Melbourne School of Population and Global Health - Theses
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ItemThe Relationship Between Mental Health Problems and Gambling Harm( 2023-11)Gambling is a legal, recreational activity in many countries. It can provide benefits for some, such as enjoyment or socialisation, but can be harmful for others. Common harmful consequences of gambling include financial harm, relationship stress, and poorer health. Mental health problems, common sources of social disadvantage, are highly correlated with gambling harm. However, the causal effects and the underlying mechanisms of this relationship are poorly understood. If gambling causes mental health problems, this would indicate that gambling may create social disadvantage. If mental health problems lead to gambling harm, this would indicate that gambling may exacerbate existing disadvantage and widen social inequalities. Therefore, better understanding the causal relationships is important for informing the need for policy to reduce the effects, and better understanding the mechanisms underlying the relationship would help to identify interventions that could do this effectively. This thesis aims to improve the understanding of the relationship between mental health problems and gambling harm by exploring the causal effects and the underlying mechanisms of the relationship. It does this through a body of research covering theoretical, experimental, and econometric methods. Chapter 2 presents a new theoretical model of gambling behaviour. The model helps to identify personal characteristics that may increase the risk of gambling harm for people with mental health problems, and features of the gambling environment which may be particularly conducive to causing mental health problems. Chapter 3 presents results from a Discrete Choice Experiment mimicking online gambling on horse racing. The study finds that people with mental health problems put less thought into their bets and prefer riskier bets, two characteristics linked with a higher likelihood of developing gambling harm. Chapter 4 presents econometric analysis of spatial data with information on the location of gambling venues and residence of people who died by suicide over an 18 year period. The study finds that greater accessibility to gambling venues is associated with higher rates of suicide. Collectively, the studies in this thesis improve understanding of the relationship between mental health problems and gambling harm, and make important methodological contributions. The findings highlight higher propensity to gamble as an escape and impaired cognitive functioning as two key reasons why people with mental health problems may be more likely to develop gambling harm, and that easy access to gambling is a key feature of the gambling environment that can contribute to mental health problems. These findings have important implications for informing policy that aims to reduce the risk of gambling harm for people with mental health problems, mitigate the causal effect of gambling on mental health problems, and ultimately reduce social disadvantage.
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ItemIdentifying interventions to prevent suicide in public places and evaluating the impact of these interventions( 2023-12)Information is lacking about the extent to which suicides occur in public places, and about the factors that influence suicides in these places. There is also a lack of understanding about which interventions, other than restriction of access to means, might effectively contribute to suicide prevention in public places where suicides are frequent. This thesis comprised four studies designed to address these gaps in knowledge. Study 1 was a descriptive epidemiology study, and Studies 2-4 took the form of pre-post evaluations that assessed the population-level effectiveness of three different interventions. The aim of Study 1 was to identify the percentage of suicides occurring in public places in Australia, and to examine the socio-demographic factors associated with these suicides in public places. Study 2 sought to evaluate the effectiveness of fixed phone boxes, utilising data from six different sites (five bridges and one cliff) in Australia and the United States. Study 3 aimed to assess the effectiveness of incomplete restriction of access to means (i.e., the installation of barriers which still allowed for jumping from part of the site), using data from four bridges in Canada, South Korea, and the United States. Study 4 evaluated two interventions – a Video-based Incident Detection System (VIDS) and rolling bars – that were sequentially applied to a bridge in Korea. All data were obtained from government agencies including data managed by, or for, coroners, police, sheriffs, or national suicide prevention foundations. Study 1 indicated that 25% of suicides in Australia occurred in public places, 69% at home, and 6% in non-public places other than homes (such as institutional facilities and aged care facilities). Males had higher odds of dying by suicide in public places than females, while those who were divorced, separated, or widowed (in comparison to those married), those aged 30-54 or 55 and above (compared to those under 30), and those who were employed or not in the labour force (compared to employed individuals) had lower odds of dying by suicide in public places. Study 2 showed that since the installation of fixed phone boxes, two sites exhibited a statistically significant increase in suicides, while four other sites showed little evidence of an increase. The pooled rate ratio indicated substantial heterogeneity between the effects and insufficient evidence to conclude that there was a difference in the rate between the pre- and post-intervention periods. Study 3, which explicitly evaluated incomplete restriction of access to means, revealed significant site-specific differences in effectiveness. At two of the bridges included in the study there was a decrease in the suicide rate at the site after installation of barriers, while the rates in two other sites after installation did not differ significantly compared to the pre-installation period. Study 4 demonstrated that the installation of the VIDS increased the rate at which interventions occurred when someone engaged in suicidal behaviours before jumping but did not change the suicide rate at the site. Subsequent installation of rolling bars led to a significant decrease in the rates of both suicidal behaviours at which intervention occurred and suicide at the site. These findings indicate that suicides in public places comprise a substantial proportion of all suicides. Site-specific suicide prevention approaches in public places vary in their effectiveness, with restriction of access to means at these sites generally being more impactful than other site-based measures. However, some sites in the above studies demonstrated a significant reduction in suicide rates through interventions other than means restriction, suggesting that a carefully considered approach to implementing site-based interventions could enhance suicide prevention efforts.
