Background Miscarriage is a common event estimated to affect up to one in four confirmed pregnancies and can result in significant psychological morbidity. Appropriate psychosocial support at the time of a miscarriage can lead to better psychological outcomes in the months or years following a loss. Early Pregnancy Assessment Services (EPASs) are typically dedicated outpatient clinics in public hospitals designed to manage patients with pain and/or bleeding in early pregnancy and are considered the “gold standard” for miscarriage care. Despite some best-practice recommendations outlining the psychosocial support EPASs should offer, very little is known about what they provide. Aim The aim of this study was to explore the provision of psychosocial support in Early Pregnancy Assessment Services in Australia. Method A mixed method approach utilising audit, field notes and semi-structured interviews was conducted to acquire information on clinic structure and operation, and the provision of psychosocial support. Thirty-one key-informants were recruited from 13 EPASs and two miscarriage support organisations across Australia. Interviews were audio-recorded, transcribed, and thematically analysed. Results Findings demonstrated considerable variability in how EPASs functioned in Australia, and therefore the provision of psychosocial support. Results were presented in three categories: psychosocial support currently provided, psychosocial support considered ideal by participants, and barriers to changing psychosocial support. Considerable variation in the structure and function of services were observed, such as staffing arrangements, physical location of service, and availability of ultrasonography. However, most participants described the emotional support provided by EPAS staff similarly, noting the importance of acknowledging and validating patients’ feelings, guilt mitigation, and providing individualised care. Referrals for additional psychological support were rarely reported, however many participants discussed the importance of utilising General Practitioners for follow-up and ongoing support. Common barriers to providing ideal psychosocial support was reported and primarily centred around limitations on time and resources, resulting in the physical care of patients taking priority over psychological care. Despite these restrictions, all EPAS staff demonstrated a clear and strong commitment to providing best possible patient care within their own clinical setting and acknowledged the need for improved psychosocial support. Conclusions This study provides the first exploration of Australian EPASs’ provision of psychosocial support. It has demonstrated that health care professionals working in EPASs are dedicated to providing the best possible care to their patients within their clinical setting. Time and funding restrictions were considered major barriers to providing improved psychosocial support. More research into where psychosocial support is best offered is needed to improve patient experience and lower psychological morbidity following miscarriage.

Background Financial incentives are commonly used to drive improvements in health care delivery. There is a large body of evidence around the impact of the delivery of financial incentives on health outcomes, quality and prevention. Results from a systematic review of published reviews found that randomised controlled trials and time series studies undertaken between 1980 and 2000 have contributed most of the evidence. Most of the studies looked at associations between the introduction of incentives and improvements in quality. However, poor study design and unaddressed methodological errors have significantly limited the drawing of sound conclusions from the evidence to date. There is a paucity of published research on the removal of financial payments to general practitioners (GPs) and its effect on preventive care. Aim This thesis aims to: (i) determine if the removal of general practitioner financial incentive payments for immunisation are associated with a reduction in paediatric immunisation coverage; (ii) determine if there is evidence of associations between levels of socio-economic disadvantage and paediatric immunisation coverage after removal of financial incentive payments to general practitioners, and; (iii) determine if there is evidence of an association between levels of relative remoteness and paediatric immunisation coverage after removal of financial incentive payments to general practitioners. Method Childhood immunisation has been linked to the delivery of two financial incentives provided to Australian general practitioners for the reporting of paediatric immunisation coverage to the Australian Childhood Immunisation Register (ACIR). The General Practice Immunisation Service Incentive Payments (SIP) and Outcomes Bonus Payments (OBP) were removed incrementally in 2008 and 2013. A systematic review of reviews was undertaken on current evidence of the effect of incentives on immunisation. Paediatric immunisation coverage data for all Australian children under the age of seven was used to examine the impact of the removal of these incentives on immunisation rates. Interrupted segmented regression times-series analysis (ITSA) was performed on postcode-level immunisation coverage data across 64 quarters between 2000 and 2016. Sub-group analysis was performed on the data stratified for socio-economic disadvantage and rurality. The data were transformed using an autoregressive integrated moving average (ARIMA) model to address autocorrelation. Results The results revealed an immediate and statistically significant drop in immunisation coverage following removal of the second of two incentive payments to GPs, the OBP. This drop persisted even after the data was modelled to control for heteroscedasticity and the inflationary effects of the ‘No Jab No Pay’ policy. The effect was still evident after the series had been transformed with weighting coefficients to address the issue of small cells. The analysis also showed an additional 19,441 children would have been reported as being fully immunised between January 2000 and 1 January 2016 had the SIP and OBP incentives not been removed. A reduction in immunisation coverage was evident across all socio-economic quintiles after the national series had been stratified across areas of disadvantage. This effect was found to be larger in areas of greater disadvantage. The same outcome was observed across all geographic regions of Australia, where major city, regional and remote areas showed a statistically significant reduction in immunisation following removal of the OBP. The postcode areas which showed the greatest decrease in immunisation were those outer regional to very remote regions of Australia. There was no statistically significant change in coverage after removal of the SIP. Conclusion This thesis establishes evidence of a strong relationship between the removal of incentives to GPs and the provision of preventive services. Not only does this analysis provide estimates which are statistically significant, it also provides multiple analyses which test the validity of the outcomes. To the author’s knowledge, the innovative methods which have been used in this thesis to measure the effects of the removal of financial incentives to GPs, has not been previously applied to the research around incentive effectiveness in either Australia or overseas. This places this research in a unique position to both contribute evidence and influence future policy.

