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(2022)ThesisCardiovascular diseases and type 2 diabetes mellitus are highly prevalent chronic diseases. They have similar risk factors and are preventable with lifestyle changes. Mobile applications (apps) can provide behaviour change interventions widely at a relatively low cost. This thesis aimed to identify risk assessment tools suitable for laypeople to determine their cardiovascular and diabetes risk, develop an app for risk awareness and prevention of the two diseases, and test the feasibility of the mobile health intervention. Chapter 2 contains a rapid review of cardiovascular and diabetes risk models. In Chapters 3 and 4, two models based on lifestyle-related risk factors were externally validated in a large Australian cohort. In Chapter 5, the literature was systematically reviewed to evaluate the effectiveness of preventive mobile interventions for the two diseases. Chapter 6 comprises a cross-sectional analysis of mobile health use in older Australians. Chapter 7 describes the development process of a smartphone app according to a framework and iterative testing of the app's usability in a small sample. In Chapter 8, the feasibility of the intervention was assessed over three months with app data and a survey. The rapid review in Chapter 2 included the risk models routinely used in Australian clinical practice and two lifestyle-based risk models without Australian validation. In Chapters 3 and 4, the lifestyle-based diabetes risk model performed satisfactorily, but the cardiovascular model predicted a 5-year risk poorly. The systematic review in Chapter 5 found some indications for the effectiveness of mobile interventions in preventing cardiovascular disease and diabetes. The cross-sectional analysis in Chapter 6 showed low mobile health use in older Australians. The app developed in Chapter 7 encompassed four modules: risk assessment, goal setting, self-monitoring, and health information. Usability testing participants found the app easy to use. In the feasibility study in Chapter 8, 20 out of 46 participants never used the app, 15 dropped out, and 8 used the app weekly. The overall app quality rating was satisfactory. Although the intervention was easy to use, the levels of adoption and sustained use were low. Further research is needed to adapt the app to make it more appealing and provide greater benefits. The potential utility of digital health interventions is vast, but they still need to live up to their expectations.
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(2022)ThesisIt has been suggested that when adherence to infection prevention control (IPC) protocols is in place, the risk of transmission of infectious diseases to patients and other healthcare workers (HCWs) appears low. Adherence to IPC recommendations and protocols depends on many factors including availability of resources, health priorities, staff ratios, workload allocation, and patient turnover. Lastly, HCWs may be unsure of how and when to adhere to local guidelines. Evidence to date has established that HCW feel there is a lack of training about infections, IPC and about how to use personal protective equipment. While guidelines often stipulate that HCWs should be trained, there is currently a gap in our understanding about how IPC training programs are being designed and implemented across low, middle- and high-income settings. This research program aimed to examine how the topic of training is framed and discussed in policies, as well as critically analyse the current landscape of IPC training and the factors impacting on delivery. Following a multi-method approach, four studies were undertaken to examine IPC training across a range of countries, with a focus on pandemic and non-pandemic recommendations. The first study, a scoping review of publicly available IPC guidelines, was conducted to examine recommendations around IPC training programs. This study highlighted that mode of delivery and IPC curriculum differed across guidelines. It also highlighted that there is a failure to acknowledge adult learning principles. The second study examined the current landscape around occupational IPC training of HCW, across six low/middle-income/high-income countries via in-depth interviews. This work identified policy variations, lack of dedicated funding, poor resource allocation and impact of COVID-19 as factors affecting the delivery of training. Focusing on pandemic relevant IPC training, the third study examined the discourse around IPC training from the pandemic plans and COVID-19 specific guidelines from countries across every WHO region. This study found omissions and inconsistencies in the way pandemic specific IPC training programs were considered within the documents. Based on an extensive literature review as well as the factors identified in the previous three studies, a modified Delphi approach was used in the final study, to develop best practice principles to optimize the provision of occupational IPC training programs for HCWs. The thesis contributes new knowledge regarding the framing of the topic of training across guidelines and policy documents, as well as an absence to recognise the need for dedicated resources and trained personnel. The recommendations offered can potentially support policy development and improvement in the delivery of occupational IPC training programs for HCWs in low-, middle- and high-income countries.
