Melbourne School of Population and Global Health - Theses
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ItemIndividual and environmental determinants of fast food purchasing(University of Melbourne, 2008)
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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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ItemThe spirit of emancipation and the struggle with modernity : land, art, ritual and a digital knowledge documentation project in a Yolnu community, Galiwin'ku, Northern Territory of Australia(University of Melbourne, 2008)This thesis concerns Indigenous knowledge systems, agency, technology and modernity. It presents an ethnographic study of a contemporary Yolrp documentation project devised in a remote township in north-eastern Arnhem Land, in the Northern Territory of Australia, in order to produce meaningful representations of modernity for the young generations. The study sets out the possibility to rethink the implications of the digitisation of Aboriginal knowledge within the broader theoretical frame of cultural transmission. It draws on the dynamic tension between structure, performance and agency to transcend common views of what culture is in order to investigate the performative aspects of knowledge production. In other words, the ethnography tracks the social life of Yolnu culture, from the field to the archive (ethnographic, digital) and back again and describes how these trajectories are inscribed in multi-sited knowledge systems which in turn inform contemporary meaning making practices and strategics of representation and becoming. Research questions were originally framed around the changing status of images in Yolrju society, a people who have a long tradition of anthropological dealings and whose material collections can be found in numerous archival institutions. In these times of rapid change, I was and am particularly interested in examining the use Yolnu made of Information and Communication Technologies (ICT) in cultural resource management projects and the ways in which these experiments influenced contemporary approaches to knowledge transmission. For this purpose, fieldwork undertaken on Elcho Island between February 2003 and December 2004, revolved around the Caliwin'ku Indigenous Knowledge Centre, a community organisation which, as part of a state wide strategy to support "sustainable" communities, had just received seed funding from the Northern Territory Libraries to build a digital cultural archive. In this thesis, I document how this digital experiment evolved in the community, further departing from the original project-plan as it was gradually being appropriated by the local actors and fitted into Yolgu reality of being in the modern world. While the "knowledge centre" concept itself became increasingly entangled in a web of controversies and strategically reconfigured at the local level, the organisation was taken over by a group of senior Yolnu men whose primary concern lay with the recognition of their ancestral law and historical agency, the transmission of knowledge to the young generations and the projection of meaningful representations into the future.
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ItemPre-existing mental disorders and health outcomes after release from prison: a case for continuity of care( 2018)Globally, there is good evidence that people in prison are distinguished by their poor health profile and by entrenched socio-economic disadvantage. Mental disorders, especially severe mental illness, are overrepresented among people in prison. People released from prison are at particularly high risk of poor health outcomes and this risk is higher among people with pre-existing mental disorders compared to those without mental disorders. However, beyond drug-related outcomes, infectious disease epidemiology, and mortality, substantial gaps in evidence exist, limiting the capacity to respond to the often multiple and complex needs of people with mental disorders released from prison. This thesis fills this internationally recognised gap in the literature. It comprises a review of the literature and six discrete studies. The studies included in this thesis generate previously unavailable evidence on gaps in transitional service provision for people with intellectual disability released from prison; patterns of health service utilisation, and health outcomes for people with and without pre-existing mental disorders released from prison; and the determinants of findings of unfitness and unsoundness for people with cognitive disability referred to a Mental Health Court in Australia. The findings reported in this thesis indicate that people with pre-existing mental disorders experience gaps in transitional service provision; and are at increased risk of poor health and related outcomes compared to those without a mental disorder after release from prison. Given their poor outcomes and inherent vulnerabilities in the criminal justice system, people with mental disorders should be considered for diversion from incarceration into therapeutic environments where appropriate. Furthermore, the findings in this thesis provide new evidence that injury is a key target for prevention among people released from prison, especially among those with co-occurring mental illness and substance use disorder. When taken together, the findings across the studies included in this thesis make a compelling case that increased integration between forensic and community healthcare providers would improve the continuity of care and prevent poor health outcomes experienced by people released from prison. Furthermore, these findings can be used to inform the development of interventions and service responses to improve the continuity of care for people with mental disorders released from prison.
