Melbourne School of Population and Global Health - Theses
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ItemComparing health services access across regions of Melbourne: a case study of diabetes services( 2017)Introduction Melbourne, located in Victoria, has some of the fastest growing municipalities in Australia with the population in Melbourne growing from a current 4.5 million residents to an estimated 8 million by the year 2050. Much of this population growth is occurring in urban growth areas up to 50-100kms away from the central business district (CBD), as well as infill areas across inner and middle suburbs of Melbourne. Infrastructure in urban growth areas, such as health services, may be lacking if they are not built and delivered simultaneously alongside housing. Access to health services is a key social determinant of health (SDOH). As urban growth areas develop, there will be greater requirement for health infrastructure and services to be located in these areas in order to meet the increasing demand of the growing population and to ensure equitable access to services. Primary health care services, such as general practitioners and pharmacists, serve the majority of health care needs for consumers across Melbourne. However evidence suggests that a higher density of such services exists within inner and middle suburbs of Melbourne. This means residents living more centrally likely have greater access to primary health care services compared with those living in outer suburbs and urban growth areas. Previous studies have shown inequities of access to health services exists in rural compared with city areas, however there is little published research about access to health services in urban growth areas compared with established areas of cities. Type 2 diabetes mellitus (T2DM) is a major chronic health condition in Australia, with some of Melbourne’s urban growth areas having some of the highest prevalence across Australia. People with T2DM are required to frequently access a number of primary and secondary health care services. Using T2DM as a disease case study, this research explores travel times to diabetic health care services for populations residing in inner, middle and outer suburbs of metropolitan Melbourne. Currently, little is known about differences in travel times when using private and public transport to access primary and secondary health care services across Melbourne generally and Melbourne’s urban growth areas. Therefore, this research aims to examine the extent to which inequities exist when accessing health services for T2DM across Melbourne for both private and public transport. Method A literature review was undertaken which considered access to health care services in urban growth areas with a focus on spatial and social access. Penchansky and Thomas identify five domains of health care access being: availability, accessibility, accommodation, affordability and acceptability. This research focused on spatial accessibility to health services for T2DM. The study area was metropolitan Melbourne divided into five regions of inner, middle, outer established, outer urban growth areas and outer fringe areas. Diabetic health services of interest were identified through Diabetes Australia Victoria and included general practitioners, optometry, pharmacy, podiatry, dieticians, endocrinologists, diabetic educators and physiotherapists/exercise physiologist. Following this geographic information systems (GIS) software was used to map the location of selected diabetic primary and secondary health care service providers across metropolitan inner, middle, outer established, outer urban growth and outer fringe areas of Melbourne. An origin-destination matrix was used to estimate travel distances from point of origin (using a total of approximately 50,000 synthetic residential addresses) to the closest type of each diabetic health care service provider (destinations) across Melbourne. ArcGIS was used to estimate travel times for private transport and public transport, and comparisons were made by area. Results This research indicated increased travel times to diabetic health services for people living in Melbourne’s outer urban growth and outer fringe areas compared with the rest of Melbourne (inner, middle and outer established). Compared with those living in inner city areas, the median time spent travelling to diabetic services ranged between 2.46 and 23.24 minutes (private motor vehicle) and 12.01 and 43.15 minutes (public transport) longer for those living in outer suburban areas. Compared with middle suburbs it was 1.1 minutes and 21.22 minutes (private motor vehicle) and 8.29 minutes and 40.62 minutes longer (public transport) for those living in outer suburban areas. Irrespective of travel mode used, results indicated that those living in inner and middle suburbs of Melbourne have shorter travel times to access a range of diabetic health services, compared with those living in outer areas of Melbourne. Private motor vehicle travel times were approximately four to five times faster than public transport modes to access diabetic health services in all areas. Discussion Plan Melbourne refresh, Melbourne’s foremost strategic land use document, outlines the need for a 20-minute city. This is where essential services such as primary health care can be accessed within a 20 minute trip across Melbourne; this research highlights health services inequity gaps when accessing essential primary health care services. Key social infrastructure planning documents such as the Australian and Social Recreation Research (ASRR) document Planning for Social Infrastructure in Growth Areas and the Growth Areas Social Planning Tool (GASPT), consider health services planning in a broader context of planning for social services. Neither tool has been validated to test their efficacy when planning health services in urban growth areas. Evaluation of these tools is required to help plan for equitable access to health services in urban growth areas. Those living in urban growth communities spend considerably more time travelling to access essential diabetic health services, particularly specialists’ services, than those living in established areas across Melbourne. To increase equity of access more specialist diabetic services, in particular, are required in outer suburban areas. Given that Melbourne is in a time of planning for its forecasted population growth, examining current access to health services for common and increasing non-communicable diseases could ensure equitable health services access. To reduce health services access inequities gaps, integrated planning is needed, where health services are planned alongside transport system and land use planning. Integrated planning allows for health services provision closer to people’s homes thus reducing travel times and increasing equity of access for those who rely on public transport, additionally integrated planning will provide better access to these services by public transport. As the population in urban growth areas continues to expand and the demographic profile changes, further investigation is warranted to explore alternative ways to delivery diabetic health services to people living in these areas.
