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Item Immunological failure in HIV-infected adults from 2003 to 2015 in Southwest Ethiopia: a retrospective cohort study(BMJ Publishing group, 2018-07-10) Gesesew, Hailay; Ward, Paul Russell; Woldemichael, Kifle; Mwanri, LillianObjective To assess the prevalence, trend and associated factors for immunological failure (IF), and the magnitude of antiretroviral therapy (ART) shift among adults infected with HIV in Southwest Ethiopia. Setting A retrospective cohort study was undertaken using the data from ART clinic at Jimma University Teaching Hospital from 21 June 2003 to 15 March 2015. Participants Retrospective analysis of 4900 HIV-infected adult patient records dating from June 2003 to March 2015 was conducted. Primary outcome measure The primary outcome was IF defined when cluster for differentiation 4 (CD4) count falls to the baseline (or below) or persistent CD4 levels below 100 cells/mm3 after 6 months of ART treatment. The analyses included descriptive and inferential statistics. Results 546 (19.5%) adults had developed clinical failure (CF), 775 (19.7%) adults had developed IF and 1231 (25.1%) had developed either CF or IF or both. The prevalence of IF was consistently high throughout the decade. Age 25 to ≤50 years adjusted OR (AOR 1.5, 9% CI 1.2 to 2.4), being female (AOR 1.8, 95% CI 1.3 to 1.9), late presenter for HIV care (AOR 2.2, 95% CI 1.6 to 2.7) and having baseline CD4 count below 200 cells/mm3 (AOR 5.5, 95% CI 4.1 to 7.4), and having no history of HIV testing before diagnosis (AOR 0.7, 95% CI 0.5 to 0.9) were the predictors for IF. Only 29 (0.9%) adults infected with HIV were shifted to second-line ART regimen. Conclusions The magnitude of CF or IF or both was found significant and consistently high throughout the calendar year although ART shift was found minimal. HIV-infected adult patients with IF were early age adults, females, late presenters for HIV care, and those who had low baseline CD4 counts and history of HIV testing before diagnosis.Item The acceptability of participating in data linkage research: research with older Australians(Wiley, 2018-06-12) Harrison, Stephanie L; Milte, Rachel; Bradley, Clare Eileen; Inacio, Maria C S; Crotty, MariaAustralians are increasingly concerned about the privacy of their data, but the biggest concerns relate to online services and identification fraud. Australians may be supportive of research that uses linked data; however, there have been conflicting findings as to whether formal consent from individuals should be sought, and the views of the older population have not been elicited specifically. A previous survey suggested half of Australians would expect consent to be sought for the use of de‐identified health information for research purposes, but the respondents were not specifically asked if they would expect an opt‐in or opt‐out approach to consent. The objectives of the current study were to determine if older Australians would find it acceptable to be part of the proposed registry and to explore different methods of consent.Item Ecosystem-based translation of health research: expanding frameworks for environmental health(Wiley, 2018-08-08) McFarlane, Rosemary; Butler, Colin David; Maynard, Simone; Cork, Steve; Weinstein, PhillipThe high capacity of science and health infrastructure in countries such as Australia has contributed to the relatively low public health impact of many environmental health hazards, including our endemic, wildlife‐origin zoonotic diseases. However, understanding how these and other health risks may be reduced within an ecosystem service framework will be increasingly valuable as climate change and pressures on natural environments intensify. Benefits could transcend national boundaries, especially if regional epicentres of ecological, political and social disintegration widen, creating milieux for potential pandemics. We are in a gainful position to progress research and translation of research into policy using the frameworks already available in Australia. This will be strengthened by promoting common language and metrics across disciplines and agencies, including costing that includes externalities and co‐benefits, and by supporting research into ecological linkage mechanisms and the broader ecosystem service ‘settings’ of health risks. Existing tools inclusive of stakeholder inputs can address ecosystem service trade‐offs. These can be used to identify or trial primordial preventative ‘eco‐social’ strategies. Aggregated, these have the potential to address GEC as health risk. We advocate concerted effort to refine these approaches and to promote a sense of urgency in their implementation.Item Real-world use of fidaxomicin in a large UK tertiary hospital: how effective is it for treating recurrent disease?