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ItemThe challenges of international scientific collaboration in twin research( 2018)Twin studies enable powerful approaches for untangling the roles of genes and the environment on human traits and conditions. Twin registries have been established across the globe since the 1950’s to facilitate twin studies through collecting and maintaining data and contact information of twins. International scientific collaboration in twin research represents an opportunity for establishing a large pool of twin data and expertise for analysis. However, such collaborations are rare. The International Network of Twin Registries (INTR) has, so far, failed to deliver large multi-registry twin studies that can tackle big problems related to the health of the population. I investigated the challenges of international scientific collaboration in twin research through a case study approach. To explore individual and interpersonal aspects of such challenges, I conducted 18 in-depth semi-structured interviews with researchers. To explore structural aspects, I studied the Brazilian Twin Registry (BTR), Twins Research Australia (TRA) and the INTR through participant observation. I also analysed documents, data reports and other information from the above case study sites. I found that these challenges can be grouped in three major themes: (1) the ‘silos’ in international twin research; (2) the capacity and the future sustainability of twin registries; and (3) ethical challenges in engagement, communication and policy-making. Striking differences in resources between researchers and twin registries operating in the global arena of collaborative twin research appeared as substantial obstacles. My findings also suggest that twin research is currently divided into silos related to the researchers’ disciplines, personal motivations and belief systems. While such silos are not necessarily detrimental to scientific productivity within disciplines, they represent barriers to the large-scale international twin studies that can achieve sufficient sample sizes for robust study outcomes. More importantly, while most informants appeared confident in the capabilities of co-twin control studies, especially those with MZ twin pairs discordant for disease, many of them seemed to question the validity and clinical relevance of classical twin studies. Classical twin studies have continuously influenced public discussion and policy-making debates related to a variety of human traits and conditions for almost 100 years. My findings have implications for the future of the BTR, TRA and, more broadly to other twin registries. They also contribute to possible future pathways for the INTR. However, the most significant contribution of my research pertains to how the misinterpretation of heritability estimates from classical twin studies by researchers and the media can lead to an agenda of genetic determinism. The confusion arising from the misleading communication of scientific findings from classical twin studies appeared as a major ethical challenge. These practices can also jeopardise the credibility of twin research as a tool to the understanding of the role of genes and the environment on human complex diseases. Researchers should take a proactive approach in helping educate the media, the public and policy-makers on what the findings from twin studies are really telling us, and perhaps even more importantly, what they are not.
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ItemListening to the voices of children, parents, and teachers about children’s school life: promoting children’s wellbeing in Yogyakarta, Indonesia( 2018)Background. This thesis reports on a study to identify the experiences of children at school and to develop a school model that promotes children’s wellbeing in Indonesia. This study is significant for two important reasons. The first is that the link between children’s school life and wellbeing in Indonesia appears to have received little interest from researchers, despite children’s mental health and education both being significant factors influencing the quality of future generations of nations. Therefore, developing a school model that potentially promotes children’s wellbeing would increase the understanding that schools as educational institutions have significant responsibility for children’s wellbeing. The second is that a greater understanding of the responsibility of promoting will enable more strategic formulation and implementation of mental health promotion for young generation within Indonesia. The aims of the study. The first aim is to identify positive and negative experiences of school life in Indonesia. Second, it is to develop a model/concept of a school that potentially promotes children’s wellbeing within Indonesia context Methods. This study consists of two questions. Question 1 identifies the positive and negative experiences of children’s school life from the perspective of parents, teachers, and children. Question 2 develops a school model that potentially promotes children’s wellbeing. The participants were thirty primary students, thirty primary teachers and thirty parents from three types of schools (public, private and Islamic school). The study was conducted in Yogyakarta in 2014. Data were collected using focus group discussions based on creative activities (photovoice, art, and drawing). For question 1, data were analyzed using content analysis, and for question 2, a grounded analysis was used to analyze the data. Results. The findings - question 1. This study found that positive experiences of children’s school life in Yogyakarta are associated with: good facilities and infrastructure, innovative learning methods, good quality of teachers, good friends, sports activities, art, and cultural activities, fun classroom circumstances, fun school activities, extra curriculum activities, and subject lesson. All of the positive experiences found in the Indonesian context have been identified by research conducted in other contexts. However, this study specifically found that in Indonesia good infrastructure and facilities are significant factors for children to have positive experiences at school. This study also found the negative experiences in school life were associated with: poor facilities/infrastructures, negative learning circumstances and neighborhood, low-quality teachers, bad friends, negative children’s behaviors, conventional