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ItemThe cure depends on us: the role of Australian patient organisations in rare disease research( 2015)In this thesis, I explore how Australian patient organisations devoted to specific rare diseases are involved in biomedical research. As with patient organisations for more common diseases, many rare disease patient organisations (RDPOs) have broadened their historical focus on self-help and now seek to advance research on “their” diseases. RDPOs are thought to have special opportunities to influence researchers because they can provide resources – such as funding, study participants, and disease-related knowledge – which are often scarce in rare disease research. RDPOs’ involvement in research is important to theorists concerned with the “public shaping” of science, but it also has immense practical significance. Collectively, rare diseases are estimated to affect six to eight per cent of the population; and most are life-threatening or chronically disabling conditions with no specific or effective treatments. The need to accelerate therapy development, and the absence of government or industry-funded research for many rare conditions, underpins growing international interest in strengthening collaborations between RDPOs and researchers. In the first study of RDPOs in Australia, I reviewed 112 RDPO websites, conducted an online survey completed by 61 RDPO leaders, and interviewed ten RDPO leaders and two key informants. Consistent with international literature and empirical case studies, I found that RDPOs are highly motivated to support research. However, while some Australian RDPOs have helped to advance the understanding and treatment of their diseases, I argue that RDPOs are far from the robust challengers of the research establishment portrayed in the literature. In fact, RDPO leaders face considerable difficulties in upholding organisational interests in their various forms of engagement with academic and industry researchers. For example, leaders may struggle to direct RDPO funding in ways which best meet the goals of the organisation; they may lack the expertise or power to assert their knowledge and ideas when collaborating with researchers; and they may run the risk of real or perceived conflicts of interest in financial relationships with pharmaceutical companies. These problems are related to RDPOs’ limited funds and capabilities, the competing interests of researchers, and the marginalisation of rare diseases in Australian health and research policy. I argue that my study provides a more realistic picture of the challenges faced by “ordinary” RDPOs than previous studies focusing on the successes of large, well-resourced organisations and groups with highly driven, entrepreneurial leaders. Despite the difficulties I identify, I contend that RDPOs have much to contribute to research. They can also play an important role in providing their members with information about biomedical research, including the risks and benefits of participating in mainstream and novel forms of research – such as participant-led clinical trials and crowd-sourced health studies. I suggest that there are considerable opportunities in Australia, building on the findings of this study and international initiatives, to support and safeguard RDPOs’ involvement in research, for the benefit of Australian research and people affected by rare diseases.
