Melbourne School of Population and Global Health - Theses
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ItemEconomic evaluation of intensive hand rehabilitation in patients with recent traumatic tetraplegia( 2020)Background This thesis investigated the cost-effectiveness of an innovative 8-week intensive functional electrical stimulation (FES)-assisted hand therapy program for people with recent traumatic tetraplegia that was conducted alongside a pragmatic assessor-blinded phase 3 randomised controlled trial (‘SCIPA Hands On’) at seven sites across Australia and New Zealand, and the issues that emerged during the trial regarding its two multi-attribute utility instruments, Health Utility Index Mark 3 (HUI-3) and Assessment of Quality of Life-8 (AQoL-8). Methods The economic evaluation was an intention-to-treat cost-utility analysis from a third-party payer perspective over a six-month time horizon. Costs were expressed in Australian dollars (AU$); the price year was 2015. In-depth analyses of sample- and participant-level HUI-3 and AQoL-8 responses were undertaken from a subgroup of SCIPA Hands On participants with complete utility data (80% of total sample) to identify factors that may have affected the utility results. Results Irrespective of instrument, the probability of the SCIPA Hands On intervention being cost-effective was above 75% and 78% for willingness-to-pay thresholds of AU$50,000 and AU$100,000 per quality-adjusted life-year respectively. Exploratory sub-group analyses found that for the more severe AIS A or B motor complete injuries, the intervention’s cost-effectiveness probability was unlikely to be more than 55%; for less severe AIS C or D motor incomplete injuries however, it dominated standard care hand therapy alone. In-depth analyses of HUI-3 and AQoL-8 found that while there were significant improvements in some of the expected instrument attributes/items over time as hypothesised (HUI-3 dexterity and ambulation, AQoL-8 household tasks and mobility, but not family role) and significant associations between them and change in summary utility, there were some unexpected associations between change in HUI-3 summary utility and changes in HUI-3 emotion and pain, and change in AQoL-8 summary utility and changes in AQoL-8 general feeling and pain. Instrument responses appear to have been affected by secondary health conditions, hospital discharge, post-injury recovery and psychosocial adjustment. There was also evidence of potential respondent error, possibly linked to confusing or vague items and/or linked to other factors such as cognitive difficulties or fatigue, which may have underestimated the intervention’s effect. Additionally, AQoL-8 was unable to adequately capture important mobility improvement in people with incomplete injuries, and family role responses may have been affected by inconsistent conceptualisation of health with respect to inclusion/exclusion of participants’ physical limitations. Conclusion Although traumatic spinal cord injury is comparatively rare, its impact is devastating with respect to health-related quality of life (HRQoL) and high care costs over an individual’s lifetime. With life expectancy now approaching non-injured populations, full economic evaluations of interventions designed to improve physical function and HRQoL are highly desirable to assist decisions regarding the translation of these interventions into usual practice. The unique opportunity to undertake a full economic evaluation of the SCIPA Hands On intervention and to conduct in-depth analyses of the two multi-attribute utility instruments is therefore timely in view of new interventions that are under development. The findings reported in this thesis provide an important benchmark for future economic evaluations involving spinal cord injured populations, and have the potential to influence the conduct of future trials in this group.
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ItemThe significance of the child’s voice in child death inquiries( 2019)International agreements on human rights declare that all children should have the opportunity to express their views on their lives and experiences. When it comes to children who are involved with child protection services, however, research from a number of countries suggests that their perspectives are rarely represented. In Australia, each year, around 3% of children are involved with child protection services because of concerns about their safety and well-being. I wanted to understand how professionals in Victoria represent the voices of children subject to child protection services. With child protection services files not accessible for privacy reasons, to pursue my research question I used the reports of 14 child death inquiries conducted by Victoria’s Commission for Children and Young People. The Commission for Children and Young People is mandated, under particular circumstances, to inquire into the deaths of children who were child protection services’ clients at the time of death or within 12 months of their death. These inquiries examine the services provided to the child and his/her family, prior to the child’s death. The children’s deaths that I explored occurred over a decade from 1 January 2005. In all 14 cases, the child died in adolescence, having been subject to a report to child protection services before the age of three. I asked how did professionals who came into contact with the 14 children describe and document the child’s voice and experience? I asked what these children said, literally or metaphorically, about their lives, experiences, and their feelings. Using a conceptual framework of child development and attachment theory, my methodological approach was content and discourse analysis of documentary texts produced by the Commission. Seen through the lens of Commission for Children and Young People inquiries, my research shows that child protection service documentation in Victoria, at best, minimises and, at worst, completely excludes the perspectives of children, particularly very young children. These results mirror child protection services practice internationally. I hypothesise why this silencing of children’s voices occurs in Victoria’s child protection service files. I outline a new approach to listening to children’s voices and experiences, and a new mechanism to document those voices in child protection service files. Called the Child’s Life Biography Tool, this instrument is intended to be a means of valuing and protecting the child, fulfilling the child’s human rights, while also meeting legislation, policy and practice requirements.
