding of reasons for poor adherence are attributed to this phenomenon. It is widely understood that LMICs are impacted by financial pressures and a health workforce shortage to tackle these problems. Mobile phone uptake is high in LMICs and provides an opportunity to deliver tailored messages to improve medication adherence and contribute to blood pressure control. We aimed to develop and evaluate the feasibility of a text messaging mHealth intervention to improve blood pressure control among patients with hypertension in Nepal. We performed our research in two phases. In Phase I, a formative qualitative study (using a theoretical approach) was conducted to understand the barriers and facilitators for blood pressure control among patients with hypertension This study provided detailed insight into individual barriers to blood pressure control, such as low literacy of hypertension, non-adherence to treatment, and system-level barriers such as poor communication between providers and patients. In addition, we explored stigma and non-disclosure issues and social-cultural barriers attached to behaviour modification in this setting. The second part of this formative study reported the high potential of mHealth intervention in the study setting. Informed by the qualitative study, we co-designed a text messaging intervention (TEXT4BP) as part of Phase II. The feasibility of the TEXT4BP intervention was tested using a pilot randomised control trial study design. The TEXT4BP intervention was effective (p<0.001) in reducing systolic and diastolic blood pressure, improving blood pressure control and medication adherence among the intervention group when compared to the control group receiving usual care. In addition, the TEXT4BP intervention was found to be feasible and acceptable in the study setting. Our research has generated novel evidence on the co-design process of a mHealth intervention and demonstrated the effectiveness and acceptability of the intervention for hypertension management. The findings will inform further large-scale mHealth research and contribute to clinical practice with evidence-based adherence guidelines in Nepal.

  • (2020) Radhakrishnan, Seema
    Thesis
    Lower limb amputation is a common cause of disability across the globe especially with the increase in the prevalence of risk factors for lower limb amputation including increasing age, diabetes, obesity, international conflicts and natural disasters. Limitation of mobility is arguably the most important impairment that affects the quality of life in people with lower limb amputation. There is a lack of mobility outcome measuring tools to compare mobility outcomes across countries and settings. The International Classification of Functioning, Disability and Health (ICF) provides a universal language for rehabilitation professionals internationally and offers a base for development of a mobility outcome tool that can be used internationally. The aim of this work is to develop a mobility outcome tool based on ICF categories to measure mobility outcomes following rehabilitation of people with lower limb amputation and to establish the psychometric properties of the tool. A literature survey, patient focus groups and expert surveys were employed to identify the concepts regarding mobility which are common across people with lower limb amputation and their rehabilitation therapists. These concepts were linked to ICF categories using published linking rules. The number and the type of categories for the tool were selected by a consensus conference using a modified Delphi technique. A 22-item tool, the ICF-based mobility assessment tool (IBMAT) was created by this process. Validation studies were performed across six international study centres with 191 participants to establish the reliability, validity and responsiveness of the IBMAT. Rasch analysis was used to explore the dimensionality of the tool and to identify redundant items. The validation studies confirmed that the IBMAT is valid and reliable, and is able to capture changes following rehabilitation interventions. The tool was found to have good internal consistency. The items of the tool measure the construct of mobility as a continuum. Further development of the tool with testing after removal of redundant items identified by the Rasch analysis is possible.

  • (2020) Mellor, Richard
    Thesis
    Remission from alcohol problems is often studied in association with treatment, yet most people who resolve their alcohol problems do so without seeking support. The concept of remission has traditionally been understood in relation to abstinence and binary changes (from an ‘addict identity’ to a ‘recovery identity’), but analysing the lived experiences of people in untreated remission warrants a rethink of these prevailing concepts. Researching untreated remission also has the potential to inform the development of formal and informal treatment across the globe; knowing how many people remit without treatment is vital for treatment planning approaches, and understanding which services are accessed outside of formal alcohol treatment forces a reconsideration of what constitutes ‘alcohol treatment’. This thesis is made up of three components, each one addressing some or more of these aspects, using both quantitative and qualitative methods. A systematic review was conducted covering the rates of untreated remission, and based on this research, a planning tool analysis was conducted (using the Drug and Alcohol Services Planning Model), detailing the impact untreated remission data has on the projected costs and resources required for treatment service planning. An online survey method was used to understand the characteristics of people in remission from alcohol problems in Australia, and it was concluded that untreated remission occurs frequently in Australia, and in general does not discriminate based on socio-demographic factors. Participants reported a range of remission behaviours (abstinence and otherwise) and reported accessing various types of treatment (formal alcohol treatment, mental health treatment, self-help groups, and digital support services). People in untreated remission were interviewed using a life-curve methodology, and the accounts participants gave of their lives invoked various narratives and identities (of discovery, emancipation, mastery, and coping), and within these the process of resolving an alcohol problem figured in complex ways. This thesis has demonstrated that people experience remission in a variety of ways, often without treatment (but also in connection with a range of formal and informal services outside the scope of formal alcohol treatment). This research complicates straightforward notions of remission, and highlights the importance of diversifying the treatment response.

