Melbourne School of Population and Global Health - Theses
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ItemLook wide: searching for health in the borderlands: experiences of disease prevention and health promotion in a Central Australian indigenous settlement( 2005-08)Until recently, place has been of little interest to health research. While fundamental to anthropological accounts, place has been largely relegated to the bounded and inert ground on which human agency is exercised. In this dissertation the relationship between people and the places in which they live is brought to the foreground. I am interested in bridging the gap between human agency and the social structures that underpin health by examining the subjective experiences and narrative accounts of individuals linked to the social organisation of places and their histories. The social theory of Pierre Bourdieu and his concepts of habitus, field and capital, brings analysis of these health encounters closer to the experience of everyday practice. The broader interest that runs in the background of the thesis is the interplay between the social determinants of health, the capacity to act and health inequality. Based in the Warlpiri settlement of Yuendumu in Central Australia, the ethnography critically examines the engagement between Indigenous understandings of health, well-being and being ill, and the dominant biomedical discourse that shapes disease prevention and health promotion interventions. Against a landscape of a rapidly changing Warlpiri social world, the search for Indigenous health extends beyond the biomedical life world and into the tensions of a wider social context. These sites of engagement are imagined as borderlands - emergent intra-cultural meeting places between yapa and kardiya. The search begins at the clinic in Yuendumu, the site of practitioners' biomedical practice, before moving into the settlement spaces to explore Warlpiri experiences of health promotion and disease prevention. Finally the thesis shifts beyond the cartographic boundary of Yuendumu to the symbolic boundaries of the nation. Issues of social exclusion and marginalisation are implicated in Indigenous health as the thesis explores the historicized connections between people, place and identity, both in Central Australia and within a wider national discourse of belonging. Rather than the narrow frame of the biomedical lifeworld to explore health disadvantage, I argue for the inclusion of an ethnographic approach that will foreground the quotidian lived world.
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ItemGenetic ties: are they morally binding?( 2005)What determines parenthood? The advent of IVF and the rapid growth of reproductive technologies have challenged the significance historically associated with biological relationships. It is now possible for a child to have many different people in the role of genetic, gestational, nurturing or legal parent and for the formation of many novel types of families. While frequently some or all of these roles are combined, it is now possible for someone to be a ‘parent’ in one sense, without necessarily taking on the obligations and rights associated with parenthood in a moral sense. Despite the expanded options for constructing families and the proliferation of novel arrangements for raising children, the essential feature of what it means to be a ‘real parent’ and to have a child of ‘one’s own’ is often grounded in the transmission of genes. This thesis examines the claim that genes define ‘moral’ parenthood. It investigates whether or not genetic relatedness is morally weighty in determining which individuals incur obligations for and rights over children. My thesis adopts a novel approach to address this question. It combines the analysis of both people’s views as captured through a qualitative study and those found in philosophical literature relating to the moral significance of genetic parenthood. I design and conduct a study to capture more directly the meanings that people attach to passing on their genes, which acts as a starting point for identifying and evaluating possible arguments about the moral relevance of genetic parenthood. I then analyse the principles imbedded in the participants’ views in light of the current philosophical literature.
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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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ItemInformed Consent: ethical theory, legal obligationsand the physiotherapy clinical encounter( 2005-10)Obtaining a patient’s informed consent to treatment is an expected component of clinical interactions. The notion that a person as an autonomous being has a right to decide whether or not to consent to medical treatment from an informed basis has its origins in both law and ethical theory. In this research I investigate the issue of informed consent from two overall perspectives. The first concerns its basis in ethical theories of autonomy and its interpretation by the law and by health professional guidelines. The second involves an empirical examination of its occurrence within the communicative interaction between a physiotherapist and their patient, and its interpretation by the physiotherapist. I use qualitative research methods involving analysis of individual audio-taped treatment encounters in private physiotherapy practice and interviews with the treating physiotherapist. A central tenet of this study is that the translation of both legal and ethical criteria into the context of the clinical encounter requires a process of negotiation and communicative interaction between the patient and health professional. This research seeks to understand this process, and the factors that influence it in the specific context of physiotherapists and the private practice clinical encounter. (For complete abstract open document)