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ItemProsperity on country: How to reposition the social, cultural and economic value of Indigenous people in the Goulburn Murray region( 2020)Prime Minister Gillard's 'Closing the Gap' speech in February 2011 called on the country's First Peoples to take responsibility for improving their situation. This kind of rhetoric highlights one of the underlying reasons there has been no substantial improvement in the position of Indigenous Australian peoples. Indigenous peoples are predominately identified as 'the problem' and positioned as the agents who need to 'fix it', which ignores the influence of dominant culture in maintaining the current position of Indigenous peoples. Drawing on the experience and knowledge of Indigenous and government leaders working on strategies to empower Indigenous communities, this thesis captures the work undertaken in the Goulburn Murray region of Victoria in the quest to reposition the social, cultural and economic value of Indigenous peoples. For substantive change to be made, power relations between Indigenous and non-Indigenous Australians need to be realigned and dominant social structures reconstituted. Only once these shifts have been made can the country’s original inhabitants enjoy parity in education, health, employment, and economic prosperity. A collective approach that recognises the need for all Australians – Indigenous and non-Indigenous – to play a role in creating these shifts is needed. This thesis is the story of the Yorta Yorta people’s quest to find prosperity on country to reposition the social, cultural, and economic value of Indigenous people in the Goulburn Murray region of Victoria. The research seeks a solution to address the disparity between Indigenous and non-Indigenous peoples from one regional community’s perspective. A shared sense of humanity is central to repositioning the value. An ability to recognise and envision a world of tolerance, kindness, and acceptance in the hearts and minds of all cultures, regardless of race, colour, or religion, can alter everything. The perspectives of participants throughout the thesis make it clear why repositioning the value of Indigenous people is so important.
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ItemObesity indicators and their impact on the cardio-metabolic disease in an Asian-Indian ethnic population( 2020)Background: Obesity has attained pandemic proportions globally, including in many South Asian countries. The spectrum of obesity in the Indian setting may vary from apparently thin looking individuals with normal weight obesity (NWO) to those at the far end of the spectrum with morbid obesity. However, several knowledge gaps have been identified regarding the utility of clinical and genetic indicators of obesity, across this spectrum, in this unique population. Aims and Objectives: In this study I explored the prevalence of normal weight obesity (NWO) in a cohort from southern India and studied the cardiometabolic disorders associated with this phenotype. I have evaluated the impact of a peer-led lifestyle intervention in individuals with NWO, at a two-year follow-up and determined the obesity indicators that would best predict metabolic disorders in this population. I have also studied the clinical and genetic indicators of obesity in a cohort of patients with morbid obesity. Material and Methods: The objectives mentioned above, across the spectrum of obesity were studied using two datasets. The first dataset, the Kerala Diabetes Prevention Program, is an ongoing longitudinal cluster randomized study, wherein 3552 study subjects were screened and those recruited were subjected to a peer-led life style intervention and followed up on an annual basis up till two years and hereby planned for a 7 year follow-up. The objectives in individuals with morbid obesity were studied in prospectively recruited individuals, from the Vellore bariatric clinic. All patients, recruited from both the datasets, underwent standardized measurements of obesity indicators, had a rigorous cardiometabolic screening and assessment of body composition which included body fat. The genetic analysis in a subset of young-onset morbidly obese individuals was undertaken using a Next Generation Sequencing (NGS) based protocol covering 35 monogenic causes for obesity. Results: The prevalence of NWO in this population was found to be 32% (95% CI: 29.1-34.5%). Individuals with NWO had a significantly higher prevalence of T2DM, hypertension and dyslipidaemia as compared to those without obesity and similar to those who were traditionally identified with obesity. Two years after a peer led lifestyle intervention, only a slight trend towards a favourable change in systolic blood pressure and HDL cholesterol was noted. Amongst several clinical obesity indicators that were studied, waist-height ratio and waist-hip ratio were most significantly associated with cardio-metabolic complications. METS-VF (Metabolic score for visceral fat), a novel obesity indicator, was validated in the Indian population and found to be a good predictor of visceral adipose tissue among individuals with morbid obesity. Sixteen percent of individuals with young onset morbid obesity were found to have a monogenic aetiology for obesity. Conclusion: The obesity phenotype in India differs significantly when compared to other populations. A significant proportion of people have normal weight obesity, which is associated with a high prevalence of cardiometabolic disorders and had minimal trend towards improvement following a two-year life-style intervention. In this setting, the utilization of surrogate measures that predict visceral adiposity and screening for monogenic disorders with NGS in those with young-onset morbid obesity, may be useful adjuncts in the evaluation of obesity in this population.
