Medical Education - Theses
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ItemThe indigenous health agenda in medical education( 2017)This thesis describes the indigenous health agenda as a unique landscape located within the wider field of medical education. The indigenous health agenda offers medical educators the opportunity to contribute to indigenous health and wellbeing. The thesis reviews the commitments of medical schools in Aotearoa New Zealand and Australia to the indigenous health agenda and asks how these commitments are currently being enacted and can best be realised in future. The research identifies an indigenous rights to health approach as under-utilised and potentially beneficial. Using Kaupapa Māori methodology a research study consisting of thirty-two semi-structured interviews (28 individual, two joint, and two focus group interviews) was undertaken across two research phases. In Phase One, key informant interviews were conducted to gain insight into stakeholder perceptions of medical school commitments to the indigenous health agenda. In Phase Two, a case study was carried out at The University of Auckland Faculty of Medical and Health Sciences, in which key informants discussed the relevance and potential applications of Phase One findings. Thematic analysis was used to encode and order data. Study findings establish the viability of a rights approach, and bring into focus drivers of the indigenous health agenda, obstacles to the indigenous health agenda, and strategic pathways for the indigenous health agenda. The indigenous health agenda is redefined as building a strong indigenous presence in medical schools via four strategic pathways - indigenous knowledge and information, indigenous process and practice, indigenous personnel, and indigenous resource base - and transforming institutions to enable that presence to have impact. When the four strategic pathways are applied across the domains of clinical teaching and learning, cultural understanding and critical awareness, community relations, and indigenous leadership and organisational autonomy, a 4 X 4 table of the indigenous health agenda is developed. The indigenous health agenda is then understood to consist of ends, means, and motives. The ends are to reduce indigenous health inequities and contribute to indigenous health and wellbeing. The practical means are to develop indigenous presence within and across pathways and domains in medical education. The motives are human rights to health and more specifically and powerfully, indigenous rights to health. Developing each facet of the indigenous health agenda is a task still to be achieved, as is mastering the complex dynamics of equitable partnerships between medical schools and indigenous communities, and between indigenous leaders and their non-indigenous allies. Even so, the thesis predicts a bright future for better understanding and further practical developments of the indigenous health agenda in Aotearoa New Zealand and Australian medical schools.
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ItemHealth self-care using self-quantification : a framework for formalising research and practice( 2016)This PhD thesis examines self-quantification using apps and wearable devices –for short, self-quantification systems (SQS) – specifically for health self-care. Health self-quantification (SQ) is a way of working in which, by using SQS, people can collect, manage and reflect on personal health data in order to gain a better understanding of their own body, behaviour, and interaction with the world around them. A literature review found many unknowns about how SQS are used for health self-care, what constructs could describe the use of SQS and related effects on individuals’ health outcomes, and how such effects could be modelled. The key challenge addressed by this thesis is whether the data management and health management activities within health self-quantification and their constructs can be described comprehensively in order to formalise the research and practice of health self-quantification. This thesis has developed a framework called the health SQ activity framework based on activity theory (AT) and patient activation theory (PAT), to address this challenge. Mixed methods were used to build, test and refine the framework. This framework is important because it is the first step to operationalise health SQ fully. This may in turn benefit a variety of stakeholders: biomedical researchers, developers, health informaticians, healthcare professionals, and personal users who seek to study or make changes in health outcomes. Future research using the framework across a range of conditions and contexts will generate more rigorous evidence about health outcomes from SQS use.