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ItemEpidemiology of adult chronic cough( 2023-10)Background: Cough is common in adults and has major impacts on individuals’ physical and mental health, and a high economic burden. Cough is a heterogenous condition and clinical guidelines recommend classifying or phenotyping cough by its duration (i.e., acute, subacute, and chronic cough) and the underlying conditions causing the cough (e.g., asthmatic cough, reflux cough, etc.). Diagnosing and treating the underlying conditions responsible for cough is often challenging, as sometimes no underlying conditions can be identified and treating the conditions may not fully resolve the cough. Therefore, using cough-related symptoms to explore heterogeneity can be simpler and more practical. Research Gaps: The heterogeneity of cough in the general adult population is poorly understood as most studies have recruited patients from cough clinics, reducing the generalisability of the findings. Furthermore, several studies have been published to investigate the longitudinal risk factors of cough in adults, but the evidence has not been systematically synthesised. There is also inadequate and inconsistent evidence on some risk factors of cough such as occupational exposures and ambient air pollution. This inconsistency may stem from the use of standard definitions of cough (i.e., chronic cough, chronic phlegm, and chronic bronchitis) which may not fully capture the heterogeneity of cough. Aim: My overall aim was to investigate the risk factors for and heterogeneity of cough in the general adult population. My specific objectives are: i) to systematically synthesise the evidence on longitudinal risk factors for adult cough; ii) to investigate the heterogeneity of cough based on cough-related symptoms (i.e., denoted as cough subclasses in my thesis) among a middle-aged population; and iii) to investigate the associations between potential risk factors and the novel cough subclasses identified in the previous objectives. Methods: My doctoral research utilised systematic review methodology and original data from the population-based Tasmanian Longitudinal Health Study (TAHS) that followed participants from age 7 to 53 years. Latent class analysis was used to identify cough subclasses in middle age based on cough-related symptoms. Clinical features of different cough subclasses were described using prevalence with logit-transformed 95% confidence intervals (CIs) and were compared using t-tests or chi2 tests. Occupational exposures were coded into a Job-Exposure Matrix (JEM) using data from participant work history calendars. Markers of ambient air pollution were derived from the residential addresses of participants using satellite-based land-use regression models. Multinomial logistic regression models were performed to assess associations between exposures and the cough subclasses, after adjusting for confounders. Logistical regression models were used for the standard cough definitions (chronic cough, chronic phlegm, and chronic bronchitis) to enable comparisons with the results from my newly identified cough subclasses. Results: In Chapter 3, I present my findings from the systematic review and meta-analysis. It found heterogeneous definitions of chronic cough used in the literature. Asthma, persistent smoking, and lower education were consistently associated with an increased risk of chronic cough in adults with little to moderate heterogeneity. There was inconsistent evidence for risk factors such as occupational exposures and ambient air pollution and substantial heterogeneity was observed across primary studies precluding any meta-analysis for these factors. In Chapter 5, I present my novel classification of six cough subclasses in a middle-aged general population using latent class analysis. Each of the cough subclasses had distinct clinical features cross-sectionally and longitudinally from childhood to middle age. The subclasses were labelled as “minimal cough”, “cough with colds only”, “cough with allergies”, “intermittent productive cough”, “chronic dry cough”, and “chronic productive cough”. In Chapter 6, I report my findings on the associations between occupational exposures and my novel cough subclasses. Specific occupational risks were identified for different cough subclasses, which were not fully captured when using standard cough definitions as outcomes. These included associations between aromatic solvents and chronic dry cough; biological dust and allergic cough; and herbicides, other solvents, and productive cough. In Chapter 7, I report my results of associations between ambient air pollution and my novel cough subclasses. There was a linear, dose-response relationship between ambient nitrogen dioxide (NO2) and productive cough (intermittent and chronic), as well as fine particulate matter with an aerodynamic diameter <= 2.5um (PM2.5) and chronic dry cough. These associations were present even in a low polluted setting as the pollution levels in this study were lower than the Australian National Environment Protection Measure. Conclusions: The identified novel cough subclasses have largely addressed the heterogeneity of cough in the community as shown by their distinct clinical characteristics cross-sectionally and longitudinally. Distinct associations between occupational exposures, ambient air pollution, and cough subclasses were uncovered, which were not detected by the standard cough definitions. Future studies should consider adopting a similar framework to address the heterogeneity of cough in general populations. This will help generate better quality evidence to inform individualised clinical management of cough.