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ItemRisk factors for anaemia during pregnancy and postpartum in Papua New Guinea: a cohort study( 2020)Anaemia in pregnancy is a substantial public health problem, particularly in resource-limited settings where every second pregnant woman is estimated to be anaemic. This thesis aimed to address gaps in our knowledge of maternal anaemia in order to inform effective prevention strategies in resource-limited settings. Specifically, this thesis sought to determine: the drivers of haemoglobin level changes in pregnancy and the first 12 months postpartum; the interactions between key anaemia risk factors; and the impact of maternal anaemia on infant haemoglobin and iron stores. This was done using a cohort of 699 women and their infants living in the East New Britain province of Papua New Guinea. Firstly, I determined the relationship between red blood cell genetic polymorphisms, anaemia and the malaria-causing Plasmodium species (spp.) infection in pregnant women; and the subsequent effects on birthweight. Women with the homozygous alpha+-thalassemia genotype had significantly lower haemoglobin levels and babies with significantly lower birthweight compared to wildtype individuals, with the association between alpha+-thalassemia and birthweight mediated largely through mechanisms independent of maternal haemoglobin levels. There were no significant associations between genetic polymorphisms and maternal Plasmodium spp. infection. These findings contribute to our current understanding of how genetic polymorphisms influence pregnancy outcomes. Secondly, I determined the contribution of iron deficiency to maternal anaemia and assessed temporal changes in haemoglobin and ferritin levels from enrolment through to 12 months postpartum. Haemoglobin levels remained consistently low, with at least 69 percent anaemic throughout the study period (haemoglobin <110g/l in pregnancy; haemoglobin <120g/l postpartum). Ferritin levels were more dynamic with iron deficiency (ferritin <15 micrograms/l) highly prevalent in pregnancy (>80%), but less so in the postpartum period (~30%). Iron deficiency was identified as a key intervenable anaemia risk factor, associated with a significant 5-fold increased odds of anaemia over the entire study period, compared to iron replete. Plasmodium spp. infection was also an important intervenable risk factor for maternal anaemia throughout the study period. Thirdly, I investigated the relationship between host iron status and Plasmodium spp. infection during pregnancy and postpartum periods, in order to inform the safety of iron supplementation as an anaemia prevention strategy. Host iron status (replete/deficient) was not significantly associated with the prevalence of peripheral Plasmodium spp. infection at any evaluation time, suggesting iron supplement use is safe in this setting. Inflammation was shown to confound the relationship between host iron status and infection, biasing results towards a protective effect for iron deficiency; highlighting the need for future studies assessing this relationship to adjust for inflammation. Finally, I assessed the impact of maternal anaemia on infant haemoglobin and ferritin stores from birth through to 12 months old. Severe iron deficiency anaemia in pregnancy was associated with significantly lower infant haemoglobin and ferritin levels during the study period; demonstrating that maternal haemoglobin and ferritin levels in pregnancy impact newborn and infant stores. This suggests that infant anaemia could be prevented by targeting maternal anaemia during pregnancy. Overall, this thesis outlines the high burden of anaemia during pregnancy, as well as the first 12 months postpartum for women in the East New Britain province of Papua New Guinea, and provides a comprehensive assessment of maternal anaemia aetiology. The data suggests that effective provision of iron supplementation both during and between pregnancies, in conjunction with malaria prevention strategies, would significantly reduce maternal anaemia prevalence and improve infant haemoglobin and iron stores.
