Melbourne School of Population and Global Health - Theses
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ItemDiasporas of medical beliefs : a multi-ethnic clinic and the experience of tuberculosis in a low incidence country(University of Melbourne, 2006)This thesis reports on a qualitative, ethnographic study of a multicultural migrant population in a tuberculosis clinic in Melbourne, Australia. The thesis focuses on two groups of people and their interaction � health professionals who work with tuberculosis, and patients who have, or have had, the disease. My focus in interviewing the health professionals is on their management of disease in the face of widely different patient beliefs. In analysing interviews with patients and their families, I focus on narrative and conceptual syncretisms, where a partially assimilated explanatory framework of western medicine coexists with other traditional or personal models about tuberculosis. For none of the patients interviewed, was is it the case that these alternative models blended together without friction, nor was there evidence of one idea or component over-riding or replacing another. Rather, it was repeatedly found that ideas or models, which outwardly appear inconsistent and contradictory, appeared to fit together quite comfortably. While nearly everyone who goes through the clinic already has (or has recently acquired) a good understanding of their infection, disease and treatment from a biomedical perspective, this does not lead to a rejection of preexisting models. For example, the two apparently contradictory statements that "TB is caused by a pathogen" and that "TB is caused by the supernatural" regularly co-occur within the narratives I collected. A deeper analysis of what is being said indicates that in cases of this type, people are presenting information on different, though parallel, levels. This results in a multitude of discrepant assessments that are somehow commensurate, resulting in a functioning clinic where treatment is extremely successful despite the great diversity surrounding the two groups and health models. The individual's comfort with incommensurable models is thus a central interest in the thesis. Importantly for health professionals, this research shows that the impact of non-western models of disease aetiology on TB treatment regimes may be far less than it appears at first sight. Contrary to expectations, even seemingly incompatible propositions held by patients rarely cause problems of compliance, or otherwise hinder the patient's integration into the biomedical treatment regime presented to them in the course of their dealings with the clinic.
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ItemKanyirninpa : health, masculinity and wellbeing of desert Aboriginal men( 2004)Kanyirninpa, or holding, exists as a deeply embedded value amongst desert Aboriginal peoples (Puntu). It is disclosed as authority with nurturance, where older generations assume the responsibility to care for and look after younger people. Kanyirninpa also holds in balance two other key cultural patterns of desert life, autonomy and relatedness. These values are transmitted across generations where they provide desert society with identity, cohesion and strength. While kanyirninpa can be identified in the nurturance provided a child after birth, its presence and power is particularly disclosed at ceremonial time. Here, the meanings of the ancestral tjukurrpa (dreaming) are celebrated and renewed. Desert society is reproduced as the deeper, social and cosmic meanings around ngurra (land), walytja (family) and tjukurrpa are gathered, ritualised and re-enacted. The older generations of men and women enable this holding to occur. When boys (marnti) become men (wati) the manner of kanyirninpa changes. No longer do young men seek to be held by their mothers and female relations. Instead, they seek to be held by older men: brothers, uncles and other males. By holding them older men induct younger men into the social meanings and behaviours of desert, male adulthood. A generative and generational male praxis is disclosed. Colonialism and mission activity in the south-east Kimberley severely impacted desert society. Puntu were dislocated from their traditional lands as a sedentary life in Balgo mission was accompanied by a dormitory, rations and labour system that effectively and forcibly separated generations of men and women. The research that conducted in this desert region investigated how Puntu perceived kanyirninpa, its transmission and how this transmission had been affected by colonial history and experience. Male and female Puntu emphasised that, despite the effects of seventy years of colonial contact, they continued to value holding as an essential ingredient for social and emotional wellbeing (palya). They also revealed that young men continued to explore experiences that offered the possibility of kanyirninpa. Within the social contexts of petrol sniffing, football and prison particular aspects of male holding could be identified as could risks to men's health. Finally, the research led to an elucidation of the social circumstances that have been inscribed on the contemporary Puntu male and social body (yarnangu). They reveal the effects of colonisation on transgenerational processes and key social relationships. The Puntu social body can be understood as traumatised. Transgenerational trauma describes how separation has wounded the transmission of kanyirninpa within key social relationships. While desert people have worked to protect the value and continuity of kanyirninpa, expressions of social trauma continue to seriously affect the health and wellbeing of all, particularly young men.