Dating violence, or intimate partner violence, in young people’s relationships is a serious, prevalent and important public health concern. It is estimated that approximately one in four Australian young women have experienced dating violence. Despite the well-known burdens of dating violence on Australian young women’s health and well-being, little is known about how Australian young women perceive dating violence in their romantic relationships. This qualitative study explored Australian young women’s perceptions of dating, other romantic relationships, and dating violence. Social constructionist and feminist theoretical perspectives informed the study design. Young women aged 17 to 25 years, were recruited from a range of social and occupational backgrounds if they screened positive for dating violence. Individual narrative interviews were conducted with 35 young women, from across urban and rural Australia, who had predominantly had romantic relationships with young men. Interviews were conducted face-to-face or via telephone. The interviews were analysed using a thematic approach while ensuring that the young women’s stories remained at the forefront of the analysis. This was followed by the application of social script theory with a feminist lens, as an explanatory framework, to better understand the young women’s perceptions of romantic relationships and dating violence. The young women shared stories of their experiences of romantic relationships which were predominantly with young men. Findings revealed that the young women had experienced a range of casual and committed romantic interactions. The young women discussed their experiences and perceptions of these relationships and their roles within them. The young women’s perceptions of romantic relationships, particularly committed ones, were overwhelmingly gendered and scripted. These scripts were reminiscent of romantic fairy tale narratives, such as Beauty and the Beast, which the young women strived to live by. This perception influenced how they made sense of and recognised dating violence within these relationships and therefore how they responded. The young women struggled to leave their abusive relationships and exit was usually only possible if a crisis occurred or if the young man left the young woman. An exit model was formed which highlights these pathways and also the defining gendered roles of the young woman and young man. The young women’s perceptions of dating and dating violence were in conflict with their perceptions of gender equality and feminist identities. While the young women in this study perceived themselves to be liberated individuals in the current wave of feminism, in contrast, their dating and relationship scripts were informed by oppressive and patriarchal master narratives, such as romantic fairy tales. This study contributes to a better understanding of dating and dating violence in the Australian context from the perspective of a typical Australian young woman living in the year 2015. The findings from this study are useful and important to inform policy and practice for the primary and secondary prevention of dating violence. Existing patriarchal social scripts should be challenged with feminist counterstories that empower young women and contribute to practical implications for promotion of gender equality.

