Melbourne School of Population and Global Health - Theses
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ItemKoori kids and otitis media prevention in Victoria( 2007)Otitis media and consequent hearing loss are known to be high in Koori communities. Previous research on otitis media in Koori communities has focused on its identification, treatment and management. Little research has focused on the prevention of otitis media. Victorian Aboriginal communities often have small populations which result in small sample sizes for research projects. Consequently use of traditional quantitative methods to measure of change arising from health interventions can be problematic. The aim of the research was to describe Koori children’s otitis media risk factors using a Koori research method in order to develop, implement and evaluate preventative interventions.
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ItemMarkers of midlife: interrogating health, illness and ageing in rural Australia( 2007-06)The aim of this thesis is to explore rural women’s midlife experiences and interrogate the roles of health, social and community factors in these. In the cultural imagination, midlife signifies the onset of ageing and is thus framed in a discourse of decline. For women, it is often considered in terms of menopause and the end of fecundity and fertility. I propose that women’s experience of midlife is much broader than this; instead, it is characterised by transformation in multiple domains and health status is important. I suggest that the continuity theory of ageing is useful when conceptualising the life course. The concept of habitus enables exploration of how identity is re/constructed during the ageing process in response to changing bodily circumstances, such as health problems. (For complete abstract open document)
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ItemMental health care roles and capacities of non-medical primary health and social care services: an organisational systems analysis( 2007-05)Top-down, centralised approaches to reform of mental health services implemented over the past 15 years in Australia have failed to achieve the widely shared aim of comprehensive, integrated systems of care. Investment to date has focused on the development and integration of specialist mental health services and primary medical care, and evaluation research suggests some progress. Substantial inadequacies remain however in the comprehensiveness and continuity of care received by people affected by mental health problems, particularly in relation to social and psychosocial interventions. Intersectoral collaboration that includes the diverse range of non-medical primary health and social care services is one of the most fundamental remaining challenges facing mental health system reform.
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ItemDevelopment and evaluation of a training program in cross-cultural psychiatric assessment for crisis assessment and treatment teams (CATTs)( 2005-02)The aim of the current project was to improve the cross-cultural clinical competence of mental health staff in Victoria’s Crisis Assessment and Treatment Teams (CATTs) by developing, delivering and evaluating a training program in Cross-Cultural Psychiatric Assessment (CPA). The project was guided by a program logic framework. A literature review demonstrated cross-cultural differences in manifestations of mental disorders and disparities in mental health service provision to racial and ethnic groups, suggesting clinician bias, unfamiliarity with cross-cultural manifestations, or delayed help-seeking by ethnic groups. No research has been identified into crisis service provision to ethnic communities. (For complete abstract open document)
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ItemRace, racism, stress and Indigenous health( 2006)This thesis is a transdisciplinary study aimed at exploring the role of race, racism and stress as determinants of health for indigenous populations and other oppressed ethnoracial groups. Commencing with an analysis of continuing racialisation in health research, it is shown that there is no consistent evidence that oppressed ethnoracial groups, who suffer disproportionately from type 2 diabetes, are especially genetically susceptible to this disease. Continued attribution of ethnoracial differences in health to genetics highlights the need to be attentive to both environmental and genetic risk factors operating within and between ethnoracial groups. This exploration of racialisation is followed by a theoretical examination of racism as a health risk factor. This includes a comprehensive definition of racism, a diagrammatic representation of the aetiological relationship between racism and health and an examination of the dimensions across which perceived racism can be operationalised. An empirical review of 138 quantitative population-based studies of self-reported racism as a determinant of health reveals that self-reported racism is related to ill-health (particularly mental health) for oppressed ethnoracial groups after adjustment for a range of confounders. This review also highlights a number of limitations in this nascent field of research. This thesis then attempts to clarify the plethora of conceptual approaches used in the study of stress and health as a first step towards comprehending how stress interacts with both racism and health. A review of the empirical association between stress and chronic disease for fourth world indigenous populations and African Americans was also conducted. This review, which located 65 studies, found that a range of chronic diseases (especially chronic mental conditions) were associated with psychosocial stress. Utilising the conceptual work on operationalising racism discussed above, an instrument was developed to measure racism and its correlates as experienced by Indigenous Australians. This instrument demonstrated good face, content, psychometric and convergent validity in a pilot study involving 312 Indigenous Australians. The majority of participants in this study (70%) reported some experience of inter-personal racism, with this exposure most commonly reported in employment and public settings, from service providers and from other Indigenous people. Strong and consistent associations were found between racism and chronic stress as well as between racism and depression (CES-D), poor/fair self-assessed health status/poor general mental health (SF-12) and a marker of CVD risk (homocysteine), respectively. There was also evidence that the association between inter-personal racism and poor mental health outcomes was mediated by somatic and inner-directed disempowered reactions to racism as well as by chronic stress and a range of psychosocial characteristics. To conclude this thesis, an examination of approaches to addressing racism for Indigenous Australians is undertaken. The theoretical issues pertinent to the study of anti-racism are discussed along with empirical findings from social psychology on effective approaches to anti-racism. Recommendations for implementing these approaches through institutional and legal policies are also presented. Strategies for engendering political will to combat racism in the current neo-liberal capitalist climate are also briefly considered.