(Elsevier, 2018-05-07) Enoch, David A; Santos, Reem; Phillips, Cameron J; Micallef, Christianne; Murphy, Michael E; Aliyu, Sani Hussein; Massey, Dunecan C O; Brown, Nicholas MAll courses of fidaxomicin use in the study hospital were reviewed. It was used for first recurrence (six times), second recurrence (eight times) and one case of third recurrence. One patients received fidaxomicin as first-line treatment. Eight patients initially responded to therapy; of these, three patients were asymptomatic at 90 days, three patients remained asymptomatic at 30 days, and two patients had recurrences five and nine days after stopping therapy. Four patients failed to respond; of these, two patients required faecal transplantation and one patient required a colectomy. Two patients deteriorated and two patients died. Fidaxomicin was well tolerated. These findings suggest that the utility of fidaxomicin at this stage of infection is unclear.Item Early mortality among children and adults in antiretroviral therapy programs in Southwest Ethiopia, 2003-15(Public Library of Science, 2018-06-18) Gesesew, Hailay; Ward, Paul Russell; Woldemichael, Kifle; Mwanri, LillianBackground Several studies reported that the majority of deaths in HIV-infected people are documented in their early antiretroviral therapy (ART) follow-ups. Early mortality refers to death of people on ART for follow up period of below 24 months due to any cause. The current study assessed predictors of early HIV mortality in Southwest Ethiopia. Methods We have conducted a retrospective analysis of 5299 patient records dating from June 2003- March 2015. To estimate survival time and compare the time to event among the different groups of patients, we used a Kaplan Meir curve and log-rank test. To identify mortality predictors, we used a cox regression analysis. We used SPSS-20 for all analyses. Results A total of 326 patients died in the 12 years follow-up period contributing to 6.2% cumulative incidence and 21.7 deaths per 1000 person-year observations incidence rate. Eighty-nine percent of the total deaths were documented in the first two years follow up—an early-term ART follow up. Early HIV mortality rates among adults were 50% less in separated, divorced or widowed patients compared with never married patients, 1.6 times higher in patients with baseline CD4 count <200 cells/μL compared to baseline CD4 count ≥200 cells/μL, 1.5 times higher in patients with baseline WHO clinical stage 3 or 4 compared to baseline WHO clinical stage 1 or 2, 2.1 times higher in patients with immunologic failure compared with no immunologic failure, 60% less in patients with fair or poor compared with good adherence, 2.9 times higher in patients with bedridden functional status compared to working functional status, and 2.7 times higher with patients who had no history of HIV testing before diagnosis compared to those who had history of HIV testing. Most predictors of early mortality remained the same to the predictors of an overall HIV mortality. When discontinuation was assumed as an event, the predictors of an overall HIV mortality included age between 25–50 years, base line CD4 count, developing immunologic failure, bedridden functional status, and no history of HIV testing before diagnosis. Conclusions The great majority of deaths were documented in the first two years of ART, and several predictors of early HIV mortality were also for the overall mortality when discontinuation was assumed as event or censored. Considering the above population, interventions to improve HIV program in the first two years of ART follow up should be improved.Item The health and wellbeing needs of veterans: a rapid review(BMC, 2017-12-29) Oster, Candice; Morello, Andrea; Venning, Anthony; Redpath, Paula; Lawn, Sharon JoyBackground: For the majority of serving members, life in the military has a positive effect on wellbeing. However, the type, intensity and duration of service, along with the transition from fulltime military to civilian life, may have a negative effect on veterans’ wellbeing. Such negative consequences, alongside the growing veteran population, indicate the need for greater exploration of veterans’ physical, mental and social wellbeing. Methods: The current paper reports on the findings of a rapid review of the literature on the health and wellbeing needs of veterans, commissioned by the Australian Department of Veterans’ Affairs to inform future programs and services. The databases Embase, Medline, Cinahl, PubMed, Web of Science and Cochrane Database were searched for systematic reviews reporting on veterans’ physical, mental and social wellbeing published in English in peerreviewed journals. Results: A total of 21 systematic reviews were included. The reviews reported on a range of mental, physical and social health problems affecting veterans. While there was limited information on prevalence rates of physical, mental and social health problems in veterans compared to civilian populations, the reviews demonstrated the interconnection between these domains and the effect of demographic and military service factors. Conclusions: A key finding of the review is the interconnection of the mental, physical, and social health of veterans, highlighting