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ItemThe proximate advocate: improving indigenous health on the postcolonial frontier( 2006)This thesis presents an ethnography of white researchers who work at the Darwin Institute of Indigenous Health Research. This group of ‘proximate advocates’ is made up of predominantly middle-class, educated and antiracist white health professionals. Their decision to move from more populated areas to the north of Australia, where Indigenous disadvantage is most pronounced, is motivated by the hope of enacting postcolonial justice so long denied to the nation’s first peoples. This ethnography thus contributes to the anthropology of postcolonial forms, and specifically benevolent forms. The Darwin Institute of Indigenous Health Research is an example of a postcolonial space where there is an attempt to invert colonial power relations: that is, to acknowledge the effects of colonisation on Indigenous people and remedy them. The thesis begins with an account of suburban life in contemporary Darwin focused on the figure of the ‘longgrasser’ who threatens to create disorder at my local shops. This is an example of the postcolonial frontier, the place where antiracist white people encounter radically-different Indigenous people. Part 1 develops a conceptual model for understanding the process of mutual recognition that creates the subjectivities of Indigenous people and of white antiracists. Drawing on critiques of liberalism and postcolonial theory, in Part 2 I describe the knowledge system dominant in Indigenous health discourse, postcolonial logic. It is postcolonial logic that prescribes how white antiracists should assist Indigenous people by furthering Indigenous self-determination. I argue that postcolonial logic can be understood as the junction of remedialism (a form of liberalism) and orientalism. The melding of these two concepts produces remediable difference: a difference that can be brought into the norm. In Part 3 I describe how white researchers at the Institute experience radical difference, or at least its possibility. These experiences challenge the concept of remediable difference. If Indigenous people are not remediably different, but radically different, the process of mutual recognition breaks down, and the viability of a white antiracist subjectivity is called into question. The ensuing breakdown of postcolonial logic threatens to expose white antiracists as no different from their assimilationist predecessors. Part 4 explores the underlying dilemmas of the postcolony that are revealed when postcolonial logic unravels. The dilemma of historical continuity emerges when the discursive techniques that enact historical discontinuity between postcolonisers and their predecessors break down. The dilemma of social improvement is the possibility that the practices of the self-determination era not only resemble assimilation, but are assimilation. It is the possibility that any attempts to extend the benefits of modernity enjoyed by non-Indigenous Australia to Indigenous people will erode their cultural distinctiveness. The postcolonial condition is the experience of living with these aporias. In the conclusion, I consider the implications of my argument for the current Australian political context, for the project of liberal multiculturalism, and for the broader problem of power and difference. I look to friendship as a deceptively simple, perhaps implausible, and yet powerful trope that can relieve the postcolonial condition and offer hope for peaceful coexistence in the postcolony.
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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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ItemBreastfeeding and maternal touch after childhood sexual assault( 2006-09)Introduction: The study is a qualitative exploration of breastfeeding and maternal touch with new mothers who are survivors of childhood sexual assault (CSA) by a family member. Objectives: The objective of this study is to explore the experience of breastfeeding in mothers with a past history of CSA perpetrated by a family member. Methods: Using an interpretive framework, eleven women were interviewed with an in-depth semi-structured method and the transcripts coded and analysed by themes. All participants were new mothers who volunteered in response to a community based advertisement. Each woman self-identified as being sexually abused as a child by a family member. Results: Significant themes that emerged about breastfeeding were the importance of breastfeeding to the maternal-infant relationship and infant development. Other more challenging themes included detachment and dissociation, exposure and control, lack of pleasure, and splitting of the roles of the breasts into maternal or sexual objects.During the course of the study maternal-infant touch was raised as an important theme associated with body boundaries between the mother and her child and related to the mother’s past CSA experience. Baths and nappy changes were two areas in which some mothers encountered difficulties associated directly with their CSA. Some participants encountered difficulties associated with their healthcare. These were largely associated with the participants’ lack of control in the professional encounter and intimate examinations. Baby examination was also problematic with women reporting being concerned about their ability to protect their children within the professional encounter. Conclusion: Many participants described breastfeeding as a positive experience which enhanced their bonding to their babies. They faced challenges as CSA survivors due to the duality of the breasts as sexual and maternal objects. Touch and maternal-infant boundaries emerged as important themes after CSA
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ItemThe experience of birth and early mothering after assisted conception( 2006-12)There is emerging evidence that after infertility and assisted conception women are at increased risk of early parenting difficulties. The aims of this study were to characterize postpartum psychological functioning of women conceiving through assisted reproductive technology (ART) and to identify factors that may be associated with early parenting difficulties defined as: postpartum psychological distress, low maternal confidence and admission to residential early parenting services. (For complete abstract open document)
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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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ItemIntergenerational sexual relationships in urban Botswana( 2006-05)This thesis describes the prevalence, determinants and dynamics of intergenerational sexual relationships in urban Botswana. The study was conducted in three stages, the survey, in-depth interviews and radio talk-back. The survey was conducted with schoolgirls in all four public senior secondary schools in Gaborone, Botswana. The survey was completed first before proceeding to the other two stages. However, the last two stages were done concurrently. A quantitative survey was conducted with 600 schoolgirls (18-22-year-olds) in order to establish their sexual practices, find out the prevalence of intergenerational sexual relationships among them and find out their perceptions regarding intergenerational sexual relationships. More than three-quarters of the participants had boyfriends in their age group and about one-quarter of those who were approached by older men had older boyfriends. The results revealed the practice of multiple sexual partners both in intragenerational and intergenerational sexual relationships. The issue of multiple sexual partners has been identified to be one of the factors that fuel STI/HIV infections. Girls who were in intergenerational sexual relationships have positive perceptions and attitudes towards them. However, the majority of the girls did not perceive such relationships as good. They associated them with the danger of engaging in unprotected sex and thus a greater risk of contracting STI/HIV.