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(2021)ThesisBackground The existing models of care developed to comprehensively address the needs of people with multimorbid chronic obstructive pulmonary disease (COPD) may not be directly applicable to low- and middle-income countries (LMICs) like Nepal. Therefore, this research sought to co-design, with end-users and stakeholders, an integrated model of care to deliver a comprehensive self-management intervention to people with multimorbid COPD in rural Nepal. Methods This research was conducted in two stages: i) a parallel mixed-method descriptive research to understand self-management practices (SMPs), health literacy (HL) and patient activation (PA), along with their barriers and facilitators; and ii) Evaluation of the feasibility and acceptability of a co-design process used to develop a model of care. The descriptive research included a survey of 238 people with multimorbid COPD and qualitative explorations using in-depth interviews (IDIs) of selected stakeholders. The evaluation included qualitative analysis of IDIs, video recordings from co-design workshops and observation notes. Data were collected between September 2018 and December 2019 in the Sunsari district, Nepal. Results More than two-thirds of participants had low levels of SMPs and HL and were less activated. Qualitative exploration identified inadequate family support, inadequate infrastructure and resources at primary care, limited skills of primary level providers and lack of educational materials for COPD, as barriers for SMPs. These findings guided the ideation of an integrated model of care, which was later refined in the prototype stage. This model of care included screening the community for people with COPD and morbidities within primary health care, establishing referral pathways and establishing a community-based support system. Evaluation of the co-design process showed that the approach was well accepted and feasible. A co-design evaluation framework was developed. Conclusion The descriptive research findings suggest that SMPs, HL and PA among the participants were low and had several barriers that an integrated model could address. The evaluation of the co-design approach revealed that the co-design process was feasible and acceptable to end-users and government agencies in Nepal. This has important practice, policy and research implications for the application of co-design in LMICs and for delivering self-management intervention targeting people with multimorbid COPD in Nepal or settings of similar context.
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(2022)ThesisIn the past 5 years, Sport for Development and Social Change (S4SC) organizations have developed a growing interest in social enterprise to support their sustainability. The purpose of this doctorate thesis is to conduct an in-depth analysis in response to this growing interest, asking how does social enterprise support the sustainability of the S4SC organization? To address this question, dimensions of sustainability are first clarified. The role social enterprise can play to support these dimensions and the type of investment this may require are then explained. Fourth Generation realist Evaluation (4GE) underpins the development of this study’s research design. 4GE is a methodology that aims to maintain reciprocal accountabilities between stakeholder groups in the research process. In doing so, this study’s end-users – the SFW network - have driven the trajectory of this study’s iterative design. What unfolds is a journey presented over five phases of study. In the first phase, this study presents how accountability to the study end-users encourages us to renegotiate our conceptualization of social enterprise and sustainability. The latter is presented as a conceptual framework on sustainability. This framework is the most prominent conclusion to be drawn from this doctoral study as it acts as a heuristic, or lens, to make sense of the complex socioecological ecosystems surrounding the S4SC organizations - ecosystems that inform their sustainability. In the final phases, a case study of 3 SFW network organizations is presented to ‘test’ this conceptualization against unique contexts in low and high-income countries. In conclusion, this doctorate thesis makes significant contributions to how we conceive of and action sustainability in the S4SC organization. It highlights the role social enterprise can play and the key factors such as purpose, democratic intention, strategic position and organization ecosystem, and the regulatory environment that may inform what this looks like. Findings from this study also shine light on key resourcing options available to the supporting institutions of the S4SC field and how their investment reinforces key processes of sustainability. Finally, this study’s findings highlight a potential fault line in current conceptual approaches to social enterprise and sustainability. For this reason, concluding remarks provide examples for future research to further explore the foundation set by this study.