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ItemOverseas doctors in Australian hospitals: an ethnographic study of how degrees of difference are negotiated in medical practice( 2009)In this thesis I ethnographically examine overseas doctors' negotiations of hospital settings that are similar, yet simultaneously unfamiliar, to those they have previously known. The study foregrounds the social labour involved in moving medical practices from one clinical context to another, a process too often hidden from view in the myth of medical universalism. The stories take place in hospitals on the metropolitan fringes of a large city in Australia. The research assumes that doctors with overseas (i.e. non-Australian/New Zealand) medical qualifications have developed a different set of practices to 'locals' because they have received their education and training in medical places 'elsewhere'. In the thesis, I argue that overseas doctors negotiate these various differences with modes of adjustment. I examine adjustment as an embodied, sensory and situated process that entails constant threading between the overseas doctors' past and the environment they find themselves part of, revealing something of both along the way. The overseas doctors' new environment is one that includes an evolving arrangement of people and paperwork, registration and assessment procedures, and buildings and tools. Whilst adjustment to these human and non-human aspects of a doctor's ecological terrain is an everyday event in medicine, I suggest that it is made more obvious by international migration, by practitioners who do not take their new environments for granted. For overseas doctors, subtle variation can mean an exciting, yet more often unsettling world of difference. This research highlights the contextual nature of medical practice, exploring its embeddedness within a multifarious environment. At the same time, the thesis departs from the majority of literature on overseas doctors, and skilled migrants more generally, that regards their skills as too context specific, thus requiring their integration into a nationally distinct system through the acquisition of nationally distinct practices. With this thesis I contribute an empirically and theoretically rich analysis that provides a more nuanced perspective of this political issue in Australia (and other 'receiving countries'). It is a thesis that will be of interest to migration and organisational researchers, medical educationalists, sociologists and anthropologists of science and medicine, individuals and organisations concerned with the steadily growing number of overseas doctors working in hospitals around the world, and last, but not least, overseas doctors themselves.
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ItemPractising surgery: a history of surgical training in Australia, 1927-1974( 2003)This thesis set out to examine the extraordinary degree of control that Australian surgeons have over their own training process and to ask how and why this has arisen. The Royal Australasian College of Surgeons was founded in 1927 and from an early date concerned itself with teaching and training as well as accrediting surgeons. Over the next forty years, a number of different models of surgical education were trialled, often closely following British ideas, but none had more than limited success. The model of training that finally found favour with trainee surgeons and public hospitals in the early 19705 owed much to the "long residency" pattern of training that was proving successful in the United States. However, in Australia, in contrast to the situation in the United States and Britain, the training agenda has been set almost exclusively by the body representing surgeons. Between 1927 and 1975, relatively little attention was given to teaching the manual skills involved in operating. Greater importance was attached to teaching and examining in the "science" of surgery and to the acquisition of "clinical judgment". Training in surgery involved what was generally described as an "apprenticeship", practising surgery on public hospital patients. The reasons why surgery was not practised on private patients (or cadavers, or animals) lay in the deep-seated cultural attitudes to public hospital patients within the moral economy of the hospital. When the College managed to set up a coherent training program in the early 1970s, it was allowed to control this training—by governments, hospitals, the universities and surgeons—partly because it was the only body that had shown sustained interest in the issue in the past, and partly because it had succeeded in capturing and holding the moral high ground in Australian surgery. It achieved this largely through its use of the moral economy of the gift. Most surgical training took place in public hospitals, where it relied on the gift by the patients who allowed themselves to be practised upon, and the gift by surgeons, who were not paid to teach. The only other organisations that were involved in providing any surgical education—the universities and State postgraduate committees—could not match the College's ability to mobilise surgeons and persuade them to form the unpaid workforce for its training program. However, as the thesis progressed, the unacknowledged role of the patient in training came to seem increasingly important. Consequently, it is suggested that in future the role of patients in the gift exchanges surrounding training should be explicitly recognised. It is proposed that surgeons should acknowledge that they need patients for their training, that they should invite both public and private patients to participate, and that they should thank them for doing so.
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ItemStill me: being old and in care: the role of social and communicative interactions in maintaining sense of self and well-being in residents in aged care( 2006)This ethnographic nursing home study explores the meaning which residents make of being old and in care. Its primary focus is on the role of social and communicative interactions in maintaining residents’ sense of self. Throughout the thesis I argue that the self is socially constructed, narratively communicated and is continuous throughout the life span. This narrative, relational self is diminished in old age by bereavement and the loss of social networks, and threatened by the loneliness and isolation of the institutional environment. Nonetheless, despite the stripping of relational layers entailed in the loss of the people with whom the younger self was constructed, there is a continuing core of self which, while bending, does not break. I argue that the nursing home can be a site of recovery for this vulnerable, diminished self, offering support and the opportunity to take on new roles and form new relationships, and through these relationships, new layers of self. Staff are key players in the healing process, and staff-resident relationships important new sources of meaning for the relational self. The ageing, marginalised self is strengthened through empathetic communication which recognises the individual person and the importance of that individual’s life, acknowledges residents’ adult status, and enhances self-esteem by enhancing personal control. For residents, telling their stories and remembering their past lives provides a means of making sense of where and who they are in the present, and of envisaging a future. Consequently, it is vital that residents have opportunities to speak and be heard, and to be recognised and spoken to. These opportunities are sometimes adequately provided by families, friends, church and other visitors and volunteers, but frequently they are not. Staff then become the main source of resident support. The capacity of individual staff to meet residents’ communication needs is dependent on many factors including the legislative framework and funding of the aged care system, the philosophy of the individual provider organisation (translated into work routines, staffing practices, and the training, mentoring and support available to staff) and the individual personalities and communication skills of staff themselves. Continuity of staffing is a vital factor, with “Know your resident” identified by staff in this study as the most important element in understanding and recognising the needs of residents withcognitive and communicative impairment, and in building relationships which support residents and enhance their autonomy.