Melbourne School of Population and Global Health - Theses

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    The relevance of perseverative cognition for Aboriginal Australians
    James, Terry Lynne ( 2020)
    Aboriginal and Torres Strait Islander people are the most marginalised and disadvantaged group in Australia, experiencing measurably worse health and social outcomes than do other Australians. A substantial body of evidence suggests that perseverative cognition – a psychological state characterised by excessive worry, rumination, and anticipatory stress – increases the risk of psychological and physical ill-health through extending the stress response. Historical and contemporary experiences of structural, cultural, and individual race-related violence and discrimination may leave Aboriginal and Torres Strait Islander people particularly vulnerable to perseverative cognition and its long-term effects on physical and psychological health. This takes the form of conditions such as depression, anxiety, and cardiovascular disease, all of which are highly prevalent among this minority. This study applied critical race theory and participatory action research approaches to explore experiences and responses to racism with 39 Aboriginal adults from a regional urban context in 2015. Thematic analysis of seven discussion groups identified three major themes in the data including 1) The nature, sites and normalisation of racism and discrimination; 2) Anti-racism, redress, and reconciliation mechanisms; and 3) Predicting, protecting, and preserving self and others. Findings indicate study participants experience multiple forms of societal racism that promotes sustained cognitive vigilance or ‘action readiness’ for race-related threat and an array of adaptive context-driven and dynamic cognitive, emotional, and behavioural responses. This result supports the relevance of the perseverative cognition hypothesis in this context and recommends a more comprehensive mixed-methods investigation, broad-ranging structural, cultural, and individual anti-racism education, and effective redress mechanisms for Aboriginal and Torres Strait Islander people.
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    Engaging men in conversations about masculinity and suicide – An evaluation of the Man Up social media campaign
    Schlichthorst, Marisa ( 2020)
    Male suicide continues to be a major public health concern both internationally and in Australia. While a number of factors have been found to contribute to high suicide rates, little is known about what drives the much higher rates in men compared to women. Mostly, risk factors for suicide are considered in isolation, with little regard for the mechanisms that may underpin them. In more recent discussions on male health, masculinity has been highlighted as a potential driving force underpinning unhealthy male behaviors. In Australia, the “dominant masculinity” is one that endorses the norms of stoicism, independence, invulnerability and avoidance of negative emotions. Conformity to these masculine norms has been associated with suicidal thinking, poor mental health and reduced and delayed help-seeking. Men also describe experiencing stigma and how the fear of being alienated prevents them from seeking help for mental health issues. For these reasons, men are often described as a “hard-to reach” population group when it comes to mental health messaging. Suicide prevention interventions are needed that adopt a gendered approach and attend to the influence of masculine norms on mental health and suicide. The Man Up intervention was an innovative media-based male health promotion and suicide prevention intervention that featured a three part television documentary and digital campaign delivered via a website and five social media platforms (Facebook, Twitter, Instagram, YouTube and tumblr). It was funded by the Movember Foundation in Australia and its aim was to address the high suicide rate among men by promoting help-seeking for personal or emotional problems via an exploration of Australian masculinity. The documentary and digital campaign examined how society shapes the way men and boys see themselves and explored how this might affect mental health and, potentially, lead to thoughts of suicide. It was aired by the Australian Broadcasting Corporation (ABC), Australia’s national public free-to-air broadcaster, in October 2016. This thesis explores the potential for social media to be used in health promotion with the view to generate and increase engagement and influence conversations on the issue of male suicide and its link to masculinity. As such, this thesis focuses on the evaluation of the social media components of the digital campaign. The thesis is based on the idea that masculinity, the rules prescribed by society about how men should live their lives, is a fundamental determinant influencing how men negotiate their health throughout life. Following social constructionist theory, this thesis proposes that by challenging dominant masculinity social learning processes can take place that will support redefining restrictive behavior patterns and opening up alternative behaviors which in turn will help reducing stigma for men facing mental health problems, increasing male help-seeking and ultimately reducing male suicide rates. The above aim was addressed through two empirical studies that analyzed various data sources collected through two social media platforms: Facebook and Twitter. In Study 1, Twitter Insights data were used to assess reach and engagement with the campaign and to determine highest and lowest performing tweets. We also analyzed the volume of conversations over time by tracking the use of common campaign hashtags and conducted thematic analysis on a sub-set of