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ItemCommunication performance in the career medical interview: a new model for preparation( 2016)The career medical interview is rare in that it is a central discriminator for aspirant doctors and trainees. Not only does the outcome determine the future job prospects for the candidate, but it also decides access to continued education and training. Despite the importance of the interview and these tensions, little training is provided to aspirants and there are often conflicting messages. Furthermore, the interview is not a reliable test measure; it is susceptible to a range of bias and rating difficulties. Additionally, the number of places is outweighed by the number of potential applicants, hence adding further tension to the process. One possible outcome of the lack of training programs specific to the career medical interview is the susceptibility to impression management. Impression management is where a candidate intentionally influences the outcome of an interview by engaging in the active manipulation of their image portrayal. At worst, candidates might engage in faking (where facts are made up or deceitful responses are given). Presently, little is known about the impact or strategies of medical candidates and impression management in the career medical interview. It is known that a key factor in successful career interview performance is the management of anxiety. Too often, anxiety in regards to the interview or communication apprehension can cause distorted behaviour. This may result in excellent candidates being unsuccessful not because they may not be the best candidates, but because they were unable to manage their anxiety sufficiently well. This can result in clinical and training impacts if the wrong candidates are selected. This thesis successfully proposes a new model for communication training for the career medical interview to address these tensions. Drawing on the body of research known as applied theatre, a new training model is developed and tested using psychometric scales designed to measure anxiety. Kirkpatrick’s model of measuring training effect is utilised. This thesis also draws new insight into existing training strategies used by candidates undertaking interviews in Australian medical contexts as well as capturing data in regards to impression management being utilised by currently successful surgical trainees.
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ItemThe implementation of generic skills in Vietnamese universities: facilitators and inhibitors( 2016)This study investigated the question, What factors influenced the implementation of generic skills (GS) in Vietnamese universities? taking into account the perspectives and experiences of university leaders and academics. The Business Administration programs of six diverse Vietnamese universities were used as case studies to examine this question. This study is significant because it examined GS implementation in a developing non-English speaking country with different higher education (HE) contexts and values, whereas most studies about GS implementation derive from Western countries. Thus, it expands our understandings about GS implementation in different HE contexts. It also points out implications for Vietnamese universities to move forward with developing GS. The study employed a multiple qualitative case study approach to capture diverse institutional perspectives on GS implementation processes within the Business schools. There were 69 interviews conducted with university and school leaders, disciplinary and general skills teachers, and staff members within the Youth Union and its associates (YUA). Additionally, relevant information from the universities’ websites, documents collected from participants, and field notes were used. First, data were analysed for each case study using a content analysis approach. Then a cross-case analysis was conducted to highlight similarities and differences in GS implementation among the universities, which also revealed major factors influencing the implementation. The study found that contextual factors significantly influenced GS implementation in the investigated Vietnamese universities. At the national level, the Ministry of Education and Training (MOET) instigated several concurrently-occurring reforms during and prior to this study. In most of the case studies, the other reforms were regulated by the MOET and linked to institutional privileges once completed, whereas GS implementation was not. This led to university leaders focusing on other reforms and delaying or not prioritising GS implementation. Second, university and school leaders found the MOET’s regulations of credits for a program an obstacle for integrating the selected GS into the curriculum. Hence, they involved the YUA extra-curricular activities as an integral component of GS implementation strategy, to compensate for the lack of curriculum autonomy. Third, GS were largely conceived as developing work-readiness skills for students, which is consistent with the industrial training focus of Vietnamese HE. This meant that in the School of Business of the six universities, developing GS for students occurred primarily in work-integrated learning. However, according to many participants, a lack of disciplinary teacher engagement and connection with industries reduced the effectiveness of work-integrated learning. The lack of connection with industries also affected the skills development activities that the YUA offered students. University D stood out in this study as a successful university in developing GS. This was due to their leadership that effectively built teacher capacity and actively supported teachers to engage with GS development in their classes. Linkages with industries, institutional culture that made GS a priority, and the curriculum autonomy granted by the MOET, which were not evident in the other five universities at the time of research, also enabled the progress of GS implementation in this university. This thesis argues that curriculum autonomy, institutional leadership and university-industry linkages are important for the successful implementation of GS in Vietnamese universities.
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ItemParticipatory health through social media in chronic disease: a framework for research and practice( 2015)As participatory health develops, healthcare as a whole continues to cautiously embrace social media and the vast possibilities they can bring. They may be useful to transform the management of people living with chronic disease by enabling them to be more active participants and shared-decision makers in their own care. Unfortunately, limited definitive evidence exists indicating that social media use can improve health outcomes, nor is research mature enough to have established stringent methodologies for examining social media in this context. Unlike a variety of evidence-based guidelines suggesting best practice for an array of chronic diseases, evidence that could underpin guidelines for use of social media remains inadequate. There are many unknowns, for example: How social media are used as part of self-management, what mechanisms underpin social media’s therapeutic potential, the health outcomes and other effects most likely to be impacted by social media, and whether social media can form an effective part of management in the clinical setting. The key challenge addressed by this thesis is whether criteria and methods for generating and evaluating evidence about health outcomes from social media use can be defined. A framework for research and practice has been developed, tested and refined to address this challenge. With further research using the framework across a range of conditions and contexts, evidence about patient-reported outcomes from social media use will grow. This will improve evidence-based decision-making about social media and ultimately benefit a variety of stakeholders: patients, clinicians, health researchers and health informaticians.