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ItemMoral distress, moral equilibrium and the moral equilibrium framework: health professionals' well-being in the face of daily challenges to moral values and integrity( 2020)The impact of moral distress on health professionals, patient care, healthcare teams, organisations and the healthcare sector itself, is at this time significant and increasing. Most research into moral distress has focussed on nurses in acute care settings, and largely in the United States. This combined ethnographic and interpretive phenomenological research investigated gaps in the moral distress literature including the experiences of health professionals’ moral distress (1) in the Australian context, (2) in a multidisciplinary specialist palliative care team, and (3) in a community setting. My research began with the question: “how do community specialist palliative care health professionals experience and respond to moral distress?” This study makes three significant contributions to the contemporary exploration of moral distress. The first is the concept of moral equilibrium-disequilibrium that offers a new way of understanding and responding to moral challenges in palliative care. This new concept emerged from the iterative analysis of the experiences of participants in this setting. Moral disequilibrium results when health professionals, faced with challenges to their values and moral integrity, are unable to adapt to maintain their moral integrity. Moral disequilibrium is part of the everyday experience of being a health professional, and like all experiences will vary from person to person and in intensity, from mild (e.g. moral discomfort) to severe (e.g. moral distress, moral injury). The moral equilibrium-disequilibrium concept provides a positive perspective to moral challenges, and also considers the psychological, spiritual and physical well-being of health professionals. The concept is of practical value to clinicians as it names the dynamic involved in their experiences without the associations of varied current definitions of moral distress. If moral disequilibrium can be identified and addressed early, it may mitigate the progression into further disequilibrium. The second significant contribution is the development of the novel Moral Equilibrium Framework (MEF). The framework comprises three dynamic phases: identification of moral disequilibrium and the moral values involved; its resolution in attaining a “good enough” moral equilibrium; and the evolution phase of growth in moral understanding including the building of moral resilience. Whilst the framework was derived from the experiences of health professionals who were part of this study, I argue that its phases and processes are consistent with various recommendations in the moral distress literature, adding to its strength. The moral distress literature also emphasised the importance of organisational responsibilities in mitigating moral distress. Similarly, whilst the MEF focusses on individual and team processes, its use does not negate the organisation’s role in helping to minimise moral disequilibrium. The third important finding of this research is that the team as an entity can experience moral disequilibrium. This is in contrast to previous studies that name moral distress as individual experiences occurring within the team. This revelation of team moral disequilibrium highlights the importance of being attentive to and addressing the state of moral disequilibrium not only at the individual level but also at the team level. In answer to my research question, I conclude that experiencing daily moral challenges, community specialist palliative care health professionals often choose to respond in ways that help to regain a “good enough” moral equilibrium, both as individuals and members of a team. The thesis will be of interest to health professionals who experience daily moral challenges in an ever growing, stress-filled environment of caring for patients, and who seek to find ways of regaining and sustaining “good enough” moral equilibrium and integrity.
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ItemAssessing the magnitude and factors contributing to socioeconomic and geographical inequalities in maternal and child health care utilisation in Indonesia( 2020)Significant progress has been made in reducing maternal and child mortality at the global level. However, the burden of maternal and child mortality remains high. Indonesia, home to over 270 million population, has one of the highest burden of maternal and child mortality in the world. One of the main challenges in reducing maternal and child health burden in Indonesia, and other LMICs, is inequitable access to essential maternal and child health (MCH) interventions, particularly among the poorest population and those living in remote areas with poor access to health services. It is crucial to understand the influence of health systems on MCH to inform the design and implementation of health interventions. Furthermore, there is also limited evidence on the impact of health insurance on effective MCH service coverage, disparities of health care, and health outcomes. The four objectives in this thesis addressed these issues. First, I described the geographical inequalities in skilled birth attendance (SBA) coverage across Indonesia regions and quantified the contributions of socioeconomic and health supply-side factors towards the geographical variations. Geographical inequality in SBA coverage was mainly driven by disparities in the availability of health supply-side, i.e. the number of skilled birth attendants and hospitals. Interestingly, the number of primary health centres did not influence the uptake of SBA. Second, I assessed the trends and inequalities in the RMCH effective coverage from 2002-2017 to examine gaps in the RMCH care cascade, and investigate variations of these cascade indicators