tweets to determine most engaging campaign content themes. Study 2 was a qualitative study of comments published on the Man Up Facebook page with the aim to provide further insight into the conversations that were instigated by the campaign. Both studies have been published as peer-reviewed journal articles and together they demonstrated that the Man Up social media campaign was able to generate an impressive reach and exposure to campaign messages in the Australian population and beyond. Overall, the studies showed that the Man Up campaign messages were perceived positively across both Twitter and Facebook. Campaign content was widely shared on social media and positive feedback showed endorsement for the campaign. It highlighted the need to openly talk about male suicide and the stigma introduced by gendered practices. The increased use of the hashtag keywords of the Man Up campaign in line with the campaign phases and the fact that the hashtag MANUP was trending during the campaign signaled a strong uptake and sharing of campaign messages. Despite this, the hashtag analysis could not find a lasting increase of engagement. The analysis of Facebook comments confirmed that the social media campaign triggered conversations about masculinity and suicide that might otherwise not have happened. For some, this may have led to shifting attitudes towards expressing emotions and reaching out to others for help, however, this could not be formally investigated based on social media data alone. This thesis concludes that social media interventions can be used successfully in engaging men in discussions about male mental health, suicide and gender norms and therefore demonstrate potential for suicide protective properties of social media. However, more research is needed to better understand how and where on the internet to best engage men, particularly men at high risk of suicide. While gender-transformative campaigns such as Man Up can help to further destigmatize help-seeking for men, the longevity of changes needs further consideration. Addressing these issues will require high quality interventions and evaluation designs for social media campaigns which follow a systematic framework for measuring effectiveness.
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    Media reporting of Robin Williams’ suicide
    Pirkis, Jane Elizabeth ( 2020)
    Background Irresponsible media reporting of suicide can lead to suicidal acts, particularly if the subject of the reporting is a celebrity. When Robin Williams took his own life on 11 August 2014, media reporting in the United States was less than optimal, with many reports detailing the suicide method Williams used, romanticising his suicide, and failing to provide information on sources of help. The reporting was followed by an increase in suicides in the United States, as well as an increase in helpline calls. In Australia, the Mindframe guidelines provide media professionals with advice on ways to safely report on suicide. This thesis set out to determine whether the Australian reporting of Williams’ suicide adhered to the recommendations in the Mindframe guidelines and whether there were increases in suicides or calls to helplines in Australia following the media reporting of Williams’ suicide. Method The thesis involved three studies. In Study 1, relevant newspaper articles were identified through a systematic search process, and trained coders rated the articles for quality against criteria in the Mindframe guidelines. In Study 2, suicide data were extracted from the National Coronial Information System for the period 2001 to 2016 and interrupted time series regression analyses were conducted to determine whether there were changes in the number of suicides in the five month period immediately following Williams’ suicide. In Study 3, weekly calls data for the period 2013 to 2015 were provided by Australia’s two most prominent helplines, Lifeline and Beyond Blue. Again, interrupted time series regression analyses were conducted, this time to determine whether there was an increase in the average weekly number of calls received by each helpline one week and one month after the news of Williams’ suicide broke. Results Study 1 identified 303 newspaper articles, 67% of which adhered to at least eight of the 10 Mindframe guidelines. Study 2 found an 11% increase in suicides in the five month period following Williams’ death, largely accounted for by men aged 30-64 years and by people who died by hanging (the method Williams used). Study 3 provided strong evidence of an increase in calls to Lifeline and Beyond Blue in the week after Williams’ suicide was reported. This levelled out over the ensuing month. Conclusion Australian newspaper reporting of Williams’ suicide was largely consistent with the Mindframe guidelines. Despite this, there were increases in suicides in the immediate aftermath of his death, which is obviously a negative outcome. There were also increases in calls to helplines, which may be interpreted either as negative (i.e., suggesting that people’s levels of distress and feelings of suicidality were heightened) or positive (i.e., suggesting that people who might have otherwise been influenced to harm themselves called a helpline instead). It may be that Australians were exposed to reports that contravened safe reporting recommendations, particularly via overseas media and social media or that some Australian reports may have had unhelpful overarching narratives, despite largely adhering to the Mindframe guidelines. The Mindframe guidelines constitute international best practice but consideration should be given to whether certain recommendations within them should be further reinforced and whether more nuanced information about how stories should be framed could be provided.
