Melbourne School of Population and Global Health - Theses
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ItemThe usage of psychotropic medications by family caregivers( 1996-07)This is a randomly selected, cross-sectional, population based study of women caring for family or friends who are elderly or have a long-term illness or disability. The purpose of the study was to investigate the usage of psychotropic medications by carers in order to identify predictors of usage of these medications relating to the caring situation. Data collected in 1993 by the Carers’ Program in the state of Victoria, Australia was used for statistical and qualitative analysis. The data base consisted of 157 carers and 219 non-carers. Women who had the main caring role for a relative or friend with a disability for at least 4 hours per week were selected for the study. Women who were living with a partner or children or both and had the main responsibility for household tasks but were not caring for someone with special needs were selected as the comparison group. Using this group of non-carers allowed direct comparison of carers and non-carers to be made and to identify the difference that the role of caregiving to someone with special needs makes when compared with usual family care responsibilities.
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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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ItemAn exploration of the model of reciprocal determinism in aged care environments( 2010)Introduction: Once dementia progresses to the later stages, behavioural and psychological symptoms of dementia (BPSD) can be prevalent. Many aged care workers have limited training and education in managing BPSD. This often impacts negatively on the quality of care provided to residents, and outcomes for the staff, including increased stress and job dissatisfaction, leading to turnover and subsequent staff shortages. One of the latest Australian government initiatives aimed at addressing many of the issues influencing resident and staff outcomes, is the Dementia Behaviour Management Advisory Services (DBMAS). This study evolved from the evaluation of the DBMAS. The evaluation was atheoretical; often the case in health care research and evaluation. Applying a theoretical model to understand the factors prevailing in aged care environments is needed. Aim: To explore the model of reciprocal determinism in aged care environments. Reciprocal determinism proposes there is a dynamic interaction between (a) personal factors, (b) environmental factors, and (c) behaviour; all factors can influence, and be influenced, by the other factors. Methodology: Involved combining two key sources of data: (i) literature relating to the application of the model of reciprocal determinism in work environments; (ii) secondary analysis of data from a client survey evaluating the DBMAS. The structured survey sought information relating to resident BPSD, effect of BPSD on staff, services provided by the DBMAS, and the impact of those services on residents (BPSD, quality of life), and staff (including skills, confidence, stress). The survey was administered (over the telephone) by the researcher. RACFs were selected on the basis that staff had used the services of the DBMAS in their jurisdiction, within August to November, 2008. At the end of the data collection period (December 2008), 137 respondents (82.5%) of 166 eligible RACFs had participated. Analysis of data primarily involved a series of cross-tabulations, where Chi sq and Fisher’s Exact tests were used to examine possible associations between various factors. Results: The literature indicates the model has not been applied in aged care environments; however, elements of the model have been examined. For example, staff self-efficacy/confidence, and stress (personal factors), resident behaviour, staff training and education (environmental factors), staff turnover (behaviour). Existing models capture many of the factors operating within aged care environments. These models were developed using an inductive approach, where the data lead the development of the theory, whereas the model of reciprocal determinism adopted a deductive approach, where social cognitive theory guided its development. The model of reciprocal determinism has proved useful when exploring other work environments, including organisational safety culture. Data collected from the client survey, provided support for possible associations between different factors within the model. For example, (i) the DBMAS intervention (environmental) was significantly positively associated with staff personal factors (skills p = .023; confidence p = .001; stress p = .002), particularly if the level of services was medium or high; (ii) the DBMAS intervention was reported to be successful in reducing the most difficult resident BPSD (environmental) to manage; (iii) improvements in staff personal factors were significantly associated with staff behaviour (skills X care time p = .000; confidence X care time p = .002; stress X care time p = .000), and (skills X absenteeism p = .020; confidence X absenteeism p = .033; stress X absenteeism p = .002). Conclusion: Overall, results were supportive of the model’s utility. Suggestions of its ability to provide insights and innovative methods for intervention design, management, and research/evaluation are provided. Although the study is exploratory, and should be viewed from a hypotheses generating perspective, this heuristic model has considerable value for focussing on the “bigger picture”, and not analysing various aspects within aged care, in isolation.