Melbourne School of Population and Global Health - Theses
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ItemRefugee youth, social inclusion and health( 2012)In recent years, refugees settling in Australia have come predominantly from countries that have experienced protracted conflict and consequent displacement of populations. Ensuing disruption to education and to family and social networks results in particular barriers to social inclusion for young refugees and there is a corresponding need for evidence-based policies and practices to support successful settlement for this population. Social inclusion is a key social determinant of health. Accordingly, this PhD research addresses the question: How can policy-makers and services promote positive resettlement experiences and social inclusion for refugee-background youth in Australia? Its overall aim is to contribute to a deeper understanding of the resettlement experiences of recently arrived refugee-background youth in Australia, and provide policy-relevant evidence to inform service provision for this population. This aim and research question entails the following further objectives: • To review the existing evidence relating to issues of social inclusion, social connectedness, employment and education opportunities for young refugee settlers; • To bring the voices of refugee-background young people themselves into the knowledge constructed around them; • To use theories of social inclusion and social capital to inform understanding of their experiences; • To assess the impact of a support program for recently arrived refugee youth on their resettlement experiences. The project comprised mixed methods evaluation research with young people aged 16 to 24 from refugee backgrounds, who were participating in an innovative intervention called Ucan2, designed to improve settlement outcomes for this group. The research focus is on experiences of resettlement; the mediating role played by social connections; education and employment experiences, aspirations and outcomes; and the impacts of program participation. Theories of social inclusion and social capital - along with Ager and Strang’s (2008) conceptual framework for understanding integration - are used to frame the investigation. Research methods included participant observation, social network mapping, demographic and wellbeing surveys, focus groups and individual interviews. Research findings indicate that young humanitarian entrants to Australia are generally resilient but face threats to wellbeing and inclusion associated with poverty, separation from family and difficulties encountered within unfamiliar education systems. The findings make a contribution to conceptual understandings of settlement experiences and demonstrate a compelling rationale for providing targeted and intensive support such as that offered by the Ucan2 program to young people during the early years of resettlement. They also add weight to recent calls for more flexible and expanded family reunion policies.
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ItemWhat do we mean by support? The receipt of disability services and compensation for people with a Spinal Cord Injury (SCI) in Victoria( 2012)This qualitative study examines the concept of support for people with a permanent impairment of Spinal Cord Injury (SCI) in Victoria. It examines the concept of support in relation to receipt of funded services and compensation provided by three of the state’s major support funders - the Department of Human Services, the Transport Accident Commission and the Victorian WorkCover Authority, and examines the various legal and policy frameworks designed to support people with SCI. Utilising relativist and constructivist grounded theory approaches, it examines the experiences of 11 participants who receive services from within this service framework, and examines how support within this framework is understood and conceptualized and what it means for the these participants to feel supported.
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ItemSettling the mind: psychiatry and the colonial project in Australia( 2012)Set in Australia during the late nineteenth and early twentieth centuries, Settling the Mind tells the story of three Sydney psychiatrists who sought to understand the relationship between race, nativity and madness: Frederic Norton Manning, Chisholm Ross and John Bostock. Their influential (albeit limited) contributions to comparative psychiatry centred on insanity in Aboriginal people, immigrants and native-born settlers. Drawing on asylum case records, official government reports, scientific studies and medical literature from the period, this thesis argues that the doctors’ interpretations of mental disease in ‘others’ were, in the main, reflections of their own concerns and self-image. Manning, Ross and Bostock’s preoccupations with notions of progress and degeneration, belonging and maladjustment, and superiority and inferiority so shaped their findings and distorted their conclusions that the patients upon whom their studies were based all but disappeared from view. Through a deep analysis of the doctors’ writings, this thesis tentatively recovers traces of these patients. Settling the Mind also, however, takes a much wider view, charting the spread of medical knowledge about madness in ‘other’ peoples across borders and between nations from the late eighteenth to the early twentieth centuries. In so doing, it not only illuminates Manning, Ross and Bostock’s scholarly inheritance, but also sheds light on two persistent and seemingly contradictory facets of the Western medical and scientific imagination: first, the theory that civilisation was a potent cause of insanity; and secondly, the association between madness and savagery. This thesis explores why madness was associated with savagery when it was supposedly caused by civilisation, and how mental disease was interpreted in peoples already defined as savage, and thus mad, by nature. It argues that from the late nineteenth century, comparative psychiatry destabilised the opposition between madness and reason, just as it reflected and informed emerging neurological and psychological theories about the nature of insanity itself.