learning methods, uninteresting subject lesson, ghosts at school, and final national examination (UAN). Interestingly, ghosts at school and national final examination were findings that differed from previous research. In this thesis, I discussed these two factors in the Indonesian context. The finding of this study is significant for raising awareness of all educational stakeholders to know that children’s experiences of school life are valuable for understanding the factors that impact children engagement and disengagement in school. In addition, providing information about experiences from children themselves, which has never been acknowledged before in the Indonesia education system, supports school leaders and policymakers in Indonesia to improve the quality of education that enables the engagement of students in learning processes at school. The findings - question 2. The model is based on two main Indonesian values namely kekeluargaan (kinship) and gotong-royong (communal works/mutual aids). These values underline the whole school model with the aim to promote children’s wellbeing. Kekeluargaan (kinship) is defined as “a value believing that school community is a part of nation’s family and all members in the school (student, teachers, parents) are tied as a family. “ The relationship among teachers, students, and parents in Indonesia is more than ‘a professional relationship’, but more as a family. As a family, they should work together, help and support each other. In the Indonesian culture, it is called gotong royong (communal work/mutual aids). So, the definition of gotong royong is “a value believing that as a family, all members of the school should help and support each other as well as work together to solve personal, school and social problems.” These two values influence Indonesian behaviour and culture including school culture. The values of the model underlie the principles of the school model. There are five principles that should be included in the model, those are positive learning circumstances, children’s engagement, parent and community involvement, cultural and real-life learning, and social and emotional learning. In other words, schools in Indonesia should be committed to extending their role in promoting children’s wellbeing to influence the school’s culture based on these five principles. In order to effectively implement the principles that are strongly influenced by the nation’s basic values, schools may use some strategies suggested in the model. Four strategies offered within the model are leadership and management, collaboration and partnership, school’s curriculum and school activities (either extra or non-curriculum activities). Finally, the outcome of the school model is health, safety, friendly, respectful, joyful, creative and challenging learning, and connected to society.
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ItemSupercomputing pipeline for the Ark (SPARK)( 2018)Data is the primary asset of biomedical researchers and the engine for both discovery and translation. The challenge is to facilitate the discovery of new medical knowledge, supported by advanced computing technologies based on heterogeneous medical datasets. At the beginning of the 21st century, the much-anticipated Human Genome Project was completed, thus commencing an era of high-dimensional genomic datasets. Additionally, the internet era has introduced advanced and more user-friendly computing technologies for data storage, processing, and analysis. The biomedical informatics research field has emerged to fill the void between medical research and computing technologies. The Ark is an open-source web-based medical research data management plat- form which currently supports multiple medical research studies. The Ark’s soft- ware architecture is modular, capable of managing multiple studies and sub-studies in a single database, including laboratory information and questionnaire data. The Ark’s role-based security infrastructure provides a secure environment for biomedical datasets. Prior to the work presented in this thesis, The Ark did not have the capability to effectively manage or analyse genomic data, nor model pedigree structures. This thesis presents a next-generation biomedical data management system, the Supercomputer Pipeline for The Ark (SPARK). SPARK provides a novel data management approach to pedigree and genomic datasets. The SPARK project enables access to high-performance computing (HPC) using a software architecture that builds upon The Ark’s researcher-friendly web-based interface. The Ark genomics module can accommodate multiple HPC facilities simultaneously, enabling multiple SPARK nodes that are attached to each HPC facility to operate independently. A SPARK plugin format for analysis algorithms is implemented, promoting the exchange of algorithm implementations within the global genomics community. In addition to HPC support, the genomics module provides functions to manage high-dimensional genome-wide association study (GWAS) data. A mechanism to manage and analyse GWAS datasets using a mixed relational/non-relational model is designed and implemented. A further major contribution of this thesis is the first open-source pedigree data modelling and visualisation tool that is integrated with a sophisticated medical data management system. The Ark’s new pedigree module is capable of modelling n-th degree relatives and twins, including multiples. It can dynamically infer family structures based upon parental and twin relationships alone, and can visualize these structures with configurable annotations, for example, affected status. In summary, SPARK implements a novel knowledge discovery platform that in-corporates HPC and genomic data management capabilities into The Ark. SPARK empowers medical researchers, who do not have a computer science background, to exploit HPC resources for genomic medical research, share algorithms and data, and extract results in a user-friendly way. The pedigree module extends The Ark to handle family and twin-based studies, which are a powerful tool to better understand the origins of disease. SPARK represents an important milestone in translating HPC and Big Data management technologies to the medical research community. The design and implementation described in this thesis are sufficiently generic that they could be readily extended to other medical domains involving Big Data, and analyses that demand HPC.
