Melbourne School of Population and Global Health - Theses
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ItemProsperity on country: How to reposition the social, cultural and economic value of Indigenous people in the Goulburn Murray region( 2020)Prime Minister Gillard's 'Closing the Gap' speech in February 2011 called on the country's First Peoples to take responsibility for improving their situation. This kind of rhetoric highlights one of the underlying reasons there has been no substantial improvement in the position of Indigenous Australian peoples. Indigenous peoples are predominately identified as 'the problem' and positioned as the agents who need to 'fix it', which ignores the influence of dominant culture in maintaining the current position of Indigenous peoples. Drawing on the experience and knowledge of Indigenous and government leaders working on strategies to empower Indigenous communities, this thesis captures the work undertaken in the Goulburn Murray region of Victoria in the quest to reposition the social, cultural and economic value of Indigenous peoples. For substantive change to be made, power relations between Indigenous and non-Indigenous Australians need to be realigned and dominant social structures reconstituted. Only once these shifts have been made can the country’s original inhabitants enjoy parity in education, health, employment, and economic prosperity. A collective approach that recognises the need for all Australians – Indigenous and non-Indigenous – to play a role in creating these shifts is needed. This thesis is the story of the Yorta Yorta people’s quest to find prosperity on country to reposition the social, cultural, and economic value of Indigenous people in the Goulburn Murray region of Victoria. The research seeks a solution to address the disparity between Indigenous and non-Indigenous peoples from one regional community’s perspective. A shared sense of humanity is central to repositioning the value. An ability to recognise and envision a world of tolerance, kindness, and acceptance in the hearts and minds of all cultures, regardless of race, colour, or religion, can alter everything. The perspectives of participants throughout the thesis make it clear why repositioning the value of Indigenous people is so important.
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ItemDeciphering despair: A study of self-harm in the Australian asylum seeker population( 2020)Australia has had a policy of mandatory immigration detention for all ‘unlawful non-citizens’ since 1992. During periods when there have been a large number of boat arrivals, the vast majority of the detention population have been asylum seekers, referred to as ‘irregular maritime arrivals’. Whilst asylum seekers are at elevated risk of self-harm, and being detained is known to further increase such risk, until recently little has been known about self-harm across the Australian asylum seeker population. This is largely due to the lack of accessible data, and the Australian immigration authorities’ poor self-harm monitoring and reporting processes. This thesis fills a number of gaps in both the national and international literature. It comprises a review of the literature, undertaken in context of the policies governing Australia’s treatment of asylum seekers, and four discrete studies. The evidence generated in the production of this thesis sheds revealing light on Australia’s self-harm monitoring and reporting practices among asylum seekers, as well as the episode rates and key characteristics of self-harm, across the entire Australian asylum seeker population (including by processing arrangements, i.e., onshore detention, offshore detention [Nauru, Manus Island], community detention, and community-based arrangements). The findings reported in this thesis indicate that Australia’s self-harm monitoring and reporting practices are substandard and inconsistent when assessed against international guidelines; and that the burden of self-harm across the Australian asylum seeker population is substantial, particularly among detained asylum seekers. The findings also indicate that episode rates of self-harm are markedly high across all three main types of onshore immigration detention, in comparison with the general population, with average rates not observed to be lower in facilities with lower security features. Variations in the distribution of self-harm were also found according to time of day and month of the year, by processing arrangements. Moreover, high rates of attempted hanging were observed among those in closed immigration detention, compared with community-based settings, as well as in all three main types of onshore detention, and in both males and females. When taken together, the findings reported across the studies included in this thesis make a compelling argument for the expansion of community-based models for processing; tailored, culturally appropriate mental health services for asylum seekers, and the implementation of independent monitoring and reporting of self-harm by a panel of clinical experts who have the statutory power to investigate self-harm among asylum seekers. Targeted, evidence-based responses such as these are likely to contribute to improved mental health outcomes for asylum seekers, and should therefore be considered an urgent public health priority.
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ItemModels of Indigenous community-controlled health care in Chile( 2019)For Indigenous peoples, community-controlled health services are a key means by which communities exert control in the planning, development and delivery of primary health care services and represent an avenue to ensure that health policy and services reflect Indigenous values and an understanding of their health needs. Sustainable implementation of community-controlled health services is strongly dependent on the existence of supportive policy, as well as a health system that is open, flexible and able to respond to external input. However, assessments of participatory health initiatives frequently examine the features of the initiative or program with minimal consideration of how the wider policy environment affects participatory processes. The current study examines the influence of local and distant factors on the effectiveness of Indigenous community-controlled health centres as participatory mechanisms, including interactions between international and domestic legislation and policy. Additionally, the research explored the applicability of lessons learned from countries’ experiences in Indigenous community participation in health to other international contexts. Case studies were undertaken with two Mapuche community-controlled health centres in Chile in order to gain perspective on the day-to-day workings and decision-making processes of the health centres. Interviews were also conducted with Ministry of Health personnel to provide a comprehensive picture of Indigenous health policy and stakeholders’ perspectives. Evidence from international experiences was then used to contextualise the Chilean findings and provide some guidance for strengthening Indigenous community participation in health both in Chile and internationally. Mapuche health administrators cited the existence of a wider system that was extremely resistant to external influence and ‘blind’ to Mapuche health as a key barrier to their work. As a result, Mapuche health centres were highly restricted in terms of their capacity to respond to local priorities and needs, even as staff considered the centres as potential vehicles for increased Mapuche political power within the health system. One of the primary aims of Indigenous community control, increased autonomy and self-determination, was thereby curtailed. Overall, the evidence indicates that international legislation alone carries little weight in facilitating consultation or engagement with Indigenous communities; however, these instruments can provide guidance to countries for the alignment of domestic policy with established principles. Such alignment both enables countries to adopt international agreements and subsequently facilitates implementation of the relevant principles and obligations. The research makes the case for approaches to Indigenous health policy that are undertaken with an eye towards building cohesion between legislation and policy across all levels to support engagement with Indigenous peoples. In conjunction with stronger political representation, incorporating the principles of reciprocal accountability into contractual agreements between the State and Indigenous health centres could support a shift towards relationships that are more equitable, provide greater stability for Indigenous health centres and facilitate increased latitude to respond to their communities’ needs appropriately. Analysis of Indigenous health policy, programs and services that takes a holistic perspective of the international, national and community-level factors impacting implementation would support decision-making in this area.