the importance that an integrated approach to veterans’ wellbeing is adopted. It is suggested that understanding key factors, such as demographic factors and factors relating to military service, can support improved service provision for veterans.Item Perceptions of Determinants of Condom Use Behaviors Among Male Clients of Female Sex Workers in Indonesia: A Qualitative Inquiry(SAGE Publications, 2018-01-03) Fauk, Nelsensius Klau; Kustanti, Christina Yeni; Liana, Debora Shinta; Indriyawati, Nina; Crutzen, Rik; Mwanri, LillianThis study aimed to explore perceived determinants of condom use behaviors among male clients of female commercial sex workers (FCSWs) in Belu and Malaka districts, Indonesia. One-on-one in-depth interviews guided by the Health Belief Model (HBM) were used to collect the data from participants (n = 42). The Framework analysis for qualitative data was employed to analyze the data. Results demonstrated several factors associated with lack of and inconsistent condom use among the participants. They included self-perceived risk of contracting HIV infection, knowledge of the severity of HIV illness and its impacts, and condom use: its benefits and its influencing factors. Additionally, factors including reduced sexual pleasure and the lack of knowledge of how and where to access condoms were important perceived barriers to condom use among participants. Having seen images of HIV-/AIDS-positive people, knowing friends and relatives suffering from HIV, and knowing FCSWs as a high-risk group for HIV infection were the cues to using condoms among several participants. Likewise, self-efficacy was also associated with condom use behaviors among the participants. The findings indicate the needs for HIV/AIDS interventions that include dissemination of HIV/AIDS knowledge, condom promotion, and improvement in the availability of condoms for both FCSWs and their clients.Item The Intention of Men Who Have Sex With Men to Participate in Voluntary Counseling and HIV Testing and Access Free Condoms in Indonesia(SAGE Publications, 2018-05-02) Fauk, Nelsensius Klau; Sukmawati, Anastasia S; Wardojo, Sri S I; Teli, Margareta; Bere, Yoh Kennedy; Mwanri, LillianThis study aimed to identify factors that influenced the intention of men who have sex with men (MSM) to participate in voluntary counseling and HIV testing (VCT) and in accessing free condoms. A qualitative inquiry using one-on-one in-depth interviews was conducted with MSM participants who were recruited using a purposive sampling technique. Data analysis was guided by a framework analysis for qualitative data by Ritchie and Spencer, and the Theory of Planned Behavior (TPB) framework was used to analyze the data. The findings were grouped into three themes—namely, (a) attitude encompassing knowledge about HIV/AIDS and HIV/AIDS services and the belief about the positive outcomes of the services; (b) subjective norms including support from MSM peers and family members and motivation to comply with the support; and (c) perceived behavioral control, which is associated with resource availability and having confidence and positive intention to participate in VCT and willingness to access free condoms. Findings indicated that personal, community, and structural factors were predictors to intention to accessing services. Interventions targeting large numbers of MSM population and further studies to understand what needs to be done by nongovernmental organizations and governmental institutions to halt the spread of HIV infections among MSM populations and increase their intention to use HIV/AIDS services are also recommended.Item Charitable food systems’ capacity to address food Insecurity: an Australian capital city audit(MDPI, 2018-06-12) Pollard, Christina M; Mackintosh, Bruce; Campbell, Cathy; Kerr, Deborah A; Begley, Andrea; Jancey, Jonine; Caraher, Martin; Berg, Joel; Booth, SueAustralian efforts to address food insecurity are delivered by a charitable food system (CFS) which fails to meet demand. The scope and nature of the CFS is unknown. This study audits the organisational capacity of the CFS within the 10.9 square kilometres of inner-city Perth, Western Australia. A desktop analysis of services and 12 face-to-face interviews with representatives from CFS organisations was conducted. All CFS organisations were not-for–profit and guided by humanitarian or faith-based values. The CFS comprised three indirect services (IS) sourcing, banking and/or distributing food to 15 direct services (DS) providing food to recipients. DS offered 30 different food services at 34 locations feeding over 5670 people/week via 16 models including mobile and seated meals, food parcels, supermarket vouchers, and food pantries. Volunteer to paid staff ratios were 33:1 (DS) and 19:1 (IS). System-wide, food was mainly donated and most funding was philanthropic. Only three organisations received government funds. No organisation had a nutrition policy. The organisational capacity of the CFS was precarious due to unreliable, insufficient