Melbourne School of Population and Global Health - Theses
Permanent URI for this collection
Search Results
1 - 2 of 2
-
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.
-
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”.