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ItemIn pursuit of belonging: a socio-ecological perspective to investigating school belonging in secondary school settings( 2015)Belonging is an essential aspect of psychological functioning. Schools offer unique opportunities to improve belonging for school-aged children through a broad network of groups and systems. Although research generally supports the importance of belonging for good mental health, research specifically on school belonging in educational settings has been fragmented and diluted by inconsistency in the use of terminology. The research of this thesis is comprised of three studies exploring belonging in schools through a socio-ecological perspective. In the first study, an extensive review of the literature was conducted. The aim was to respond to the problem statement: ‘What are the main themes that influence perceptions of school belonging in a secondary school setting?’ A systematic review identified seven themes which influence school belonging at the student level during adolescence in educational settings: academic motivation, emotional instability, personal characteristics, parent support, peer support, teacher support, and gender. Meta-analysis was then used to examine the effect sizes of the seven themes. With the exception of gender, all themes reported medium to large effect sizes, indicating that the themes identified are relevant and important factors with respect to fostering school belonging. These remaining six themes could be conceptualised into individual level themes (e.g., academic motivation, emotional instability, and personal characteristics) and microsystem level themes (e.g., parent support, peer support, and teacher support), and thus form the basis of a preliminary socio-ecological framework of school belonging. A second study was performed to investigate the priorities of secondary schools at the mesosystem level of a socio-ecological framework to examine whether school belonging was a theme found in school vision and mission statements in Victoria, Australia. A stratified sample of secondary school vision and mission statements across 308 schools was analysed using emergent coding and frequency analysis. Findings revealed that the theme of academic motivation was cited significantly more frequently than any other theme and that the themes of school belonging and mental health were cited by over half of the schools sampled. Given the importance of academic motivation for the schools sampled, a third study investigated the same school vision and mission statements to assess whether school belonging was related to student achievement. It was hypothesised that vision and mission statements endorsing greater levels of school belonging would be positively related to academic achievement at the macrosystem level. Using language analysis, the results showed a non-significant relationship between school belonging and achievement. The findings from the overall thesis are presented using a socio-ecological framework of school belonging, which outlines five levels of interconnected layers within an ecology that supports school belonging. This framework may be useful in improving perceptions of school belonging for secondary students through the design of policy, pedagogy, and teacher training. This PhD research makes an original contribution to the field of school belonging by applying a socio-ecological perspective and using innovative research methods. It encourages school leaders and educators to foster students’ sense of belonging by building qualities within the students and by changing school systems and processes.