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    Quantification of the dynamics of antibody response to malaria in pregnant women
    Dharmaratne, Aluthwala Domingu Vithanage Tharkeshi Thanuja ( 2020)
    Malaria remains a major public health threat with pregnant women and young children the most vulnerable populations. Approximately 125 million pregnant women are at risk of malaria infection every year. Immunity to malaria can significantly reduce the severity of malaria symptoms. This has long motivated efforts to better understand the immune response to malaria in order to develop an efficacious antimalarial vaccine. However, the complex behaviour of the immune system, particularly in pregnant women, has hindered identifying the underpinning mechanisms of the immune response to malaria infection. This project investigates antibody-mediated immunity in pregnant women who attended antenatal clinics located at the Thai-Myanmar border, where malaria transmission is low and P. falciparum and P. vivax (the most prevalent malaria species globally) coexist. Antibody responses during pregnancy to six parasite antigens were measured for 250 pregnant women in a median of 7 samples per woman (range 2 to 13) over the gestation period. A multivariate mixture linear mixed model was fitted to longitudinal antibody data of 250 pregnant women to characterise the highly dynamic antibody responses using a Bayesian approach. The posterior distribution of the parameters estimated via Markov chain Monte Carlo (MCMC) simulations were used to classify the antibody responses. The results show that the infectious status of a woman during follow-up is a key factor influencing the classification of the joint behaviour of the antibody responses. Hence, the two malaria exposure categories (exposed to infection during pregnancy defined as a case and those non-exposed defined as controls) were represented by the two antibody profile clusters. Using a manually developed code, entropy values were computed for each antibody, with which, the contribution made by each antibody on the classification was assessed. The antibodies PfMSP3 and PvAMA1 which maintained less dynamic antibody profiles significantly influenced the classification. However, these antibodies identified controls exceptionally well but did not perform well for the cases. For sero-surveillance, antibodies which best identify the cases are required, hence, the study was extended in performing classification based on all possible univariate and multivariate combinations of the six antibodies. The bivariate combination PfAMA1 and PfVAR2CSA resulted in identifying the majority of cases by contributing towards identification of potential biomarker(s) for sero-surveillance of recent exposure to malaria during pregnancy. Therefore, the bivariate combination of antibodies, PfAMA1 and PfVAR2CSA should be used in the field, particularly for accurate malaria surveillance of pregnant women living in low malaria transmission settings. This could lead to the early detection and treatment of malaria infections in pregnant women, reducing transmission and thereby progressing towards elimination of malaria.
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    An exploration of key informant perspectives on factors influencing settlement of male Hazara youth who migrated to Melbourne as unaccompanied minors
    Kole, John Kirwa Tum ( 2020)
    Background: Globally, there has been an extraordinary growth in refugees and asylum-seekers in the past two decades. Australia experienced a dramatic increase in boat-arrivals in 2008–2013, with many being Afghan Hazara including unaccompanied asylum-seeker minors (UAMs). Global and Australian studies highlight the significance of providing UAMs with appropriate settlement services during their adjustment period, yet few ethno-specific studies have to date sought service provider perspectives on support provided to male Hazara UAMs pre-18 years and former UAMs (fUAMs) post-18 years. Methods: This qualitative study addressed this research gap using ecological systems theory and social networks theory in a dual-sector case study design to explore the perceptions of professional case workers (n=6) and voluntary English language teachers (n=6). Based on key informant views, this study focused on the expectations and experiences of male Hazara UAMs’ compared to fUAMs’ select settlement services during their early adjustment period (2015–2016) in Melbourne, Australia and how this support influences their settlement and wellbeing. Results: The findings indicate UAMs’ three-part migration trajectory (from Afghanistan, via transit countries to Australia) was perceived to be driven by classic push and pull factors and shaped by family separation. Following arrival, Australia’s immigration and settlement policies determined the type and level of support provision, with UAMs in community detention receiving maximum services while fUAMs in mainstream community being offered highly reduced services and temporary visas. English language was perceived to have strong influence on their early adjustment, and different forms of social networks could promote their socioeconomic participation. Despite UAMs experiencing potential risks pre-arrival, protective factors post-arrival, especially support services, could rebuild their resilience. Conclusion: This study has implications for asylum-seeker and settlement policies, casework practice, and researchers to leverage settlement process and wellbeing outcomes of this group of unaccompanied youths in Australia.
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    Comparing health services access across regions of Melbourne: a case study of diabetes services
    Madill, Rebecca ( 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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    The cure depends on us: the role of Australian patient organisations in rare disease research
    Pinto, Deirdre Frances ( 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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    What is the most suitable disease management model for COPD?: Identifying effective and cost-effective programs for treating COPD
    CHIU, I-LAN ( 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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    Primary health care workers’ perspectives on the introduction of an alcohol brief intervention program in Chile
    Correa del Rio, Maria Rebeca ( 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.