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ItemA method for incorporating vertical equity for disadvantaged groups into health economic evaluations: cost-based equity weights applied to the Australian Aboriginal and Torres Strait Islander population( 2011)Health economic evaluations tend to focus on maximising efficiency, yet the need to consider societal concerns for equity for those who are disadvantaged is also an important factor in health sector resource allocation and decision-making. In this thesis, methods by which these efficiency and equity objectives can be combined within economic evaluation approaches are critically explored, and an alternative is proposed in the form of a cost-based equity weight. Based on the definition of equity ‘equal access for equal need’ and the vertical equity objective of ‘equitable access for unequal need’, it is hypothesised that a cost-based equity weight could be constructed using the ratio of the costs of delivering health interventions equitably via targeted health services for disadvantaged groups compared to delivery from mainstream ‘baseline’ health services. The construction of the weight is illustrated by its application to the Australian Aboriginal and Torres Strait Islander (or Indigenous) population as an example of a group who experience health disadvantage, with equitable primary health care delivery via Aboriginal Community Controlled Health Services (ACCHSs). This research is based within the Assessing Cost Effectiveness in Prevention (ACE-Prevention) study, which uses cost-utility analysis methods of economic evaluation and the disability-adjusted life-year (DALY) as the outcome of interest. Construction of the equity weight and its utilisation in a number of case study economic evaluations has required the development of the Indigenous Health Service Delivery (IHSD) Template to adapt cost and effectiveness evidence from the mainstream to the Indigenous setting. In addition, a decision-analytic epidemiological model of cardiovascular disease prevention has been adapted to be specific to the Indigenous population. Economic evaluation results reveal that pharmacological interventions to prevent cardiovascular disease delivered via ACCHSs produce more total health gain for the Indigenous population than delivery of these same interventions via mainstream GP services. This benefit can be attributed to improved access to these targeted services, although the greater costs associated with comprehensive health service provision makes ACCHSs appear less cost effective. A cost-based equity weight of 0.66 is calculated based on these interventions, which is the factor by which the costs of interventions delivered via ACCHSs are deflated in order to allow equitable comparison with interventions delivered via mainstream GP services. Application of this equity weight in an example significantly alters the economic evaluation results and the subsequent resource allocation recommendations that ensue. In conclusion, this thesis argues that the use of cost-based equity weighs enables economic evaluations to not only consider efficiency, but also apply equity concerns in a manner that is consistent, explicit, practical, and relevant to the target groups it endeavours to address. Therefore, the definition of efficiency used in economic evaluations is broadened to include vertical equity concepts, and results are produced that better reflect societal welfare and the needs of decision-makers.
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ItemThe application of geo-statistical techniques to explore spatial and temporal patterns of suicide( 2012)Spatial health inequalities and disease clustering have been explored in many epidemiological studies, including studies of suicide. Previous studies have found evidence of contagion among teenagers and clustering among economically deprived people. Various measures have been proposed to prevent contagion following a suicide, but additional evidence regarding spatial patterns and clustering is essential for preventing these tragic events. This thesis seeks to identify the spatial and temporal patterns of completed suicide in Australia and identify the correlates of those patterns. Four studies were conducted using a variety of geographical and statistical methods to explore patterns and clustering. Using data from the Coroners Court of Victoria, study 1 investigated the temporal patterns of completed suicide by jumping from the West Gate Bridge in Melbourne. The remaining studies used data on suicide deaths from the National Coroners Information System. Study 2 applied techniques of risk smoothing and mapping to illustrate the spatial patterns of completed suicide over all postcodes in Australia. Study 3 used scan statistics to detect suicide clusters in Australia. Study 4 involved a comparison between clustered and non-clustered suicides to explore correlates of suicide clustering. A sustained increase in jumping suicide at the West Gate Bridge was detected for the 10-year study period, but no clustering pattern was found. Such a pattern was also apparent among jumping suicides at other locations, but not among other suicide methods. These findings supported the hypothesis that a growing reputation of a site as a suicide “hotspot” might sustain the continual increase of jumping suicide at the hotspot and other locations. Responsible media reporting of suicide at the hotspot, and suicide prevention activities at locations close to the hotspot are likely to be useful strategies for addressing suicidal behavior at hotspots. Spatial variation in suicide risk across states/territories were identified, as were metropolitan-rural-remote differentials with rates higher in rural and remote areas for males, and spatial clusters in some high risk postcodes for both sexes. Socio-economic deprivation, population composition, high suicidal risks among Indigenous Australians and low access to mental health services might explain the elevation of suicide risk in rural and remote areas. These findings suggest that it is important to take geographical variations in suicide risk into account in national policy making. Particular suicide prevention interventions might be targeted at males living in remote areas, and some localized areas in metropolitan zones. Based on cluster detection by scan statistics, about 2.5% of completed suicides in Australia occurred as part of suicide clusters. Major clusters were located in the Northern Territory, Queensland, Western Australia and South Australia, and some smaller clusters were found in Victoria and Western Australia. The risk of suicide clustering was greater among Indigenous Australians than non-Indigenous Australians, and among those living in socio-economically deprived areas. These findings suggest that more resources should be allocated to the mental health services for Indigenous people and those living in rural and remote and socially-deprived areas. Sustaining infrastructure and community development in these areas may also be protective against suicide clustering.
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ItemImproving the control of chlamydia in Australia: screening and other strategies( 2010)Chlamydia trachomatis is one of the most common bacterial sexually transmitted infections worldwide, with particularly high prevalence in young people under 25 years. Left untreated it can lead to serious reproductive morbidity in women including pelvic inflammatory disease, ectopic pregnancy and infertility. Given that up to 90% of infections in men and women are asymptomatic, increased testing is required to effectively detect and control infection and limit its associated morbidity. The aim of this thesis was to examine a number of specific strategies aimed at increasing screening and improving the control of chlamydia in Australia. The strategies centered on interventions in primary care to increase chlamydia screening and improve the partner notification practices of general practitioners and individuals recently diagnosed with chlamydia. This thesis reports on six separate studies undertaken to address this aim.