among regions and socio-demographic groups over time. The study revealed that while significant improvement has been made in the levels of crude coverage for all MCH services, the quality of care is still low. The user adherence in following the standards of antenatal care and childhood immunisation was also found to be a challenge. Antenatal care and maternal delivery services were the least equitable interventions compared to family planning and childhood immunisation services. Provinces with similar levels of overall coverage had varying degrees of inequity. This indicates different pathways towards high coverage in relation to the distribution of the services. Next, I evaluated the association of the Indonesia national health insurance (JKN program), the largest single-payer health insurance program in the world, on access to maternal health service and child mortality. Findings from my thesis clearly indicated that JKN was associated with increased coverage of antenatal care, SBA and facility-based delivery. However, JKN was not associated with the reduction in neonatal or infant mortality. This study supports WHO call for universal health coverage through the expansion of social health insurance in LMICs. Quality improvement initiatives must place greater emphasis on the vulnerable population, less developed regions, and geographically remote areas. Finally, the JKN influenced women’s choice of the type of birth attendant and place of delivery. JKN could reduce unsafe deliveries by increasing the SBA use and facility-based deliveries. However, JKN also promoted the use of high-level maternal care, particularly among the richer population and women living in more developed regions in Indonesia. Hence, the main lesson from this study for the healthcare system in Indonesia and other countries is that health insurance coverage by itself may not be sufficient to address challenges in the quality and appropriateness of care. Consequently, future health system reform must place greater emphasis on strengthening integrated primary health care to achieve universal health coverage in Indonesia.
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ItemScaling-up participatory research with children: investigating the influence on co-researchers’ critical consciousness and their agency in the research process( 2020)Participatory research with children aims to actively collaborate with child co-researchers to co-construct knowledge and social action about their worlds. Recently, a growing number of studies have increased the size and scope of participatory research with children. However, there is scarce evidence on how collaborating across study sites and engaging with data that reflects the lives of children from different backgrounds and contexts influences child co-researchers’ views about themselves, their communities, and the world, as well as their experiences during the research process. Additionally, although scaled-up participatory studies tend to show overall high levels of child agency, little is known about the process of increasing child co-researchers’ agency within and beyond the research setting. My PhD research focused on answering the question of how does scaling-up participatory research with children influence child co-researchers’ critical consciousness and their agency in the research? To answer this question, I carried out a scoping review of the literature and two qualitative participatory studies. The Children’s Araucaria study focused on exploring children’s experiences in two disaster risk reduction programs, one in Chile, the other one in Australia. My second study, Kids Contribute, was part of a larger initiative led by the Child and Community Wellbeing Unit at the University of Melbourne and carried out in collaboration with a children’s television news program. Child co-researchers from different backgrounds and places in Australia helped create questions and interpret results for a poll about how children contribute at home, school and elsewhere in the community. Then, a group of child co-researchers presented their findings and recommendations at a national forum, organized with the Australian Human Rights Commission. My work in this project focused on examining the qualitative and participatory component of the research. My findings showed that scaling-up participatory research with children can help promote child co-researchers’ critical consciousness at the individual, social and global levels of awareness. As the research process increased their exposure to other children’s perspectives, child co-researchers began to explore the connections between their personal experiences and those of other children in their communities and across Australia. Child co-researchers were also motivated to learn about the realities of children in different parts of the world and to collaborate across geographic frontiers to address global issues like climate change and racism. My research also found that, if the goal is to scale-up participatory research with children, child co-researchers should have opportunities to engage in research activities beyond their local community across the different stages of the research process. This task can be complex, since the context of each study location can facilitate or constrain child agency in different ways. Through their dialogue with child co-researchers, adult researchers can promote critical consciousness at different levels of awareness by using research activities as prompts and integrating discussions about the different geographic and ecological levels involved in the study. Child co-researchers can also benefit from collaborating with each other across study sites. Finally, to increase the impact of the research and child co-researchers’ empowerment in their relationship with adults, researchers can help build increasingly wider audiences that are willing to listen and act upon children’s ideas.