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ItemHolding your breath: predictive genetic testing in young people( 2005-07)A clash in perception is taking place. Some perceive predictive genetic testing in young people to be too potentially harmful to allow. Others perceive it to be an opportunity for benefit, even an opportunity for the prevention of harm. In this thesis I consider the issue of potential harm to mature young people who seek predictive genetic tests. There are two parts to this thesis. In part one (chapters 1-4) I provide a background to the current debate. I describe the prohibitive stance purported within current guidelines, the arguments used to justify this stance and the opposition that has arisen in response. I discuss the psychological and social ways in which young people differ from adults, arguing that it is likely young people will react differently from adults in response to predictive genetic tests. However, I conclude that the lack of empirical evidence means we are unable to determine if these differences will confer a greater potential for harm or benefit when young people are tested. Finally, I present a discussion of two fundamental gaps in our knowledge about testing in young people: a lack of knowledge about current practice and a lack of first-hand evidence about the effects of testing. I argue that empirical research is required. In part two of this thesis (chapters 5-7) I present the findings of my own empirical research. Firstly, I describe the findings of an international survey of clinical geneticists. Secondly, I describe the outcomes of 18 in-depth interviews performed with young people who have experienced predictive genetic testing for either Familial Adenomatous Polyposis or Huntington Disease. These young people ranged in age from 14 to 25 years. The international survey uncovered 49 cases where predictive genetic tests had been provided to young people for non-medical reasons. When such tests are provided, the impacts are rarely followed-up as part of a formal research protocol. Clinicians’ reasons for providing and refusing tests are highly varied and are driven more by the nuances of individual cases than by any one ethical principle or set of guidelines. When young people talk about the predictive genetic tests they have experienced, they refer to the entire experience of being at risk of a genetic condition, not simply the time after receipt of their test result. Young people speak about a far more extensive range of harms and benefits associated with the testing process than have been previously researched. I argue that some young people growing up at risk of a genetic condition suffer several harms prior to their request for predictive genetic testing, because of their risk status. I argue that when we understand this, it becomes clear that for these mature young people who seek such testing, the provision of a test may not only serve to alleviate some of these harms, but may in fact create benefits for them, irrespective of their test result. In these cases, the provision of a predictive genetic test is appropriate, logical and ethical.
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ItemBorders of fertility: unwanted pregnancy and fertility management by Burmese women in Thailand( 2005-05)In this thesis, I describe how women who are forced to migrate from Burma into Thailand manage their fertility, unwanted pregnancy and pregnancy loss. The study was initiated by Dr Cynthia Maung, a Burmese medical doctor, herself a stateless person who coordinates a refugee-led primary health service five kilometres inside Thailand. Unsafe abortion is a common problem and much time and resources are taken with the care of women suffering haemorrhage, infection and pain after self-induced abortion in both Thai and Burmese-led health facilities. The thesis examines the characteristics of Burmese women admitted to health facilities with post-abortion complications and their chosen methods of self-induced abortion. Local meanings of abortion and post-abortion care are explored. Lay midwives play a central role in fertility management and some are abortionists. Men’s role in the management of fertility is also presented. The women are generally married with children. Considered illegal migrants, they are employed and work in Thailand without work permits. Many women have a history of escaping human rights abuses and entrenched poverty in Burma. At least a third of women admitted into care with post-abortion complications had induced their abortion with oral herbal preparations, pummelling manipulations or stick abortions. Most of the abortion services were provided by Burmese lay midwives. Reasons for terminating the pregnancy include: poverty, gender-based violence and the local illness of ‘weakness’. In addition, low sexual health knowledge, and difficult access to reproductive health services play a part in mistimed pregnancy. There is no commonly agreed definition of abortion between formal, informal health workers or women. Most people considered it against cultural lore and in some cases judicial law but still felt it was necessary. Women’s perceptions of the viability of their pregnancy and its outcome prevailed. Men played a limited role in fertility management. I argue that a lack of rights to work and earn a fair wage; to move without fear, a lack of sexual health information, and the ability to safely control fertility increases women’s risk of unsafe abortion. Furthermore, violence perpetrated at the individual and state level contributes to unsafe abortion. Burmese women’s mortality and morbidity associated with unsafe abortion is largely unrecorded by Thai processes and unknown to the Burmese military government. Unwanted and mistimed pregnancy can be avoided through reproductive technologies, education programmes, and access to modern contraceptives. To safely terminate unwanted pregnancies and to treat the complications of pregnancy loss is not only possible but a woman’s right as delineated in the international treaty CEDAW, to which Burma and Thailand are signatories. Yet Burmese women continue to suffer: become sterile, socially vilified, unemployed or repatriated against their will due to their reproductive status. Their sickness and deaths are secondary to the economic imperatives of Burma and Thailand and their human rights continue to be violated.....
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ItemA population-based family study of prostate cancer in an era of prostate-specific antigen testing( 2005-11)Familial aggregation of prostate cancer has been demonstrated in studies conducted in a number of countries prior to the widespread adoption of prostate-specific antigen (PSA) testing for prostate cancer detection. PSA testing leads to over-diagnosis of asymptomatic disease that may not have become clinically significant within a man’s normal lifetime. This increase in the number of asymptomatic men diagnosed might alter the magnitude of familial risk estimates and the importance of a prostate cancer family history. (For complete abstract open document)