Medicine (St Vincent's) - Theses

Permanent URI for this collection

Search Results

Now showing 1 - 2 of 2
  • Item
    Thumbnail Image
    Enhancing the hepatitis B care cascade in Australia: addressing barriers in the Chinese community and general practice, and evaluating cost-effectiveness
    Xiao, Yinzong ( 2021)
    Chronic hepatitis B infection is a significant global public health concern, with untreated chronic hepatitis B leading to cirrhosis, liver failure and liver cancer. In 2015, an estimated 257 million people worldwide were living with chronic hepatitis B, of whom only around 10% were diagnosed, and fewer than 1% received treatment. An estimated 870,000 deaths are attributed to hepatitis B each year. In 2016, the World Health Organization launched the global health sector strategy on eliminating viral hepatitis, which provides guidance and frameworks for country efforts to eliminate viral hepatitis as a major public health threat by 2030. In Australia, despite a high hepatitis B vaccination rate by global standards, there are significant gaps in the coverage of service delivery among people living with chronic hepatitis B. One in three people with chronic hepatitis B are not diagnosed, and 78% are not receiving ongoing clinical care. One of the priority populations of hepatitis B infection are people born in endemic countries, with China being the most common country of birth among overseas-born people living with hepatitis B in Australia. To increase hepatitis B diagnosis, care and treatment (that is, to enhance the hepatitis B care cascade) in Australia, several critical areas for improvement have been identified, including adapting services to the affected population, building health workforce capacity to meet demands, and building the investment case to support models of care that will promote hepatitis B elimination. The overarching aim of the research presented in this thesis was to generate evidence targeting each of these three aspects, with particular emphasis on: 1) engaging the Chinese community in hepatitis B testing and clinical management; 2) engaging general practitioners (GPs) in the provision of hepatitis B-related care; and 3) formulating a robust hepatitis B investment case. To accomplish these objectives, five interlocking studies were conducted. The first two studies focused on an affected community (the Australian Chinese community), the second two on health service providers, and the final study on the cost effectiveness of hepatitis B care. More specifically: Study 1 was a randomised controlled pilot and feasibility study of the impacts of an educational program designed to improve hepatitis B testing uptake in the Australian Chinese community; Study 2 was a qualitative study to explore enablers of hepatitis B clinical management among the Australian Chinese community; Study 3 was a before-and-after evaluation of a self-guided learning package among GPs practising in Victoria; Study 4 was a nationwide survey of knowledge, attitudes, barriers and enablers to the provision of hepatitis B care among GPs in Australia; and Study 5 was a cost-effectiveness study analysing the impacts of enhancing hepatitis B care cascade to reach global and national targets in Australia. The findings of this research indicated that a culturally tailored education program can contribute to improving hepatitis B-related knowledge among the Australian Chinese community. Key messages identified to resonate most strongly among people living with chronic hepatitis B included availability of effective and cheap treatment, and that long-term engagement with clinical management has substantial benefits. A holistic response from community, healthcare providers and the public health sector is required to motivate testing and clinical management among the Australian Chinese community at risk of hepatitis B infection. Additionally, this research showed that concise, clear and practical resources can support GPs to identify who to test for hepatitis B. It also showed that GPs lack of awareness, knowledge, confidence and intention to prescribe treatment for hepatitis B, highlighting the need for interventions to increase their interest and skills in the provision of hepatitis B-related care. Economic evaluation findings suggest that an improvement in the hepatitis B care cascade is required for Australia to reach the global 2030 targets, and that it is cost-effective to spend up to AUD328 million to AUD538 million per year on demand generation activities to reach the national and global targets. Overall, this research provides novel evidence about feasible and effective interventions for improving the hepatitis B care cascade in Australia. It also provides insights into ways to enhance the global hepatitis B care cascade.
  • Item
    Thumbnail Image
    A model of culturally informed integration of Diabetes Education and diabetic Eye disease Screening (iDEES) in Indigenous primary care settings
    Atkinson-Briggs, Sharon Ruth ( 2021)
    Diabetes mellitus, particularly Type 2 diabetes (T2D), is a fast-growing pandemic and leading public health problem. If not managed well, T2D can lead to serious complications, such as diabetic retinopathy (DR). DR is a retinal complication of diabetes and one of the leading causes of vision impairment and blindness in working-aged adults globally. Although there have been many attempts to treat and eradicate DR, the burden tends to fall on the most vulnerable people in low-income countries, rural settings, and indigenous populations. Indigenous Australians are more likely to have T2D and are at higher risk of being visually impaired or going blind due to DR then non-Indigenous Australians. Studies have demonstrated that early detection and management practices, such as DR screening, are effective strategies to detect and manage DR to reduce the risk of sight-threatening visual complications and blindness (NHMRC, 2008). Despite the benefits of DR screening, screening rates among Indigenous Australians are substantially