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ItemWhat is the most suitable disease management model for COPD?: Identifying effective and cost-effective programs for treating COPD( 2013)Pulmonary Rehabilitation (PR) has been developed to target the physical function recovery, and Cognitive-Behavioural Therapy (CBT) has become a potentially useful treatment for managing depression and anxiety disorders induced by COPD. However, it has been difficult for health providers to select appropriate program models because there has been insufficient knowledge of the effectiveness and the cost-effectiveness of these two programs. This thesis therefore aims to investigate in two important questions: 1. What is the optimal model of a PR program that can provide sustained effects with cost-effectiveness? 2. How can more information be provided about the effectiveness and cost-effectiveness of CBT programs by conducting more trials with more robust study designs? This thesis has two parts to its current study of the effectiveness and the cost-effectiveness of PR and CBT and Part B is built on the results from Part A: PART A of the thesis focuses on the effectiveness of PR and the potential cost-saving through reduction of hospital readmission. In previous studies there has been no empirical study measuring the long-term effects of PR up to one year. More importantly, previous meta-analysis studies do not consider the difference of the study designs in their analysis and so create the problem of "comparing apples with oranges." This study is the first study to apply systematic review, meta-analysis and meta-regression analysis to summarize those PR components that are the most critical in producing a lasting improvement for COPD patients. Statistical program, R, is applied for the meta-analysis and meta-regression analysis. Random-effect model is applied for the meta-analysis, and mixed-effect model is applied for the meta-regression analysis. The meta-analysis in this study is the first empirical research to demonstrate that PR components produce both short-term and long-term effects up to one year. The summarized effects indicate that PR components can improve HRQoL of COPD patients by an SGRQ score of -4.33, 95% CI(-5.8, -2.87) in the short-term and -3.7, 95% CI (-6.34,-1.06) in the long-term. The meta-regression analysis further identifies the critical components of PR, which produce the effects lasting up to one year, as the scheduled exercise and the home-based training. PART B: PART B gives the protocol of an economic evaluation alongside with a telephone-based CBT trial and is the first economic evaluation of telephone-based CBT for COPD patients. Cost-utility analysis and cost-effectiveness analysis are applied. A telephone-based program is believed to improve the accessibility of patients to the service. This economic evaluation uses the societal perspective with a life-long time-frame. Patients aged over 45 with stable COPD and mild to moderate depression or anxiety have been recruited. 70 patients are in each arms of the study. The study is a randomized-controlled trial. The time-frame of this trial is 16 weeks, including 8 weeks of treatment program and 8 weeks to observe the prolonged effects. The measurement of outcomes includes the effectiveness measurements of depression measurement - PHQ-9, anxiety measurement – BAI, and the disease-specific measurement of the COPD Assessment Test (CAT). For the utility measurement, AQOL-4D is applied. In order to capture the costs for COPD patients, new cost diaries and questionnaires are developed based on the characteristics of COPD patients. A Markov model will be established to extrapolate the effects beyond the clinical trial. Sensitivity analysis is also applied in order to explore the uncertainties of this study. The economic evaluation from this study will be a unique, current and important assessment for the management of COPD. Overall, this thesis highlights the home-based training of PR is an important component to produce lasting effects. This study does not show that PR components other than scheduled exercise training and home-based training produce significant impacts lasing for 1 year. It is recommended more robust study designs with appropriate time-frame is needed to investigate the effects of these PR components on HRQoL and reduction of hospital readmission. The economic evaluation protocol of this thesis further provides an opportunity to explore not only the effects of CBT for COPD patients, but also the cost-effectiveness of providing this service.
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ItemPrimary health care workers’ perspectives on the introduction of an alcohol brief intervention program in Chile( 2013)This is a study of a brief intervention (BI) program addressing risky drinking in Chile, introduced in 2011. It investigates health workers’ attitudes to BI, implementation contexts and training needs. It aims to identify enablers and barriers for BI implementation in Primary Health Care (PHC) settings. This topic has not been examined in Chile. Data collection included responses to an online survey from 374 Chilean PHC workers and telephone interviews with six key informants from Chilean health departments. As a mixed-method research project, survey data were subjected to quantitative descriptive analysis and qualitative inductive content analysis, and the interview transcripts were analysed qualitatively. The study shows that while health workers welcome the program, successful implementation is contingent on organisational support, continuous training, on-site supervision and changes in how alcohol-related harm and population-based interventions are understood. Among the most common enablers identified in the study were the positive attitudes towards and good experiences of BI that health staff have, particularly non-professionals, the linkage of BI with existing PHC programs, the opportunity of specific BI training, and the team approach of BI. Conversely, the most frequently mentioned barriers were time constraints and the need for a supportive environment, mainly from workers’ closest contexts (managers and team of the health centre). The study stresses the need to consider system and organisational support to encourage and ensure both sustainability of individual staff changes and integration of the BI program in PHC clinical practices. It suggests that, in order to promote implementation of BI in PHC settings, both the BI training package for health staff and the BI delivery should consider diversity of health workers' needs, keeping a team approach; and also that health non-professionals require additional alcohol-specific and skill-based training and additional support. The study’s findings will be of particular relevance to the design of implementation of BI programs in other countries of similar characteristics like low and middle income and places where a substantial proportion of the health workforce comprises non-professional technicians.