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ItemEngineering articular cartilage from human infrapatellar fat pad stem cells for transplantation therapy( 2015)Mesenchymal stem cells (MSCs) have shown promise in cartilage tissue engineering due to their unlimited capacity for self-renewal and capability to differentiate into cartilage tissue lineage under certain physiological or experimental conditions. In this thesis, we harvested MSCs from human infrapatellar fat pad tissue (hIPFP) and further fully characterised using flow cytometry. Human IPFP-derived MSCs at passage three (P3) show good homogeneity for MSCs cluster differentiation (CD) markers including CD29, CD44, CD73, CD90, and CD105. Hyaline articular cartilage repair is a significant challenge in orthopaedics and traditional therapeutic options result in inferior outcomes. We believe traditional methods can be improved through applications based on three-dimension (3D) culture systems and tissue engineering strategies. In this thesis, we planned to investigate the chondrogenic potential of hIPFP-derived MSCs, stimulated by TGFβ3 and BMP6, over 7, 14 and 28 day in vitro in 3D pellet culture, a 3D printed chitosan scaffold and a 3D scaffold comprising methacrylated hyaluronic acid and methacrylated gelatin (called HA/GelMA). Therefore, endpoints included histology staining, immunohistochemistry, immunofluorescence, and temporal changes in expression of specific chondrogenic genes using quantitative real-time polymerase chain reaction (qPCR). In vitro 3D pellet culture maintained cells to be in close proximity to each other and promoted cell aggregation that mimics the cellular condensation process within native cartilage tissue. Furthermore, research has shown the potential of 3D biomaterial scaffolds for providing a suitable environment for chondrogenic induction and significantly enhancing the proliferation, differentiation, and chondrocytic extracellular matrix synthesis by MSCs. Collaborators at the Intelligent Polymer Research Institute (IPRI) at the Uiversity of Wollongong have developed extrusion printing for diverse bioengineering projects and this technique has developed for provision of both 3D chitosan scaffolds and 3D hyaluronic acid/biogel scaffolds for this project. The biocompatibility of chitosan and its structural similarity with glycosaminoglycan make it attractive for cartilage tissue engineering. Also, methacrylated HA and gelatin polymers were utilised to produce UV- crosslinkable HA/GelMA scaffold. A cartilage extracellular matrix component, HA, is the main non-sulphated glycosaminoglycan and offers a promise candidate for engineering of cartilage. In all three types of cultures (pellet, chitosan and HA/GelMA), over 14–28 days, clusters of encapsulated chondrocytes formed. Collagen type 2 and proteoglycan production were confirmed using immunohistochemistry and immunoflourescence. Chondrogenic lineage markers including: SRY-related transcription factor (SOX9), collagen type 2 alpha 1 (COL2A1), and aggrecan (ACAN) gene expression increased significantly over the time course. We reported that chitosan and HA/GelMA scaffolds enhance and increase the efficiency of chondrogenesis in our model. Finally, advanced microarray technique was conducted to provide novel informations about overall gene expressions during chondrogenesis across all three cultures. This is the first time that in vitro microarray has been used in the assessment of the chondrogenic differentiation of hIPFP-derived MSCs cultured in 3D pellet and seeded into chitosan and HA/GelMA scaffolds. Microarray gene analysis requires high-end programming for assessment of the test statistics that show whether a particular gene or a set of related genes are highly regulated (up- or down-regulated). Another challenge is to select a ‘ranking of expressed genes’ that may be relevant to a particular set of experimental conditions or of particular interest from a biological perspective (e.g. a particular metabolic pathway or a set of apoptotic genes). Therefore, we have successfully demonstrated in vitro production of hyaline-like cartilage from infrapatellar fat pad (IPFP)-derived MSCs in 3D culture. Microarray has provided novel informations concerning genes involved in chondrogenesis of hIPFP- derived MSCs and our approach offers a viable strategy for generating clinically relevant cartilage for therapeutic use.
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ItemThe role of brain fronto-striato-thalamic networks in psychosis: clinical and experimental resting-state fMRI studies( 2014)Psychosis is a severe mental illness that blurs the boundaries between reality and illusion, confining patients to a world that is considered mostly outside of normal experience. Accumulating evidence suggests that disruption of functionally integrated brain networks—i.e., neural dysconnectivity—may underlie the pathophysiology of psychosis. The evidence further points to specific involvement of the brain’s fronto-striato-thalamic networks (FSTNs), a group of anatomically and functionally connected brain regions that work in synchrony to mediate cognitive, motor and affective processes. This thesis aimed to address a number of vital questions concerning the relevance of FSTNs to the pathophysiology of psychosis, including whether dysconnectivity in these networks pre-date psychosis onset, are under genetic control, and can be linked to specific neurochemical mechanisms. I utilized resting-state functional magnetic resonance imaging (fMRI), a validated and sensitive tool for probing the functional integrity of discrete neural networks, to address these questions. Firstly, I investigated putative disturbances in the temporal coherence of fMRI signals—so-called functional