and inappropriate financial, human and food resources and structures. System-wide reforms are needed to ensure adequate and appropriate food relief for Australians experiencing food insecurity.Item Impact of oropharyngeal dysphagia on healthcare cost and length of stay in hospital: a systematic review(BioMed Central, 2018-08-02) Attrill, Stacie Lorraine; White, Sarahlouise; Murray, Jo; Hammond, Sue; Doeltgen, SebastianBackground Healthcare systems internationally are under an ever-increasing demand for services that must be delivered in an efficient, effective and affordable manner. Several patient-related and organisational factors influence health-care expenditure and utilisation, including oropharyngeal dysphagia. Here, we present a systematic review of the literature and meta-analyses investigating how oropharyngeal dysphagia influences healthcare utilisation through length of stay (LOS) and cost. Methods Using a standardised approach, eight databases were systematically searched for relevant articles reporting on oropharyngeal dysphagia attributable inpatient LOS and healthcare costs through June 2016. Study methodologies were critically appraised and where appropriate, extracted LOS data were analysed in an overall summary statistic. Results Eleven studies reported on cost data, and 23 studies were included reporting on LOS data. Descriptively, the presence of dysphagia added 40.36% to health care costs across studies. Meta-analysis of all-cause admission data from 13 cohort studies revealed an increased LOS of 2.99 days (95% CI, 2.7, 3.3). A subgroup analysis revealed that admission for stroke resulted in higher and more variable LOS of 4.73 days (95% CI, 2.7, 7.2). Presence of dysphagia across all causes was also statistically significantly different regardless of geographical location: Europe (8.42 days; 95% CI, 4.3; 12.5), North America (3.91 days; 95% CI, 3.3, 4.5). No studies included in meta-analysis were conducted in Asia. Conclusions This systematic review demonstrated that the presence of oropharyngeal dysphagia significantly increases healthcare utilisation and cost, highlighting the need to recognise oropharyngeal dysphagia as an important contributor to pressure on healthcare systems.Item “I aspire to look and feel healthy like the posts convey”: engagement with fitness inspiration on social media and perceptions of its influence on health and wellbeing(BioMed Central, 2018-08-10) Raggatt, Michelle; Wright, Cassandra J C; Carrotte, Elise; Jenkinson, Rebecca; Mulgrew, Kate; Prichard, Ivanka Joyce; Lim, Megan S CBackground Fitspiration is a popular social media trend containing images, quotes and advice related to exercise and healthy eating. This study aimed to 1) describe the types of fitspiration content that users access and how they engage with content, 2) investigate the disordered eating and exercise behaviours and psychological distress of individuals who access fitspiration, and 3) understand the perceived influence of fitspiration on health and wellbeing. Methods Participants who access fitspiration content were recruited via social media to complete a cross-sectional online survey. Participants’ psychological distress was measured using the Kessler 10 Psychological Distress Scale (K10); disordered eating behaviours using the Eating Attitudes Test-26 (EAT-26); and compulsive exercise behaviours using the Exercise Addiction Inventory (EAI). Participants also answered a series of open-ended questions about their experiences with fitspiration. A descriptive statistical analysis was conducted for quantitative data. Responses to open-ended questions were analysed for key themes using an iterative process of open, axial and thematic coding. Results Participants (N = 180, 151 female, median age 23.0 years (IQR 19.0, 28.5)) most commonly accessed content posted by personal trainers and athletes (59.4%), posts tagged with the ‘fitspiration’ hashtag (53.9%) and posted by ‘everyday’ people (53.3%). Overall, 17.7% of participants were classified as high risk for an eating disorder, 17.4% reported very high levels of psychological distress, and 10.3% were at risk of addictive exercise behaviours. Participants described both positive and negative influences of engaging with fitspiration content. The influence on their health beliefs and behaviours was explained through four key themes: 1) Setting the ‘healthy ideal’, 2) Failure to achieve the ‘ideal’, 3) Being part of a community, and 4) Access to reliable health information. Conclusions Many participants reported benefits of fitspiration content including increased social support and access to health information. However, participants also reported that fitspiration content could negatively influence their wellbeing and perception of healthy goals. Content posted by relatable individuals or qualified experts was perceived as most trustworthy. Future research is needed to determine the individual and content-related factors associated with negative and positive fitspiration experiences.Item Online platform