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ItemAn exploration of the model of reciprocal determinism in aged care environments( 2010)Introduction: Once dementia progresses to the later stages, behavioural and psychological symptoms of dementia (BPSD) can be prevalent. Many aged care workers have limited training and education in managing BPSD. This often impacts negatively on the quality of care provided to residents, and outcomes for the staff, including increased stress and job dissatisfaction, leading to turnover and subsequent staff shortages. One of the latest Australian government initiatives aimed at addressing many of the issues influencing resident and staff outcomes, is the Dementia Behaviour Management Advisory Services (DBMAS). This study evolved from the evaluation of the DBMAS. The evaluation was atheoretical; often the case in health care research and evaluation. Applying a theoretical model to understand the factors prevailing in aged care environments is needed. Aim: To explore the model of reciprocal determinism in aged care environments. Reciprocal determinism proposes there is a dynamic interaction between (a) personal factors, (b) environmental factors, and (c) behaviour; all factors can influence, and be influenced, by the other factors. Methodology: Involved combining two key sources of data: (i) literature relating to the application of the model of reciprocal determinism in work environments; (ii) secondary analysis of data from a client survey evaluating the DBMAS. The structured survey sought information relating to resident BPSD, effect of BPSD on staff, services provided by the DBMAS, and the impact of those services on residents (BPSD, quality of life), and staff (including skills, confidence, stress). The survey was administered (over the telephone) by the researcher. RACFs were selected on the basis that staff had used the services of the DBMAS in their jurisdiction, within August to November, 2008. At the end of the data collection period (December 2008), 137 respondents (82.5%) of 166 eligible RACFs had participated. Analysis of data primarily involved a series of cross-tabulations, where Chi sq and Fisher’s Exact tests were used to examine possible associations between various factors. Results: The literature indicates the model has not been applied in aged care environments; however, elements of the model have been examined. For example, staff self-efficacy/confidence, and stress (personal factors), resident behaviour, staff training and education (environmental factors), staff turnover (behaviour). Existing models capture many of the factors operating within aged care environments. These models were developed using an inductive approach, where the data lead the development of the theory, whereas the model of reciprocal determinism adopted a deductive approach, where social cognitive theory guided its development. The model of reciprocal determinism has proved useful when exploring other work environments, including organisational safety culture. Data collected from the client survey, provided support for possible associations between different factors within the model. For example, (i) the DBMAS intervention (environmental) was significantly positively associated with staff personal factors (skills p = .023; confidence p = .001; stress p = .002), particularly if the level of services was medium or high; (ii) the DBMAS intervention was reported to be successful in reducing the most difficult resident BPSD (environmental) to manage; (iii) improvements in staff personal factors were significantly associated with staff behaviour (skills X care time p = .000; confidence X care time p = .002; stress X care time p = .000), and (skills X absenteeism p = .020; confidence X absenteeism p = .033; stress X absenteeism p = .002). Conclusion: Overall, results were supportive of the model’s utility. Suggestions of its ability to provide insights and innovative methods for intervention design, management, and research/evaluation are provided. Although the study is exploratory, and should be viewed from a hypotheses generating perspective, this heuristic model has considerable value for focussing on the “bigger picture”, and not analysing various aspects within aged care, in isolation.