Melbourne School of Population and Global Health - Theses
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ItemHIV care decentralization in lower- and middle-income countries: outcomes, costs, and cost effectiveness( 2018)Decentralized provision of HIV care continuum – from diagnosis to chronic antiretroviral treatment (ART) – at primary health care facilities (PHCFs) is a critical step towards realizing optimal care coverage in national programs of lower- and middle-income countries (LMICs). Whether such a model of provision is justified depends on considerations of effectiveness, program costs, and cost-effectiveness. This research project aims to: a) examine the effectiveness of decentralized provision of HIV testing and counseling (HTC), pre-ART (ART initiation), and long-term ART care relative to hospital provision with the following outcomes: • Cascade of service receipt in HIV testing and counseling (HTC); • The timeliness of ART initiation by baseline CD4 count and clinical stage; • Treatment adherence during ART care. b) estimate and compare ART program costs of decentralized care at PHCFs and those of hospital care; c) estimate the cost-effectiveness of decentralized provision of routine, chronic ART care relative to hospital (centralized) provision. Data from national surveys and reviews of published studies in Indonesia and sub-Saharan Africa were analyzed using multivariate statistics, meta-analysis, and model-based cost-effectiveness analysis. In HTC, pregnant women were equally likely to receive a full HTC procedure, up to post-test counseling, at both hospitals and PHCFs in four high-prevalence countries (Lesotho, Malawi, Zambia, and Zimbabwe), with a positive implication for motivating regular HTC. In pre-ART care; CD4 counts at ART initiation increased over the calendar time for both hospital and PHCF patients, with fewer patients experiencing a late HIV stage. In ART care, hospital and PHCF patients exhibited at least similar adherence to ART, indicating a non-inferior performance of decentralized provision in Indonesia. In program costs, the average cost of providing ART care for PHCF patients was not lower than hospital provision in four sub-Saharan African countries (Rwanda, Malawi, Zambia, and Ethiopia), except in Ethiopia. Cost differences were largely attributable to differential prescribing of ART regimens between facility types and minimized with a switch to the recommended regimens. In terms of cost-effectiveness, decentralizing stable ART patients from hospitals to PHCFs for routine care (down-referral) was found to be cost-effective in Ethiopia. Economically, the extra program cost represents an affordable investment to advance the performance of the existing decentralization programming and population health. HIV care decentralization redistributes the care burden across the health system without compromising patient outcomes and favorable cost-effectiveness implications. Program expansion beyond decentralization and facility-based provision may be necessary to attain optimal coverage of HIV care in many LMICs. Identifying the optimal model of decentralization for given set of program characteristics is a key research area in the direction of optimizing program outcomes and efficiency.
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ItemMental health of primary care attendees in Kota Kinabalu, Sabah( 2018)This PhD thesis aims to investigate the mental health problems, care and service among the government clinics in Sabah, Malaysia, focusing on one of the most densely populated districts of Kota Kinabalu. Background behind undertaking of this project was based on existing epidemiological facts and studies from Sabah and peninsular Malaysia is presented. The lack of adequate mental health services, mental health research, poverty, immigration and other specific issues that are discussed in the literature review. This is a cross-sectional, general health clinic-based study among primary care attendees in the Kota Kinabalu district of Sabah. Aim: The study was designed to determine the prevalence of common mental disorders among primary care attendees in Kota Kinabalu and to identify the associated factors. It also determined the treatment gap, disability and perceived need for psychiatric treatment and care and mental health service utilization among primary care attendees with probable common mental disorder. Method: Simple random sampling method was used to select patients at three government general outpatient clinics. A total of four hundred and eighty-one patients were invited to participate. Four hundred and thirty agreed and fifty-one patients (10.6%) refused. Respondents were further interviewed by trained interviewers using a standard proforma to obtain socio-demographic data and clinical profile, Patient Health Questionnaire (PHQ), Work and Social Adjustment Scale (WSAS), General Practitioner User Perceived Need Questionnaire and Mental Health Service Utilization Questionnaire. Results: The prevalence of common mental disorders among primary care attendees were 52.1%, with 224 out of 430 respondents having a probable common mental disorder. This was higher than the previous two studies done in West Malaysia, where the prevalence of mental disorder in the primary care setting was found to be 24.7% and 26.7% respectively. Ninety-five respondents (22.1%) had more than one psychiatric diagnosis. Using univariate analysis: young age, female, monthly income less than RM1000 (1AUD=RM2.97), unemployment, student, secondary/tertiary education and recent stressors were all significantly associated with common mental disorder (PHQ positive). Using a logistic regression method, five factors were significantly predictive of common mental disorders. These were young age (18-29 years of age), female gender, higher education, income less than RM1000 and history of being physically or sexually victimized. Two hundred and nineteen (97.8%) out of two hundred and twenty-four respondents with common mental disorder had some form of disability. One hundred and sixty-three (72.8%) were slightly disabled, thirty-seven respondents (16.5%) were moderately disabled and nineteen (8.5%) were severely disabled. There was a significant and consistent positive association between the moderate disability and co-morbid common mental disorder in nearly all items of disability. The severely disabled group was shown to have a positive association with co-morbidity in two of five items of disability. These were private leisure activities and family relationship. Two hundred and five, out of two hundred and twenty-four respondents with a common mental disorder were not receiving any treatment. This was a treatment gap of 91.5%. Twenty-four respondents sought help from a traditional healer, twelve went to other professional mental health services and only three were seen by psychiatrist. Only four patients had been admitted to a psychiatric ward. The most sought out mental health services in this population were counselling (49.1%) and mental health information (41.1%). The least common mental health service provided was for medication (20.5%). The most common reason given for not accessing mental health services or treatment was “I preferred to manage myself the problem”.
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ItemCalling for the doctor: an evaluation of an after hours GP helpline in Australia( 2016)In Australia and other developed countries, the provision of after hours primary care is a challenging policy area. Limited access to after hours services, geographic inequities in provision of services, burden on hospital emergency departments, and workload for general practitioners (GPs) have prompted governments to implement after hours primary care reforms. Telephone triage and advice services have been introduced in many countries to help to improve patient access and better manage demand for both in hours and after hours health services. In Australia such developments have provoked controversy. In 2011 an after hours GP telephone advice and referral service was introduced as a supplement to existing nurse-provided telephone triage and advice services in Australian states and territories. This thesis examines the recent evolution of after hours primary care policy in Australia with a particular focus on the quality, effectiveness, and provider and consumer experience of the after hours GP helpline (the helpline) in the context of Australian primary care. Four layers of the health system - policy, service, GP provider and consumer perspectives are explored using a mixed methods realist evaluation framework. The thesis aims to identify the critical characteristics and contextual factors required to embed a GP telephone advice service in an integrated after hours healthcare system. Ten studies were conducted investigating stakeholder views, consumer utilisation, safety and quality in adult and paediatric population groups, impact on emergency department utilisation, cost considerations and GP provider and consumer experience of the helpline. Together these studies provide an in-depth portrayal of the way in which the service was conceptualised, implemented, used and experienced. The research found that the helpline was not wholly successful in integrating with or adding value to the after hours primary care system in Australia during its first two years of operation (2011-2013). Multiple theories of action were developed, identifying current and possible pathways for helpline interaction at multiple levels in the health system. These theories of the way the world works identified contextual factors and causal mechanisms that can be modified to improve the helpline’s contribution to the Australian health system. At the policy level, supportive settings that reframe the policy narrative around the helpline as a service that assists the GP workforce, as well as consumers, will increase stakeholder acceptance and consolidate political support for its continuation. Service characteristics that promote continuity of care and greater uptake by community-based GPs and high need consumers will increase reach with consumers and the acceptability of the service to GPs. Continuation of quality improvement processes that support safe and appropriate advice will increase confidence in the helpline and improve demand management in the after hours period. Recognition of a new telephone GP provider role will lead to employment opportunities and professional recognition of GPs, young and old, seeking work-life balance in a telephone clinician role. Effective communication in telephone GP advice that reduces consumer dependency and empowers consumers to make appropriate health care choices may contribute to improved health literacy in the population. With these modifications to the context and characteristics of the service, the AGPH could both contribute to, and be part of, better integrated after hours care in Australia.