  • (2020) Silva Pelicioni, Paulo
    Thesis
    Postural instability and gait disorders (PIGD) increase the risk of falling in people with Parkinson’s disease (PD). In addition, lack of optimal levodopa response, executive dysfunction and increased reliance on cognitive resources may also contribute to fall risk in this population. In a series of related projects, I investigated people with PD categorised into different subtypes, including the presense/absense of PIGD symptoms, as well as investigated how levodopa response and executive dysfunction increase fall risk in people with PD. In addition, I assessed neural correlates of postural instability and gait disorders using functional near-infrared spectroscopy (fNIRS). I conducted five studies that: (i) contrasted fall rates and circumstances as well as a range of disease-related, clinical and functional measures between people with different PD subtypes; (ii) compared gait stability before and after levodopa intake between people with different PD subtypes and between individuals who took different daily doses of levodopa; (iii) identified sensorimotor, balance and cardiovascular factors that discriminated between those with normal/impaired executive function in people with PD, and determined whether executive dysfunction is a significant risk for falls in PD; and (iv & v) I compared activation patterns in cognitive and motor cortical regions using fNIRS between people with PD and healthy controls during: (iv) simple and complex stepping tasks during simple walking and; (v) gait adaptability tasks. The main findings were that (i) the PIGD subtype were more likely to suffer falls due to freezing of gait, balance-related falls and falls at home; (ii) the PIGD subtype exhibited impaired gait stability which was worsened by levodopa intake; (iii) mild and marked executive dysfunction were identified as independent risk factors for falls; (iv) people with PD appear unable to utilize their cognitive and motor cortical resources when completing stepping tasks requiring inhibition; and (v) during gait adaptability tasks, people with PD adopted a more conservative gait pattern to successfully negotiate obstacles and stepping targets despite exhibiting increased cognitive cortical activity. My findings elucidate several aspects of fall risk in people with PD, which may facilitate both the development of fall risk assessments and fall prevention strategies for this population.

  • (2020) Dinh, Kathryn
    Thesis
    Culturally responsive evaluation contests the belief in the universalism of Western-derived evaluation methods, but an identified challenge has been to modify or create new evaluation methods that are grounded in diverse, non-Western European contexts. While there have been significant advances in culturally responsive evaluation that reflect Indigenous ways of knowing, the literature on evaluation methods that are derived from South East and East Asian world views is particularly limited. In this thesis, I propose guiding principles for conducting HIV policy advocacy evaluations in Vietnam so that they are context-sensitive. I adopt a qualitative, inductive approach to explore the theory and values underpinning contemporary advocacy evaluation methods, influences on advocacy practice in Vietnam, how to incorporate diverse world views into evaluation methods, and how to identify guiding principles for adapting evaluation methods to the Vietnamese context. I conduct semi-structured interviews with diverse stakeholders from the HIV sector in Vietnam to understand influences on advocacy practice, with the expectation that this will provide the necessary data for drafting the guiding principles. I then identify that a theoretical understanding of how methods could be modified to incorporate diverse world views is needed. I subsequently conduct a theoretical analysis of world views underpinning two evaluation methods, contribution analysis and Most Significant Change technique, and their degree of congruence with the teachings of Confucius and Buddha. This results in the development of a proposed new evaluation method – later called the World View Method. I use a case study approach to apply aspects of the earlier theoretical analysis into the draft guiding principles for civil society HIV policy advocacy evaluation in Vietnam. These are tested for accuracy, relevance and appropriateness and validated using semi-structured stakeholder interviews. In this thesis, I demonstrate that it is possible to modify contribution analysis, a method commonly used in advocacy evaluation, to incorporate Confucian teachings. I use the same approach to modify a second method, the Most Significant Change technique, to consider Buddhist teachings. The research addresses a key challenge identified in culturally responsive evaluation by exploring a new process – the World View Method – suitable for developing bespoke evaluation methods that are responsive to the local cultural, historic, economic, religious and political influences that shape the context being evaluated. In the thesis, I then develop guiding principles for evaluators of civil society HIV policy advocacy in Vietnam as an example of a tool that could be used to assist evaluators in implementing the early steps in the World View Method. The guiding principles needed to be sufficiently detailed to capture the complexity and nuance of influences on advocacy practice in order for them to be useful for evaluators and to inform culturally responsive evaluation design and implementation.