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ItemHealth economics and chronic disease, with a specific focus on diabetes( 2018)Chronic diseases, which refer to diseases that are of long duration and generally slow progression, cause more than half of the deaths worldwide today and bring heavy economic burden on both individuals and health systems. Health economic evaluation has been a useful tool for the management of chronic diseases, as it takes account of cost in decision-making and usually measures long-term health outcomes from health interventions. This thesis studies on chronic diseases, with a special emphasis on diabetes, from a health economics perspective. It applies a wide range of health economics methods, with an endeavour to fill in the gaps in existing literature and provide new evidence and practical tools for chronic diseases. The thesis includes six individual studies, which can be divided into three main parts: • Cost analysis— The first part of this thesis focuses on the cost of chronic diseases. It includes two individual studies. The first study explores the potential of using administrative data to build indices and thus more efficiently evaluate on out-of-pocket expenditure. It then applies this method on four chronic disease patient groups. The second study demonstrates the trend on cost and price of insulin and other diabetes medications in the United State from 2002 to 2013. • Risk prediction on long-term health outcomes— The second part of this thesis includes two studies on long-term risk prediction, with an emphasis on regional differences. The first study recalibrates the widely used Framingham cardiovascular disease (CVD) risk equations in an Australian Indigenous cohort. The recalibrated equation corrects the underestimation and provides better CVD risk predictions in this population. The second study examines whether the predictive power of self-rated health on mortality in type 2 diabetes patients is different across different regions of the world. • The use of simulation modelling— Simulation modelling is a useful tool in health economics studies, since it can help to replicate the clinical process of a disease and extrapolate intermediate health effects into long-term outcomes. It is widely used in diseases with a complex and long process like diabetes. The last part of this thesis focuses on simulation modelling in type 2 diabetes. It includes a systematic review and meta-analysis on published model-based type 2 diabetes economic evaluations, and a self-built Asian type 2 diabetes simulation model that incorporates self-rated health as a novel predictor.
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ItemRemote Aboriginal women and meaningful work: key dimensions for Ngaanyatjarra women( 2018)This study depicts how Ngaanyatjarra women in a remote Aboriginal Australian community collectively initiated, developed and managed a suite of community service activities. It describes the development of the activities, a supportive workplace and a worker role meaningful and congruent with the social and cultural contexts of their lives. Using ethnographic methods, it outlines the women's activities and their descriptions and interpretations of these to reveal key dimensions of meaningful work and effective workplace structures and processes that enabled productive work engagement. The epistemological foundations of the research, based on a call for ethnographic research to be “inherently advocative” and emergent from “community-defined needs” (American Anthropological Association, 2002), reveals important insights for politicians, policy and program developers about productive and meaningful work for Aboriginal women in remote communities with crucial implications for government policy linking income security with work engagement.
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ItemThe epidemiology of pelvic inflammatory disease diagnosed in Australia( 2018)Pelvic inflammatory disease (PID) is a serious reproductive health issue for women that occurs when infection ascends from the lower to the upper genital tract. Possible sequalae include infertility, ectopic pregnancy and chronic pelvic pain. The sexually transmitted infections (STIs) Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhoea) are commonly implicated, however the microbial aetiology is often unknown. PID diagnosis is imprecise due to its many possible clinical features and absence of an objective reliable non-invasive diagnostic test. As PID epidemiology varies between countries and population groups due to different STI prevalence and healthcare systems, country specific estimates are critical. This thesis aims to improve understanding of the epidemiology of PID diagnosed in Australia, particularly with reference to chlamydia infection as this is the most frequently diagnosed STI in Australia. Chapters 1 and 2 discuss the evidence and describe what is known about the aetiology and epidemiology and PID, providing the rationale for this PhD program of research. Chapter 3 involved an analysis of data for 15,690 women aged 16-49 attending a sexual health clinic, to examine the microbial