Nossal Institute for Global Health - Theses
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ItemAnd they lived happily ever after: middle class women’s reproductive experiences and decisions in Yogyakarta, Indonesia( 2018)For Indonesian women and men from all social strata, the milestones of heterosexual marriage and parenthood are not only symbolic of the transition to adulthood, but also represent the path to an idealised, normative future, otherwise known as the ‘happily ever after’. This thesis explores the happily ever after trajectories of 20 predominantly middle class, Muslim women in urban Yogyakarta, Indonesia, with a focus on their reproductive experiences and decisions. Specifically, it explores women’s negotiations of family planning, infant feeding and work. The ethnographic research that informs this thesis involved in-depth interviews with 20 women; focus group discussions with seven primary health workers and seven breastfeeding counsellors; semi-structured interviews with five key community stakeholders; and participant observation. Fieldwork was undertaken over 18 months and employed a grounded theory approach to generate key themes for analysis. In exploring the themes that emerged as most important to my women informants, I deployed the concepts of reproductive agency, reproductive modernity and reproductive politics. Key findings highlight how women’s reproductive agency in relation to family planning, infant feeding and juggling reproductive work with paid work or study may be both supported and constrained in their everyday negotiations within their intimate circles and with health workers, employers and educational institutions. The thesis also theorises how reproductive modernity is intrinsic to women’s reproductive experiences and decisions, especially in relation to their preferences for non-hormonal and non-biomedical contraceptive methods. It also critiques the formal political agendas that intersect with women’s attainment of happily ever after, by informing their decisions to breastfeed, their balancing of reproductive and productive work or study, and their family planning negotiations. This thesis presents a new analytical framework for understanding women’s reproductive experiences and decisions at multiple levels, including their interpersonal relationships, societal norms and formal reproductive politics (the WRED framework). The application of the WRED framework demonstrates its utility in the development of multi-level, translational recommendations that take into account the complexity of factors influencing women’s reproductive health and reproductive agency. The thesis addresses a notable gap in research into the reproductive experiences and decisions of middle class women in Indonesia and extends prior research on family planning in the Indonesian context. It adds to recent scholarship challenging the biomedical categorisation of certain contraceptives as ‘modern’ and others as ‘traditional’. The thesis expands feminist critiques of breastfeeding promotion and unpacks the effects of discourses of morality in relation to women’s reproductive rights in Indonesia. It also expands the concept of reproductive agency by considering a form of collective agency for middle class women seeking to juggle their reproductive and productive roles. This thesis concludes that the path to happily ever after for the middle class Indonesian women in this study was only partially attained through marriage and parenthood. There were many other essential ingredients contributing to women’s happily ever afters, including post-secondary education and a career; more companionate, equal marriages; contraceptive choice and a preference for reproductive health over fertility control; and pragmatic religious piety.
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ItemHow to improve the prevention and self-management of type 2 diabetes in real-world settings( 2018)Type 2 Diabetes Mellitus (T2DM) is recognised as one of the most challenging public health problems of the 21st century with the number of people with T2DM rapidly increasing worldwide. While the efficacy of interventions in preventing and improving T2DM outcomes has been well established, there has generally been quite poor uptake, implementation and translation in populations, particularly in Low and Middle-Income Countries (LMICs). This thesis aims to evaluate the implementation of behavioural interventions for the prevention and self-management of T2DM and to identify the key factors required to improve their uptake in real-world settings. This Ph.D. thesis includes a systematic review of real-world diabetes prevention programs implemented in the last 15 years as well as a comprehensive implementation evaluation of two cluster randomised controlled trials: 1) the Kerala Diabetes Prevention Program (K-DPP), India and 2) the Australasian Peers for Progress – Diabetes Project (AusPfP-DP), Australia. This thesis utilises two existing evaluation frameworks (RE-AIM and PIPE) and has developed a novel evaluation logic model to identify the provider-, participant- and community-level factors that are most relevant for the successful implementation of real-world diabetes programs. The provider-level factors are further investigated. The systematic review identified that program intensity plays a major role in weight loss outcomes. However, low-intensity interventions that have high uptake—both in terms of good coverage of invitees and their willingness to accept the invitation—can still have considerable impact in lowering diabetes risk in a population, even when effectiveness in weight loss is low or moderate. The findings from the implementation evaluation of K-DPP demonstrated that the intervention was feasible and acceptable in changing lifestyle behaviours in high-risk individuals. The intervention was delivered as per protocol and there was high adherence to the intended design and delivery of the intervention by peer leaders. The communities’ trust in the local partnering institute and the commitment of the local political leaders were important in facilitating the high uptake of the program. The findings of the implementation evaluation of AusPfP-DP show that peer support programs are feasible, acceptable and can be used to supplement treatment for patients motivated to improve behaviours related to diabetes. However, program planners need to focus on the participation component in designing future programs. Finally, the use of the two evaluation frameworks allowed a comprehensive evaluation of a diabetes prevention and self-management program, from the provider-, participant-, community- and public health- perspectives. The research contained in this Ph.D. thesis highlights several important findings required to improve the uptake and wider implementation of diabetes prevention and self-management lifestyle interventions in real-world settings. Future implementation research needs to identify effective recruitment and program implementation strategies for targeting both reach and program participation. Rigorous evaluation should be a central feature of the implementation of prevention and self-management programs. More rigorous reporting of program components is needed to evaluate programs to assess the practical value of the diabetes interventions.