for healthy weight loss in adults with overweight and obesity - the “POEmaS” project: a randomized controlled trial(BioMed Central, 2018-08-01) Beleigoli, Alline M; Queiroz de Andrade, Andre; Haueisen Diniz, Maria de Fátima; Alvares, Roberta S; Ribeiro, Antonio LBackground Obesity is a major health problem in Brazil affecting 19% of Brazilian adults with a rising incidence over the last 10 years. Moreover, low fruit/vegetables consumption and high sweetened beverage intake are major issues. Facing the challenge of universal healthcare access, internet-based programs have the potential to reach a large number of inhabitants, be widely accessible and cost effective. Our aim is to assess the efficacy of a web-based platform to promote weight loss and diet and physical activity habits change in a Brazilian adult population. Methods We designed a three-arm parallel randomized controlled trial including 18–60 years university students or employees with 25 kg/m2 minimum body mass index (BMI). Pregnancy, conditions with specific dietary requirements and participation in other weight loss programs are exclusion criteria. Participants are allocated to one of three groups: (1) waitlist with minimal intervention, (2) web-based platform, (3) web-based platform plus online dietician assistance. Assessors are blinded. Weight and BMI loss are the primary outcomes. Diet and physical activity behaviours, health perception and online activity features are secondary outcomes. The intervention comprises recommendations of diet and physical activity habits tailored to the Brazilian population and principles of behaviour change. The web-based platform has online social network and gamification features. Analysis will be on an intention-to-treat basis at 12 and 24 weeks after baseline. Differences in weight loss between groups will be performed by analysis of covariate. Linear regression will be used to assess whether treatment group allocation is an independent predictor of weight loss. The study was approved by the Federal University of Minas Gerais (UFMG) Ethics Research Committee. All participants signed an informed consent form prior to recruitment. Discussion We present the study protocol of a three arm parallel randomized controlled trial which aims to test the efficacy of an online platform to promote weight loss for adults with overweight and obesity. We anticipate that the adoption of healthy lifestyle habits and weight loss will be more important in participants randomized to the online platform group.Item The relationship between anticipated response and subsequent experience of cancer treatment-related side effects: A meta-analysis comparing effects before and after treatment exposure(Elsevier, 2018-06-14) Fletcher, Chloe; Wilson, Carlene J; Hutchinson, Amanda; Grunfeld, Elizabeth AliceObjective To review the evidence for a systematic relationship between cancer patients’ pre-treatment expectations (anticipated side effects) and subsequent experience of treatment-related side effects, and to compare this relationship in patients with no prior treatment experience (cognitive expectations) and with some prior treatment experience (conditioned response). Methods A total of 12,952 citations were identified through a comprehensive search of the literature published on or before November 2016 and screened against inclusion criteria. Studies were eligible if they included participants undergoing curative treatment for cancer, measured a treatment side effect, examined the relationship between anticipation and experience of side effects, and reported quantitative data. Results Thirty-one studies were included in the review and meta-analysis (total N = 5069). The side effects examined were nausea (anticipatory and post-treatment), vomiting, fatigue, pain, problems with concentration, and skin reactions. Meta-analyses indicated positive associations between anticipation and subsequent experience for all included side effects in patients with no prior treatment exposure (r = 0.153–0.431). Stronger associations were found for all included side effects in patients with previous treatment experience (r = 0.211–0.476), except for fatigue (r = 0.266) and pain (r = 0.235). No significant differences were found when overall effect sizes for patients with and without prior treatment exposure were compared for each side effect, except for anticipatory nausea (p = 0.012). Conclusion These results may have implications for future interventions that target patients’ expectations of cancer treatment-related side effects. Future research could explore patient reports of messages received about likely treatment effects both before and during treatment.Item Pilot test of brief instructions to improve the self-management of general food cravings(Elsevier, 2018-05-29) Chapman, Janine; Zientara, Jacquelyn; Wilson, Carlene JObjective. To provide a preliminary investigation into the impact of brief online acceptance-based vs. control-based techniques to self-manage food cravings in women. Method. Female