characteristics of PID. At a population level, chlamydia was the more commonly identified microbial organism, with 8.2% (95% Confidence Interval (CI) 7.7, 8.6) of women chlamydia positive, 2.8% (95%CI 2.5, 3.0) diagnosed with PID, and, the adjusted population attributable fraction (aPAF) of PID associated with chlamydia was 14.1% (95%CI 9.9, 18.0). Among a subset (n=8,839) of women, 0.3% (95%CI 0.2, 0.5) were gonorrhoea positive only, 0.2% (95%CI 0.2, 0.4) were gonorrhoea and chlamydia positive, 4.7% (95%CI 4.3, 5.2) were diagnosed with PID, and the aPAF for gonorrhoea was 1%. There was a higher odds of PID for women with gonorrhoea or chlamydia (4.4-fold vs 3-fold, respectively) compared with no infection. A sub-analysis for asymptomatic women showed that 28% of PID was associated with chlamydia but only 0.6% of asymptomatic women were diagnosed with PID. Chapter 4 involved a separate comprehensive analysis of the same dataset as in Chapter 3, to investigate the characteristics of clinically diagnosed PID where no infection was identified (pathogen-negative PID). Among 330 women with PID who were tested for chlamydia, gonorrhoea, Mycoplasma genitalium and bacterial vaginosis, 62% had no infection diagnosed. Multivariable logistic regression showed that women with pathogen-negative PID were more likely to be aged >30 years (Adjusted Odds Ratio (AOR) 1.7, 95%CI 1.0, 3.0) and less likely to have evidence of vaginal inflammation (AOR 0.5, 95%CI 0.3, 0.9) or report recent unprotected sex (AOR 0.6, 95%CI 0.4, 1.0) than women with pathogen-positive PID. Chapter 5 investigated PID diagnosis characteristics and time trends at a large sexual health clinic, before and after clinical audit feedback. The study found that between 2002 and 2016, the yearly PID diagnosis rate increased from 0.8% (37/4836) to 2.9% (209/7088) and an increasing proportion of women reported any symptoms (35.7% to 56.6%) or were diagnosed with an STI or bacterial vaginosis (9.4% to 21.4%). Univariable generalised linear models showed PID rates increased after audit feedback in 2007 by 8% yearly (incidence rate ratio (IRR) 1.08, 95%CI 1.06, 1.11), but were unchanged (aIRR 1.01, 95%CI 0.98, 1.03) when patient characteristics were included in multivariable analysis. Since audit feedback, the clinic has reoriented services to increase capacity for high risk patients that appear to have had a greater impact on PID diagnosis rates than audit feedback. Chapter 6 estimated yearly (2009-2014) population rates of PID diagnosis using hospital admissions and emergency department data from three Australian states (Victoria, New South Wales, Queensland). Zero inflated Poisson regression models were used to examine variation in rates by year, age-group and residential area. In 2014 the overall PID rate per 100,000 women aged 15-44 years, was 63.3 (95%CI 60.8, 65.9) for admissions and 97.0 (95%CI 93.9, 100.2) for emergency department presentations. Comparing 2014 with 2009, the overall PID rate in admissions did not change, but when examined by type of PID, admission rates increased for chlamydial and/or gonorrhoeal PID (aIRR 1.73, 95%CI 1.31, 2.28) and unspecified PID (aIRR 1.09, 95%CI 1.00, 1.19) but declined for chronic PID (aIRR 0.83, 95%CI 0.73, 0.95). PID rates in emergency departments were higher (aIRR 1.34, 95%CI 1.24, 1.45) in 2014 than 2009 and substantially higher for women aged 15-24 (aIRR 2.78, 95%CI 2.62, 2.94) than 35-44 years. In conclusion, this thesis provided the first Australian estimates of the population level risk of PID associated with chlamydia and gonorrhoea. This new information based on the PAF suggests that eliminating chlamydia in a high prevalence population might only reduce PID by 14% and around 1% if gonorrhoea were eliminated. For low chlamydia prevalence populations, the PAF findings suggest that only a small number of PID cases might be avoided by widespread chlamydia screening. This thesis provided updated evidence for the frequency of PID pathogens in Australia, and, the many cases without an identified pathogen highlighted the need for non-invasive bio-markers for upper genital tract inflammation. In the absence of bio-markers the decision to commence PID treatment should continue to be based on clinical features and sexual risk. This thesis found that PID remains a substantial cause of attendances at sexual health clinics and hospitalisations for reproductive related health issues for women in Australia. Analyses of sexual health clinic data demonstrated the importance of adjustment for patient characteristics in interpreting time trends, and, investigation of hospital data showed how ecological analyses of data from health settings where women with PID are managed can be used to measure PID trends. Evidence was provided for an increase in PID diagnosed in Australian emergency departments that could reflect increasing PID incidence, shifting healthcare usage from primary care, or, inadequacies in PID diagnosis and management in primary care. Primary care data and systems to monitor PID incidence are needed to better understand PID epidemiology, healthcare usage, and the impact of chlamydia and STI control policies.