connectivity—among regions comprising the FSTNs in individuals experiencing an at-risk mental state (ARMS) for psychosis. The findings of this work indicated that disruptions in the functional connectivity of both dorsal and ventral FSTNs distinguished ARMS individuals from healthy control subjects. Moreover, the magnitude of dysconnectivity in these subjects correlated significantly with positive psychotic symptoms, such as delusional ideation and hallucination, linking these aberrations to clinical expression. This analysis was followed by an investigation into the heritability of the identified disturbances in FSTNs functional connectivity. The unique variance in FSTN functional connectivity attributable to additive genetic effects was modeled in a sample of identical monozygotic (MZ) and non-identical dizygotic (DZ) twins. Studying these disturbances in twins revealed moderately strong genetic influences, particularly with the dorsal (cognitive) network where 50% of the variance in functional connectivity between the dorsal caudate and the dorsolateral prefrontal cortex (DLPFC) was explained by genetic factors. The study additionally suggested that unique environmental effects accounted for the remaining 50% of the variance, while there was no influence of common environmental effects. Finally, the mechanistic basis of FSTN dysconnectivity was assessed. In particular, the potential impact of hypofunctional N-Methyl-D-Aspartate receptors (NMDARs), one of the primary candidate molecular pathologies proposed for schizophrenia, was determined using a pharmacological challenge. I investigated whether acute NMDAR antagonism in healthy volunteers via the intravenous infusion of the psychotomimetic agent ketamine induces FSTN connectivity changes redolent of those identified in ARMS subjects. The volunteers were assessed for psychosis-like symptoms and FSTN functional connectivity following both ketamine and placebo (saline) infusion. In contrast to the general reduction in functional connectivity identified in ARMS subjects, ketamine specifically increased functional connectivity in FSTNs. Furthermore, ketamine-induced psychotic experiences correlated significantly with these drug-related changes in FSTN functional connectivity. Together, the body of work presented in this thesis provides a number of novel and unique findings that serve to advance the current state of knowledge regarding the pathophysiology of psychosis. Specifically, the findings point to the utility of resting-state fMRI to probe changes in brain function prior to the onset of psychosis and provide direct support for the role of the FSTNs, especially the dorsal (cognitive) network, as a risk biomarker for the illness that is influenced by genetic as well as unique environmental factors. In addition, the findings challenge current pharmacological models of psychosis by demonstrating that acute administration of ketamine may not recapitulate the neurobiological disturbances evident in the psychosis prodrome.
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ItemThe role of visualisation for understanding complex systems( 2012)Understanding complex systems (CSs) is an important skill in science education that is characterised by the ability to interrelate multiple scales of information. Visualisations play a significant role in supporting this cognitive skill by externalising these complex interrelationships into a perceptible form. However, the information at each level of a CS, from the agent (micro) to the aggregate (macro), may be best conveyed using different types of representations, making it difficult for individuals to visually and conceptually link the multiple levels of the system. The aim of this thesis is to investigate how to optimally design visualisations to improve student understanding of CSs. In particular, for CSs in which the physical structure directly influences its behaviour and function, and where changes enacted at a level higher than the agent have implications for all levels of the system. Following a visualisation design system approach, the investigation was divided into two phases. Phase I involved two user studies that examined student-generated external representations (ERs) of a CS to assess their understanding and type of representations they associated with the system. The findings from Phase I were used to formulate a set of preliminary design principles that were applied in Phase II, the instantiation and evaluation of the design principles in functional prototype visualisations. The design principles, and corresponding prototype visualisations, underwent two iterative cycles. Students struggled with the first version of the prototype that integrated the student-generated ERs from Phase I, demonstrating a conceptual disconnect between structural, behavioural, and functional elements within and between the agent and aggregate levels of the system. These student difficulties necessitated a revision of the preliminary design principles, informing changes in the type of ERs and visualisation transition techniques to be used in the second prototype. Student evaluations of this second prototype yielded more positive results with evidence of improved student reasoning of how the CS works. This thesis makes two contributions in visualisation and CSs education: a set of design principles for visualising structure, behaviour and function of a CS based on student mental models, and a proof-of-concept exemplar of the design principles in the form of a novel functional prototype visualisation that helped to improve student reasoning. In addition, this thesis also serves as an example of empirically based design research and illustrates how a cohort’s mental models can be leveraged into effective design.