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ItemMechanisms of effect: a health systems analysis of the impact of introducing treatment services for human immunodeficiency virus (HIV) into four public primary health centres in Zambia( 2013)Between 1996 and 2008 global funding for the treatment of human immuno-deficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) increased from US$300 million to an estimated US$15.6 billion. Much of this money was directed to a small number of countries such as Zambia in sub-Saharan Africa, where HIV/AIDS constitutes a major health, social and economic threat. Although the necessity and urgency of responding to the HIV epidemics in these countries was not in question, the exceptional levels of HIV funding and the rapidity of the scale-up of HIV- services did reignite a debate regarding the impact of disease-specific programs on recipient countries’ health systems. Notwithstanding the high profile nature of this debate, little empirical research exists to inform policy makers or programmers in their efforts to meet the dual aims of improving disease-specific health outcomes and simultaneously strengthening health systems. Meeting a gap in the literature, this study examines the impact of introducing donor-funded HIV services into the Zambian health system, focusing specifically on the impact on primary health ‘micro-systems’. The conceptual framework for this study draws from theory developed in the application of complexity science and systems thinking to health systems analysis, which suggests that health systems are characterised by the interconnectedness of their component parts. The multi-disciplinary framework theorises that interactions between system ‘hardware’ and system ‘software’ influence mechanisms of accountability and trust, and through these, the quality and responsiveness of service delivery within health micro-systems. This approach challenges the implicit assumptions of more reductionist frameworks, which suggest that health systems – and particularly micro-level systems – are a simple composite of individual ‘building blocks’. This study adopted a multi-case study design, with four Zambian health centres purposefully selected based on the presence of an established HIV department (more than 3 years old), and urban, peri-urban and rural characteristics. Case data collected in each facility included facility audits, direct observation of facility operations and interviews with patients, staff, and District and non-government officials. Data were triangulated and analysed for each case first, and cross-case analysis subsequently carried out to improve the analytical generalisability of the findings. The findings from this study demonstrate that the rapid scale-up of HIV services in Zambia, which focused predominantly on investing in health system hardware, acted unevenly on mechanisms of accountability and trust and had mixed outcomes on the four health centres’ overall functionality. It was revealed, for example, that the short-term gains in health worker performance achieved through investment in system hardware for HIV services were difficult to sustain, as the lack of investment in underlying mechanisms of accountability such as improved answerability and enforceability or stronger patient-provider trust, enabled perverse work norms to flourish in ways that undermined quality and responsiveness of care. The study points to the critical importance of accounting for the ideas, values and norms of actors in the health system (system software) in order to plan and deliver disease-specific interventions that achieve both their programmatic aims as well as producing long-term, system-strengthening effects. The study constitutes an important contribution to the field of health policy and systems research providing empirical evidence of the complex, social and adaptive nature of health micro-systems and demonstrating the critical value of the hardware-software construct for analysing mechanisms of effect in this domain.
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ItemExamining Victoria’s disaster mental health capacity: towards systematic disaster mental health workforce and service planning( 2013)Natural disasters increasingly impact on the Victorian population, resulting in greater calls on mental health services and providers of psychosocial support. However, little is known about Victoria’s capacity to respond to the mental health consequences of major natural disasters. It is therefore timely to examine key indicators of Victoria’s disaster mental health service and workforce capacity and to examine the strengths and limitations of current approaches to building such capacity in view of future natural disasters. To this end, the current thesis examined key indicators of, and current approaches to building, Victoria’s disaster mental health service and workforce capacity in the context of the response to Australia’s largest bushfire disaster, the Victorian Black Saturday Bushfires. Through a series of four studies, this thesis investigated strengths and limitations of novel service delivery models and capacity building approaches, and the profile and capacity of the Victorian disaster mental health workforce. Study findings will inform a more strategic approach to disaster mental health workforce and service planning, sustainable capacity building and enhanced provision of best practice mental health support to disaster-affected Victorians in the future.