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ItemAdvancing economic evaluation methods for better medical decision making through real-world, longitudinal data( 2020)Health economic evaluation is a fundamental component in helping inform health care providers and policy makers in making decisions on priorities in health care. This is particularly relevant in today’s tight budgetary climate and in response to continued calls for sustainable health care systems. Economic evaluation evidence has influenced and contributed to many areas of health policy making, at all levels of the health care system – from shaping guidelines that guide clinical care to informing decision for subsidy of pharmaceuticals and medical services. For these evaluations to be useful to decisions makers, they need to provide useful and reliable information and to achieve this, methodological guidelines should be followed, and robust evidence of effectiveness and cost is paramount. With recent advances in information technology, data and statistical methods and implementation of electronic health records, health decision makers are increasingly seeking real-world, generalisable evidences to complement and support policy and clinical decisions. This thesis aims to demonstrate the usefulness and practicality of applying real-world longitudinal data in health economics research and applications. It features six individual health economics studies which explore longitudinal data and show their value and contribution towards advancing economic evaluation methodologies and better decision making. Each of the studies answer specific research questions and contribute to the research literature through methodological research to improve consistency in extrapolating costs, utility inputs and modelling long-term outcomes, generating robust evidence for resource allocation decisions, promoting a better understanding of real-world heterogeneity and approaches to optimise patient outcomes. Collectively, these studies highlight important variations in the cost and outcomes of health care delivery in real-world settings, provide useful insights into the implications of such variations and demonstration of translating research findings to implementation.
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ItemA survey of non-communicable disease and the associated risk factors in three different study sites in Papua New Guinea( 2020)Introduction Non-Communicable Diseases (NCDs) are the leading cause of death and morbidity throughout the world, with the greatest burden in low- and middle-income countries (LMICs). Of the estimated 17.9 million CVD deaths in 2016, more than 10 million occurred in LMIC countries. Coronary heart disease and stroke were the two major causes contributing to these deaths. Papua New Guinea (PNG) is categorized as a lower-middle-income country according to World Bank criteria and it is experiencing rapid economic growth as a result of large-scale mineral and gas resource developments. These economic changes are contributing to epidemiological transitions associated with rapid lifestyle changes that, in turn, are leading to increases in cardiovascular diseases and diabetes. NCDs and associated risk factors have not been well investigated in PNG, however, several small studies conducted over the past 40 years have been suggestive of increasing prevalence of NCDs and their associated risk factors (Chapter 3). The aim of this research is to establish an up-to-date NCD risk factor prevalence data enabling a better understanding of the differences in these risk factors in relation to socio-economic status in three locations in PNG. The present study was undertaken during the construction phase of a large-scale gas development which was projected to more than double the gross domestic product (GDP) of PNG. The study was designed to provide baseline prevalence data on NCD risk factors in the initial years of a gas project impact site (West Hiri) and in two non-project impact sites (Asaro and Karkar Island). It was also anticipated that the study findings would provide up-to-date NCD risk factor prevalence data to help the national government plan services and develop cost-effective interventions. This thesis describes the methods used and presents the initial findings for NCD risk factors in a survey of three different socio-demographic populations of PNG. Methods The analysis of the data presented in the results sections of this thesis was based on the NCD Risk factor survey. The survey was a cross-sectional study of the prevalence of NCD risk factors across three different sites namely West Hiri in Central province, Asaro in Eastern Highlands province and Karkar Island in Madang province. A modified questionnaire based on the WHO STEPwise instrument was used for data collection. In addition, physical measurement and biochemical samples were collected from participants (Chapter 4). Results A total of 785 participants participated in the survey. The prevalence of NCD risk factors varied markedly different across the three sites. The metabolic risk factors such as obesity, elevated blood pressure, increased total cholesterol and HbA1c levels were higher in West Hiri compared to the other two sites (Chapter 5). Further analysis of the data was done to investigate the association between socio-economic status (SES), and the CVD risk factors. Findings show that elevated CVD risk factors were common among all SES groups, but metabolic risk factors were more prevalent among homemakers, peri-urban West Hiri and Asaro and among the highest quintile groups. Adults in the peri-urban West Hiri had higher risk of obesity, hypertension, abnormal lipids and elevated HbA1c. Similarly, Asaro adults had increased risk of central obesity, hypertension, elevated triglycerides and MetS compared to the residents of rural Karkar Island (Chapter 6). Conclusion The research reported in this thesis adds to our understanding of the associations between SES and CVD risk factors in a LMIC like PNG. Data from high income countries show a negative correlation with socio-economic status, however findings from our study showed the association between CVD risk factors and SES varied greatly depending on the type of SES measure used. Understanding these associations is important to inform the government to develop appropriate and effective prevention and control strategies. With this information at hand, the government would be able to make informed decisions and prioritize its prevention and control strategies targeting high risk populations or settings in the country.