participants (N = 151) were randomised to ‘acceptance’ or ‘control’ groups. Measures of general food cravings (primary outcome), and depression, anxiety and stress (secondary outcomes) were taken at baseline, two weeks and four weeks. Results. Linear mixed models showed a significant group x time interaction, with food cravings significantly reduced in the thought-control group compared to the acceptance group over four weeks, along with a reduction in food consumption. Levels of depression, anxiety and stress decreased over the course of the study, but did not differ by group. Conclusion: These findings provide preliminary support for the acceptability of a minimal technique to self-manage food cravings without deleterious effects, and suggest that simple control-based techniques may be useful in non-clinical, real-world settings.Item What is the overall impact or effectiveness of visiting primary health care services in rural and remote communities in high-income countries? A systematic review(BioMed Central, 2018-06-19) Carey, Timothy; Sirett, David; Russell, Deborah J; Humphreys, John S; Wakerman, JohnAbstract Background Visiting services address the problem of workforce deficit and access to effective primary health care services in isolated remote and rural locations. Little is known about their impact or effectiveness and thereby the extent to which they are helping to reduce the disparity in access and health outcomes between people living in remote areas compared with people living in urban regions of Australia. The objective of this study was to answer the question “What is the impact or effectiveness when different types of primary health care services visit, rather than reside in, rural and remote communities?” Method We conducted a systematic review of peer-reviewed literature from established databases. We also searched relevant websites for ‘grey’ literature and contacted several key informants to identify other relevant reference material. All papers were reviewed by at least two assessors according to agreed inclusion and exclusion criteria. Results Initially, 345 papers were identified and, from this selection, 17 papers were considered relevant for inclusion. Following full paper review, another ten papers were excluded leaving seven papers that provided some information about the impact or effectiveness of visiting services. The papers varied with regard to study design (ranging from cluster randomised controlled trials to a case study), research quality, and the strength of their conclusions. In relation to effectiveness or impact, results were mixed. There was a lack of consistent data regarding the features or characteristics of visiting services that enhance their effectiveness or impact. Almost invariably the evaluations assessed the service provided but only two papers mentioned any aspect of the visiting features within which service provision occurred such as who did the visiting and how often they visited. Conclusions There is currently an inadequate evidence base from which to make decisions about the effectiveness of visiting services or how visiting services should be structured in order to achieve better health outcomes for people living in remote and rural areas. Given this knowledge gap, we suggest that more rigorous evaluation of visiting services in meeting community health needs is required, and that evaluation should be guided by a number of salient principles.Item Factors that impact access to ongoing health care for First Nation children with a chronic condition(2018-06-14) Coombes, Julieann; Hunter, Kate; Ivers, Rebecca; MacKean, Tamara Jade; Holland, Andrew J A; Sullivan, Elizabeth; Ivers, RebeccaAbstract Background Access to multidisciplinary health care services for First Nation children with a chronic condition is critical for the child’s health and well-being, but disparities and inequality in health care systems have been almost impossible to eradicate for First Nation people globally. The objective of this review is to identify the factors that impact access and ongoing care for First Nation children globally with a chronic condition. Methods An extensive systematic search was conducted of nine electronic databases to identify primary studies that explored factors affecting access to ongoing services for First Nation children with a chronic disease or injury. Due to the heterogeneity of included studies the Mixed Method Appraisal Tool (MMAT) was used to assess study quality. Results A total of six studies from Australia, New Zealand and Canada were identified and included in this review. Four studies applied qualitative approaches using in-depth semi structured interviews, focus groups and community fora. Two of the six studies used quantitative approaches. Facilitators included the utilisation of First Nation liaison workers or First Nation Health workers. Key barriers that emerged included lack of culturally appropriate health care, distance, language and cultural barriers, racism, the lack of incorporation of First