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ItemBeliefs, understanding and access to male family planning methods in Timor-Leste - a participatory and operational qualitative study( 2023-12)Abstract Background The engagement of men is essential to improving the sexual and reproductive health and rights for everyone. Effective male engagement includes increasing the availability and uptake of male family planning methods (vasectomy, male condoms and some natural family planning). The Democratic Republic of Timor-Leste (Timor-Leste) has some of the most critical sexual and reproductive health challenges in the Asia-Pacific region, including low uptake of male family planning methods. While previous studies have explored understanding of and influences upon women’s uptake of family planning methods in Timor-Leste, limited evidence exists about access to and uptake of male methods of family planning. Methods Participatory and operational qualitative research was designed and implemented to explore beliefs, understanding and access to male family planning methods in Timor-Leste from both a community and healthcare provider perspective. Fourteen participatory group discussions were held with 175 community members (84 men, 91 women; aged 18 to 72) across seven municipalities in Timor-Leste (Ainaro, Baucau, Bobonaro, Dili, Lautem, Manufahi, and Oecusse) between August - December 2019. In-depth interviews were held with 24 healthcare providers (16 women, 8 men; aged 25 to 56 years) working in the same location as the participatory group discussions. Data were analysed using reflexive thematic analysis. The ethics of reflexivity and solidarity were practiced throughout the research process. Results Community members and healthcare providers had overall low awareness and knowledge about male family planning methods and male sexual and reproductive health. Misinformation was widespread, contributing to negative attitudes about male family planning methods. Healthcare providers had limited training and experience about male sexual and reproductive health services, including male family planning services. Further, while some healthcare providers reported providing universal access to family planning, others reported restricting access based on gender, age, civil status, or number of children. Reasons for restricting access included: personal belief; misunderstandings about national health policies and laws; pressure or direction from senior health staff or colleagues; and harmful social norms regarding sexual and reproductive health and rights. Men were identified as playing a leading role in the decision to have children and a woman’s ability to access contraception by all participants. However, men were also identified as having limited interaction with healthcare services and healthcare providers. Instead, family planning services were framed as being almost exclusively about healthy birth spacing for pregnant women and mothers, delivered through maternal health services. Participants expressed interest to learn more about male family planning services, and a desire for improved access to sexual and reproductive health services more generally. Conclusion Access to male family planning services in Timor-Leste is complex and influenced by many personal, historical, socio-cultural, geographical, political, and financial factors. This study identified numerous barriers and enablers to increasing access to and uptake of male family planning methods, at the client, provider, health system and society levels. While focused on male methods of family planning, study findings are also relevant and insightful to other population groups, including young and unmarried people, and people with diverse gender and/or sexual identities. Findings indicate that Timor-Leste has a unique opportunity to design and invest in new evidence-based family planning initiatives that can better engage men, are gender transformative and are complementary to existing programs. Research findings were translated into public health practices as the study was implemented, including guiding health promotion initiatives, and informing healthcare provider training. Others working within Timor-Leste and globally can use insights from the research process and findings to inform future research, policy, and program initiatives.