lower than in non-Indigenous Australians. Thus, understanding the association between diabetes and its complications, above all DR, and the importance of regular eye screening is very important for both individuals with diabetes and healthcare clinicians involved in providing diabetes support and diabetes self-management education. Technological advances and the Medicare rebates that support the use of non-ophthalmic clinicians (general practitioners, diabetes educators, health workers and endocrinologists) to supplement coverage by ophthalmologists and optometrists can extend retinopathy screening capacity and should also facilitate improved DR screening rates among Indigenous Australians. Diabetes educators are part of a multidisciplinary healthcare team and are integral to improving diabetes support and self-management education to assist people with diabetes. Integrating ocular screening and diabetes education in primary healthcare settings has potential to synergistically improve retinopathy screening coverage, patient self-management, risk factor control, diabetes care satisfaction, health economics and sustainability of under-resourced services. Hypotheses The studies in this thesis are based on the hypotheses that Indigenous Australian with diabetes are at high risk of diabetic retinopathy due to multiple factors, including suboptimal risk factor profiles; and that a novel model of nurse-led care provision can improve diabetic retinopathy screening rates, reduce risk factors for diabetic retinopathy, and in the longer-term reduce the rates of diabetic retinopathy and related complications. The overall goal is to develop, implement and assess a novel nurse-led model of culturally informed integrated diabetic eye screening and diabetes education in Aboriginal Community Controlled Health Organisations (ACCHOs). Specific Aims 1. To develop, implement and assess a novel nurse-led model of culturally informed integrated diabetic eye screening and diabetes education for Indigenous Australian adults with diabetes in ACCHO primary care centres and related clinics in regional Victoria; including to determine (a) diabetic retinopathy screening coverage rates; (b) the prevalence of impaired vision and of diabetic retinopathy; (c) lifestyle-related risk factors for diabetes complications; (d) traditional risk factors levels including HbA1c, blood pressure and kidney function (ACCHO national key performance indicators), lipids and smoking; and (e) patient satisfaction with diabetes care. 2. To conduct a thematic review of self-management practices in Indigenous Australians related to smoking, nutrition, alcohol, physical activity and emotional wellbeing, as there is a paucity of data in this area. Methods The candidate developed a novel integrated Diabetes Education and diabetic Eye disease Screening (iDEES) model of care that was implemented and tested at three Indigenous-led primary care practices in regional Victoria, Australia. The trial was registered (ANZCTRN1261800120435) and ethics committee approved, and each participant provided written informed consent. The trial was of a pre-post design, with a single clinic visit at baseline and follow-up. Each visit included eye testing, surveys regarding lifestyle and diabetes education. Traditional risk factors, including BMI, blood pressure, smoking, HbA1c, kidney function, and lipid levels, were collected from the electronic medical record system, if available. The candidate was responsible for collecting all qualitative data, based on the surveys which, due to potential low literacy issues, she verbally administered to each study participant. This is culturally acceptable and often preferred in a culture with a strong oral tradition. The surveys were usually administered during a one-hour diabetes education and eye imaging appointment. Results were analysed using descriptive statistics, with significance taken at p < 0.05. A thematic literature review was undertaken. Results Overall 334 eligible patients, 171 (51%) participated. A high rate of 78% of the target population was screened at the main study site, in spite of COVID-19 restrictions with 76% being re-screened as per national recommendations. Smaller clinical services strived, but struggled, to embed this additional technology-based service for a range of reasons, predominantly due to understaffing, high staff turnover and management changes, with screening coverage of 18% and 27%. This study of screening coverage for diabetes eye care is one of very few available in the literature, in spite of it being a key metric for diabetes eye care. High rates of diabetic retinopathy (29%) were identified at all sites, on par with other studies of Indigenous Australians. The study also identified high rates of suboptimal self-management behaviour at all study sites, and at the main study site also identified suboptimal systemic risk factor control in adults with diabetes, with a median of four of nine traditional risk factor targets being achieved for women and three of nine for men. The vast majority participants reported being very satisfied with their current diabetes treatment. Follow-up regarding lifestyle and risk factors could not be repeated due to COVID-19 limitations. The literature review identified a knowledge gap in the areas of lifestyle and traditional risk factors among Indigenous Australians with diabetes. Hence, the data generated by the thesis contributed valuable new knowledge to the field. Conclusions An integrated nurse-led model of care was implemented in regional Australian ACCHOs and achieved diabetic retinopathy screening coverage rates of over 75% in the fully engaged sites, with much lower coverage at the less engaged sites. High rates of retinopathy and of adverse lifestyle and traditional risk factors were identified. This culturally acceptable nurse-led model of care merits longer-term follow-up and assessment in other sites, including whether it can improve long-term health outcomes for Indigenous Australians with diabetes.