Nation workers in services, financial difficulties and transport issues. Conclusion There are few studies that have identified positive factors that facilitate access to health care for First Nation children. There is an urgent need to develop programs and processes to facilitate access to appropriate health care that are inclusive of the cultural needs of First Nation children.Item Context matters for primary health care access: a multi-method comparative study of contextual influences on health service access arrangements across models of primary health care(BioMed Central, 2018-06-15) Ward, Bernadette; Lane, Riki; McDonald, Julie; Powell-Davies, Gawaine; Fuller, Jeffrey; Dennis, Sarah; Kearns, Rachael; Russell, GrantAbstract Background Equitable access to primary health care (PHC) is an important component of integrated chronic disease management. Whilst context is known to influence access to PHC, it is poorly researched. The aim of this study was to determine the contextual influences associated with access arrangements in four Australian models of integrated PHC. Methods A multi-method comparative case study design. Purposive sampling identified four models of PHC across six sites in two Australian states. Complexity theory informed the choice of contextual factors that influenced access arrangements, which were analysed across five dimensions: availability and accommodation, affordability, acceptability, appropriateness and approachability. Semi-structured interviews, document/website analysis and non-participant observation were used to collect data from clinicians, administrative staff and other key stakeholders. Within and cross-case thematic analysis identified interactions between context and access across sites. Results Overall, financial viability, objectives of the PHC model and relationships with the local hospital network (LHN) underpinned access arrangements. Local supply of general practitioners and financial viability were strong influences on availability of after-hours services. Influences on affordability were difficult to determine because all models had nil/low out-of-pocket costs for general practitioner services. The biggest influence on acceptability was the goal/objectives of the PHC model. Appropriateness and to a lesser degree affordability arrangements were influenced by the relationship with the LHN. The provision of regular outreach services was strongly influenced by perceived population need, referral networks and model objectives. Conclusions These findings provide valuable insights for policy makers charged with improving access arrangements in PHC services. A financially sustainable service underpins attempts to improve access that meets the needs of the service population. Smaller services may lack infrastructure and capacity, suggesting there may be a minimum size for enhancing access. Access arrangements may be facilitated by aligning the objectives between PHC, LHN and other stakeholder models. While some access arrangements are relatively easy to modify, improving resource intensive (e.g. acceptability) access arrangements for vulnerable and/or chronic disease populations will require federal and state policy levers with input from primary health networks and LHNs.Item Barriers to HIV testing among male clients of female sex workers in Indonesia(BioMed Central, 2018-05-30) Fauk, Nelsensius Klau; Sukmawati, Anastasia S; Berek, Pius A L; Ernawati; Kristanti, Elisabeth; Wardojo, Sri S I; Cahaya, Isaias B; Mwanri, LillianAbstract Background Frequent engagement of men in sexual encounters with female sex workers (FSWs) without using condoms places them at a high risk for HIV infection. HIV testing has been noted to be among important strategies to prevent HIV transmission and acquisition. However, it is known that not all men willingly undertake an HIV test as a way to prevent HIV transmission and/or acquisition. This study aimed to identify barriers to accessing HIV testing services among men who are clients of FSWs (clients) in Belu and Malaka districts, Indonesia. Methods A qualitative inquiry employing face to face open ended interviews was conducted from January to April 2017. The participants (n = 42) were clients of FSWs recruited using purposive and snowball sampling techniques. Data were analysed using a qualitative data analysis framework. Results Findings indicated three main barriers of accessing HIV testing services by clients. These included: (1) personal barriers (lack of knowledge of HIV/AIDS and HIV testing availability, and unwillingness to undergo HIV testing due to low self-perceived risk of HIV and fear of the test result); (2) health care service provision barriers (lack of trust in health professionals and limited availability of medication including antiretroviral (ARV)); and (3) social barriers (stigma and discrimination, and the lack of social supports). Conclusions These findings indicated multilevelled barriers to accessing HIV testing services among participants, who are known to be among key population