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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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ItemScience Communication for Public Health: Public Consultations, News Media Representations and Public Experts( 2023-09)This thesis is focused on the intersection of science communication and public health. The COVID-19 pandemic (which was declared a pandemic by the World Health Organization (WHO) in 2020 and as of writing this thesis in 2023, it is ongoing) has highlighted how crucial effective science communication is during a public health crisis. Natural sciences have been heavily influenced by the school of thought known as positivism, which involves the methodological pursuit of knowledge through empirical observations and the quest for universally applicable scientific laws. Many public health disciplines follow the principles of positivist natural science. However, the concept of positivism is subject to debate, as critics suggest its focus on objective truths disregards the influence of social, cultural, and historical factors on knowledge generation. Furthermore, social scientists view the media, and other information dissemination activities, as socially constructed rather than purely objective. The task of communicating natural science to the public via media and engagement activities such as public consultations involves translating intricate scientific information into narratives that resonate with the public. This translation process involves professionals such as scientific experts, science communicators and journalists who must balance understandability, relevance to the audience, and factual correctness. Key theoretical frameworks used in the science communication literature include the ‘public understanding of science’ (PUS) framework and ‘public engagement with science and technology’ (PEST) framework. The PUS framework assumes that the public's doubt or scepticism about science is linked to a deficiency in their understanding of science. The PEST framework has a focus on conveying diverse perspectives and critical reflections about science and involving the public in scientific dialogues and active participation. Whilst some science communication scholars have argued that there should be a shift from the PUS to PEST frameworks, there is acknowledgement that the PUS framework is still widely in use. Related to the PUS and PEST frameworks is medialisation theory, which describes the relationship between science and the media. This involves the mutually beneficial relationship between scientists and journalists and the overall orientation of science toward the media. Medialisation can result in increased media coverage of science but can also lead to the distortion of scientific reporting which can be a threat to scientific integrity. My thesis aimed to address the gap in knowledge regarding the stakeholders of science communication in socially constructed public health contexts and the applicability of science communication theoretical frameworks. Therefore, the overarching aim of this thesis was to explore the roles, tensions and experiences of the stakeholders involved in the communication of public health science in socially constructed environments. To achieve this, I conducted three separate case studies of public health-related science communication in socially constructed contexts in Australia. The first case study used qualitative content and thematic analysis to examine the written submissions to an Australian government-led public consultation run by the Therapeutic Goods Administration covering the regulation of autologous stem cell therapy. The findings showed that there was a divergence of opinion among stakeholders, with some advocating for unregulated ASCT (patients and providers) while others pushed for greater regulation (scientist and scientific organisations). This public consultation had the potential to strengthen prevailing power relationships and exacerbate social inequalities. The PUS framework appeared to underpin the approach to this Australian government-led public consultation, with disproportionate influence of scientists and scientific institutions over patients and providers. The second case study used qualitative content and thematic analysis to examine the translation of journal article to press release and the subsequent news media reporting of an Australian study on vitamin supplementation and risk of birth defects. The findings showed that, replicated from the press release to the news media reporting were issues such as sensationalism, misrepresentation, inappropriate clinical recommendations, and subjectivity. Additionally, pressures faced by journalists, scientists, and their institutions created a mutually beneficial relationship that prioritised newsworthiness over scientific integrity, with the potential to harm public health. The PUS framework and medialisation theory can help to explain the distortion of information about this Australian scientific study, including misrepresentation within the institution press release and whether independent views were sought by journalists. The third case study used a thematic analysis of in-depth qualitative interviews with public experts acting as science communicators during the COVID-19 pandemic to understand their motivations, responsibilities, impacts, and experiences. Findings showed that public experts received negative feedback from the public. However, difficult interactions for public experts extended beyond members of the public and involved journalists. Additionally, public experts had positive experiences, such as making a tangible impact on public health, alleviating community anxiety, and democratising research by making it accessible beyond academic audiences. Furthermore, public experts were not talking about their own research but were talking about the work of other scientists and how this related to society in general. From a theoretical perspective, the motivations, responsibilities, impacts and experiences of public experts who spoke in the media during the COVID-19 pandemic were explained by aspects of both the PUS and PEST frameworks. Additionally, medialisation may have equipped scientists to serve as public experts during the COVID-19 crisis, ultimately benefiting society. In conclusion, this thesis explored the roles, tensions and experiences of the stakeholders involved in the communication of public health science in socially constructed environments in Australia via three separate case studies. The findings revealed that the public consultation had the potential to strengthen prevailing power relationships and exacerbate social inequalities. Pressures faced by journalists, scientists, and their institutions created a mutually beneficial relationship that prioritised newsworthiness over scientific integrity. Public experts had negative but also notable positive experiences from engaging with the media including having a translatable impact on public health. Additionally, my three case studies demonstrated the value of the theoretical frameworks in understanding the relationships between science and society, and science and the media.