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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.
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ItemThe cure depends on us: the role of Australian patient organisations in rare disease research( 2015)In this thesis, I explore how Australian patient organisations devoted to specific rare diseases are involved in biomedical research. As with patient organisations for more common diseases, many rare disease patient organisations (RDPOs) have broadened their historical focus on self-help and now seek to advance research on “their” diseases. RDPOs are thought to have special opportunities to influence researchers because they can provide resources – such as funding, study participants, and disease-related knowledge – which are often scarce in rare disease research. RDPOs’ involvement in research is important to theorists concerned with the “public shaping” of science, but it also has immense practical significance. Collectively, rare diseases are estimated to affect six to eight per cent of the population; and most are life-threatening or chronically disabling conditions with no specific or effective treatments. The need to accelerate therapy development, and the absence of government or industry-funded research for many rare conditions, underpins growing international interest in strengthening collaborations between RDPOs and researchers. In the first study of RDPOs in Australia, I reviewed 112 RDPO websites, conducted an online survey completed by 61 RDPO leaders, and interviewed ten RDPO leaders and two key informants. Consistent with international literature and empirical case studies, I found that RDPOs are highly motivated to support research. However, while some Australian RDPOs have helped to advance the understanding and treatment of their diseases, I argue that RDPOs are far from the robust challengers of the research establishment portrayed in the literature. In fact, RDPO leaders face considerable difficulties in upholding organisational interests in their various forms of engagement with academic and industry researchers. For example, leaders may struggle to direct RDPO funding in ways which best meet the goals of the organisation; they may lack the expertise or power to assert their knowledge and ideas when collaborating with researchers; and they may run the risk of real or perceived conflicts of interest in financial relationships with pharmaceutical companies. These problems are related to RDPOs’ limited funds and capabilities, the competing interests of researchers, and the marginalisation of rare diseases in Australian health and research policy. I argue that my study provides a more realistic picture of the challenges faced by “ordinary” RDPOs than previous studies focusing on the successes of large, well-resourced organisations and groups with highly driven, entrepreneurial leaders. Despite the difficulties I identify, I contend that RDPOs have much to contribute to research. They can also play an important role in providing their members with information about biomedical research, including the risks and benefits of participating in mainstream and novel forms of research – such as participant-led clinical trials and crowd-sourced health studies. I suggest that there are considerable opportunities in Australia, building on the findings of this study and international initiatives, to support and safeguard RDPOs’ involvement in research, for the benefit of Australian research and people affected by rare diseases.
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ItemFlight of international medical graduates: a cross-country comparative study examining key events in the trajectory( 2015)In the past two decades the growth in health workforce migration has drawn global attention towards the role of different factors in influencing the observed patterns and trends. This PhD thesis is an inquiry into factors that determine health worker migration and integration in destination countries, using international medical graduates (IMGs) as an example. The thesis attempts to achieve this by exploring and analyzing both the analytical and theoretical aspects - critically appraising the literature and using comprehensive datasets to undertake sophisticated analyses to identify the drivers of international migration. I find that limitations of the existing migration theories have affected our understanding of factors that determine international migration of health workers. This has been accentuated by the lack of analytical research on the determinants of health worker migration. I analyse data from multiple secondary sources in a gravity model to identify that a range of geography, demography and cultural factors influence the movement of physician between source and destination countries. In addition, I find that immigration policies in destination countries have modest but significant influence in determining these flows. Using Australia, a key destination country, as a case study I report that in destination countries policy settings have frequently been modulated with periodic shifts between phases of containment and growth in international recruitment of health workers. I find that the dynamics of the process is determined by the level of political action taken by key groups - the profession, state and employers. Using data from the 2011 Australian Census, I demonstrate that the labor market outcome of IMGs in destination countries is an important issue. My results show that IMGs are significantly less likely to find employment in occupations commensurate with their professional training, especially in the early settlement period. The probability of being employed as a physician is lowest for IMGs from non-English speaking background countries in Asia and Eastern Europe. Using New Zealand, another key destination country, as a case study I discuss the challenges associated with managing an internationally recruited medical workforce. I highlight the need for countries to focus on finding long-term domestic answers to the workforce problems. Based on a systematic review of the literature I report that the available literature is insufficient to generalize that IMGs provide valuable service in rural areas, except in some rural communities. Further, I find that there are contradictions regarding their contribution to the rural workforce beyond the years of obligated service or training. A range of professional, personal and family factors affect their retention in rural location. I conclude that the trends and patterns of health workforce migration seem to be intrinsically linked to geographic, demographic, economic, political and cultural factors. The growing demand of health workers in destination countries and the related policy context have a clear role in shaping the migration processes. The dependence on international recruitment however raises concerns regarding their integration, retention and the sustainability of the approach in the long-term. In order to better address these concerns there is a recognized need to continue to improve our understanding through further research on key areas related to management of the migrant health workforce.
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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.