groups in HIV care. Actions to improve HIV/AIDS-related health services accessibility are required. The dissemination of the knowledge and information on HIV/AIDS and improved available of HIV/AIDS-related services are necessary actions to improve the personal levelled barriers. System wide barriers will need improved practices and health policies to provide patients friendly and accessible services. The societal levelled barriers will need a more broad societal approach including raising awareness in the community and enhanced discussions about HIV/AIDS issues in order to normalise HIV in the society.Item Burden of disease attributable to suboptimal diet, metabolic risks and low physical activity in Ethiopia and comparison with Eastern sub-Saharan African countries, 1990–2015: findings from the Global Burden of Disease Study 2015(BioMed Central, 2018-04-25) Melaku, Yohannes Adama; Wassie, Molla Mesele; Gill, Tiffany; Zhou, Shao J; Tessema, Gizachew Assefa; Amare, Azmeraw T; Lakew, Yihunie; Hiruye, Abiy; Bekele, Tesfaye Hailu; Worku, Amare; Seid, Oumer; Endris, Kedir; Lemma, Ferew; Tesfay, Fisaha Haile; Yirsaw, Biruck Desalegn; Deribe, Kebede; Adams, Robert J; Shi, Zumin; Misganaw, Awoke; Deribew, AmareAbstract Background Twelve of the 17 Sustainable Development Goals (SDGs) are related to malnutrition (both under- and overnutrition), other behavioral, and metabolic risk factors. However, comparative evidence on the impact of behavioral and metabolic risk factors on disease burden is limited in sub-Saharan Africa (SSA), including Ethiopia. Using data from the Global Burden of Disease (GBD) Study, we assessed mortality and disability-adjusted life years (DALYs) attributable to child and maternal undernutrition (CMU), dietary risks, metabolic risks and low physical activity for Ethiopia. The results were compared with 14 other Eastern SSA countries. Methods Databases from GBD 2015, that consist of data from 1990 to 2015, were used. A comparative risk assessment approach was utilized to estimate the burden of disease attributable to CMU, dietary risks, metabolic risks and low physical activity. Exposure levels of the risk factors were estimated using spatiotemporal Gaussian process regression (ST-GPR) and Bayesian meta-regression models. Results In 2015, there were 58,783 [95% uncertainty interval (UI): 43,653–76,020] or 8.9% [95% UI: 6.1–12.5] estimated all-cause deaths attributable to CMU, 66,269 [95% UI: 39,367–106,512] or 9.7% [95% UI: 7.4–12.3] to dietary risks, 105,057 [95% UI: 66,167–157,071] or 15.4% [95% UI: 12.8–17.6] to metabolic risks and 5808 [95% UI: 3449–9359] or 0.9% [95% UI: 0.6–1.1] to low physical activity in Ethiopia. While the age-adjusted proportion of all-cause mortality attributable to CMU decreased significantly between 1990 and 2015, it increased from 10.8% [95% UI: 8.8–13.3] to 14.5% [95% UI: 11.7–18.0] for dietary risks and from 17.0% [95% UI: 15.4–18.7] to 24.2% [95% UI: 22.2–26.1] for metabolic risks. In 2015, Ethiopia ranked among the top four countries (of 15 Eastern SSA countries) in terms of mortality and DALYs based on the age-standardized proportion of disease attributable to dietary and metabolic risks. Conclusions In Ethiopia, while there was a decline in mortality and DALYs attributable to CMU over the last two and half decades, the burden attributable to dietary and metabolic risks have increased during the same period. Lifestyle and metabolic risks of NCDs require more attention by the primary health care system of the country.Item The Effects of Housing on Health and Health Risks in an Aging Population: A Qualitative Study in Rural Thailand(Hindawi, 2014-07-02) Somrongthong, Ratana; Dullyaperadis, Saovalux; Wulff, Anne Louise; Ward, Paul RussellBackground. Over the last decade, Thailand has experienced an aging population, especially in rural areas. Research finds a strong, positive relationship between good quality housing and health, and this paper assesses the impact and living experience of housing of older people in rural Thailand. Methods. This was a mixed-method study, using data from observations of the physical adequacy of housing, semistructured interviews with key informants, and archival information from health records for 13 households in rural Thailand. Results. There were four main themes, each of which led to health risks for the older people: “lighting and unsafe wires,” “house design and composition,” “maintenance of the house,” and “health care equipment.” The housing was not appropriately designed to accommodate health care equipment or to fully support individual daily activities of older people. Numerous accidents occurred as a direct result of inadequate housing and the majority of houses had insufficient and unsafe lighting, floor surfaces and furniture that created health risks, and toilets or beds that were at an unsuitable height for older people. Conclusion. This paper provides an improved and an important understanding of the housing situation among older people living in rural areas in Thailand.