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ItemRe-storying place, connection and belonging: Aboriginal and Torres Strait Islander young people making space and creating futures in Narrm( 2023-10)Constructs of Indigeneity have been the locus of settler colonial interest and control since colonisation in Australia. Through historical policies of displacement, and contemporary normative processes that question the authenticity and belonging of Aboriginal and Torres Strait Islander people, urban places continue to be sites of erasure and non-belonging. However, cities will always be Aboriginal land, and places of cultural resurgence, renewal and regeneration. Internationally, a growing body of literature investigates experiences of First Nations young people in urban places, but in Australia this is lacking. This thesis explores how Aboriginal and Torres Strait Islander young urban people in Narrm (Melbourne) practise and connect to their Indigeneity, as they come into relation with place, community, and their engagement with institutional regimes. This thesis makes an original contribution to knowledge by articulating how Aboriginal and Torres Strait Islander young people in Narrm engage in processes of re-storying place, cultural resurgence and presencing as assertions of belonging, and enacting responsibilities of relationality in generating desire-based futures. Indigenous women’s standpoint theory, and a desire-based framework guide the methodological approach. Yarning methodology was used to develop partnerships with collaborating organisations, to guide the direction and methods of engagement with participants. Theories of relationality, youth refusal, resistance, counterstory, and cultural resurgence are used to understand the key formulations of Indigeneity for young people. To investigate the research question, Aboriginal and Torres Strait Islander young people (aged 16-30) living in Narrm were engaged across four sites. These sites included – an Aboriginal youth drop-in program; an arts mentoring program; a cultural support program for incarcerated First Nations men staffed by First Nations and non-Indigenous volunteers; and an Indigenous student centre at a university. Resistance and refusal are theorised as engagements of power by young people in their interactions with service systems that problematise and imagine their limited potential and future possibilities. Building on this, counterstory is a way to understand these acts of resistance and refusal by participants. The theory of re-storying is offered, to interpret how young people connect and engage with place in ways that are not a counter to colonisation, but a re-storying and continuation of Aboriginal and Torres Strait Islander presence. Presencing is in the everyday acts of resurgence, it resists colonial erasure and is a reminder of the ongoing relationships and connections of Aboriginal and Torres Strait Islander communities to place. Acts of cultural resurgence and renewal engage young people in intergenerational practises of relationality – a responsibility of ongoing learning and connection to claiming Indigeneity. Culture, belonging, identity and self-determining futures are protective factors for the health and wellbeing of Aboriginal and Torres Strait Islander people and communities. This thesis shows the ways that participants are engaging and practising their identities in Narrm and navigating paths for desire-based futures.
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ItemThe determinants of evidence use by Australian clinical networks as safety and quality stewards( 2023-05)Contemporary expectations for health services to be safe and of high quality reflect the longstanding principle of “first do no harm” and the altruistic intentions of medicine that form the essence of the Hippocratic Oath. Central to assuring safety and quality of health services is the use of appropriate evidence at the point of clinical care. Yet practitioners, institutions, and government departments still grapple with understanding what evidence-based care is and what strategies can be used to best influence evidence use across service provision. In Australia, the unique degree of system complexity and fragmentation further challenges the development of these strategies. There exists a need for diverse models of safety and quality stewardship to evaluate the evidence, deliver oversight, and achieve influence over the range of factors that ultimately shape clinical practice. This thesis examines the determinants of evidence use by clinical networks in Australia. Established across all Australian states, clinical networks rely on clinical leadership and engagement to execute safety and quality stewardship. Australian clinical networks traverse across traditional boundaries to define care expectations and facilitate improvement, with activities to be based on evidence. This thesis investigates the link between safety and quality stewardship, clinical networks, and evidence use. This research was qualitative in nature. A mixed methods study was conducted involving interviews at the national level and within the state of Victoria, including the comparative case study of three clinical networks, documentary analysis, and the use of Q-methodology. This research contributes three main empirical findings. Firstly, it demonstrates the necessity of networked stewardship models to deliver health system oversight. Secondly, because these networks are clinician-led and examine multifaceted issues, there are differences in individual capability to transmute prior understandings, predominately drawn upon for clinical practice decision-making, to matters of management and policy decision-making. This research identifies the application of positivist, pragmatic, and strategic framing of problems and problem-solving approaches. Thirdly, the underlying model of safety and quality coordination and governance shapes the way in which use of evidence occurs to exert trust-based and control-based strategies to influence practitioners and institutions. Empirical contributions strengthen the link between theories of stewardship and evidence use. It contributes new knowledge to the area of safety and quality stewardship to strengthen research, practice, and evaluation. A theoretical contribution of this research is the development of the Clinical Network Safety and Quality Stewardship Conceptual Framework. Ultimately, these scholarly contributions are positioned to stimulate new ways in which practitioners, institutions, and the bureaucracy are organised to steer the health system to be responsive to the needs and preferences of consumers served.