Partner Notification (PN) has long been considered an essential strategy for sexually transmissible infection (STI) control, but both policies and methods of implementation vary between countries. Although the provision of clinical services in sexual health has improved in Chile, syphilis among the general population is one of the most commonly reported STIs. This research explores the role of PN in syphilis control in public health services in Chile. A qualitative case study was designed, and two regional Health Services, each representing a single case, were recruited. Different data collection methods were used to obtain information from different sources. A qualitative document analysis was carried out using the latest national regulations and technical documents available on the Ministry of Health website at the beginning of the study (2015) and in April 2018 for information related to PN (12 documents were reviewed). Also, a review of the current syphilis management regulations was performed to contextualise the defined local approach at the two regional Health Services, which was explored through a syphilis management clinic review in each of the 14 primary health care centres and 6 sexual health clinics which participated. Semi-structured face-to-face interviews were conducted in participating health services with 48 health care providers (HCPs), mostly midwives with more than 10 years of professional experience, as well as with 10 key informants from different backgrounds between May and September 2016. The data collected from the clinic reviews were organised using Microsoft Excel, and from the semi-interviews were transcribed verbatim. Data from both sources were managed using QSR International's NVivo 11 PRO Software. Data were thematically analysed using an inductive approach, with both within-case and cross-case thematic analysis of data from the cases. Selected quotes were translated from Spanish to English. Codes and themes were reviewed and discussed with supervisors. Findings revealed that syphilis management has a well-organised approach in public health services, but little knowledge or understanding of the infection among patients leads to a lack of recognition of the importance of informing sexual partners about their risk of having syphilis. While guidelines and recommendations highlighted syphilis prevention, PN was not suggested as an essential strategy. The management of partner(s) or sexual contact(s) was acknowledged as critical for syphilis control in the guidelines and by participants, but no document provides comprehensive information about how to deliver PN. Patient referral was the most common approach for PN delivery; however, interviewees commented that index cases do not provide information about their partners easily and the delivery of PN is further impacted by gender and the socio-cultural context of Chile. Eventually, the use of electronic communication technologies could be an alternative for enhancing current approaches. PN was perceived by HCPs as an exhausting, difficult and challenging process due to poor public understanding of syphilis, absence of practical recommendations for delivery and health system limitations. These findings are important for local and national Chilean authorities. They need to understand how PN has been implemented in these services and the experiences of HCPs in their daily routine. By following international recommendations and by including knowledge gained from this research, current practices and guidelines in Chile could be strengthened to ensure that STI control is enhanced at the population level.

Adolescence and young adulthood are periods of major transition in physical, cognitive, social, and emotional development along the journey from childhood to adulthood. However, despite experiencing a high prevalence and co-occurrence of mental health disorders and lifestyle issues, young people do not usually seek professional help for these concerns. Yet, young people do regularly attend general practice, usually to address physiological concerns, making General Practitioners (GPs) ideally situated to opportunistically discuss a range of health and lifestyle issues and to provide health promotion and early intervention as needed. Technology-based screening provides an acceptable and systematic format for identifying health issues before the consultation. However, this screening technology is not being utilised by GPs. The aim of my research was to investigate the design, implementation, and effectiveness of a preventive screening technology intervention for supporting conversations about young people’s health and lifestyle risks in general practice. To address this aim I conducted three studies using a mixed methods multiphase design. The first study was a systematic review of the literature, which provided an understanding of the need and rationale for developing a health and lifestyle technology-based screening tool in primary care. The second study was a series of co-design workshops with 16 young people, 8 GPs, and 8 parents of young people, and interviews conducted with 11 practice support staff, to identify and explore user and stakeholder design and implementation requirements of a technologybased screening tool. The final study was an effectiveness-implementation study in one general practice clinic in Melbourne, Australia. For the effectiveness component of the final study, I compared the exit surveys of 30 young people in a one-month pre-intervention, treatment-as-usual phase with 85 young people using a health and lifestyle screening app in a two-month intervention phase, when the app was integrated into young people’s routine care. I also conducted semi-structured interviews with 14 young people from the intervention group. The implementation component of the final study was an in-depth implementation case study, with methodology informed by action research. Semi-structured interviews and focus groups were conducted with four GPs and seven support staff at the end of the implementation period. In addition, I analysed the number of times staff were supported by researchers, the location where young people completed the app, whether they felt they had sufficient privacy and received a text messaging (short message service, SMS) link at the time of making their appointment. I present the findings of my studies in this thesis in four published peer reviewed articles. The results indicated that integrating a health and lifestyle screening app into face-to-face regular care of young people improved patient-centred care, and created scope to identify and address unmet health needs. However, the implementation of the app in the dynamic and time-poor general practice setting presented a range of technical and administrative challenges. My research shows that an effective way to engage young people in their health and wellbeing may be to resource preventive screening implementation into routine general practice care. My research also provides evidence that to drive and support sustainable technology innovation and implementation in general practice settings more resources, external to existing practice staff, are needed.

Young people from a culturally and linguistically diverse (CALD) background in Australia are reluctant to engage with formal support services when they experience mental health problems, and are under-represented amongst the users of such services. These discrepancies in service engagement may be the result of differences in how they identify and explain mental distress experiences in comparison with the prevailing perspectives within the Australian health system. Kleinman described this conceptually as a conflict between “the cultural construction of clinical realities”. I had the following aims for this research project: to discover how young people from a CALD migrant background identified and described their experiences of mental distress, to identify the explanatory models and belief systems they utilised to understand these experiences, and to explore how their responses to these experiences – including any interactions with formal mental health services – were influenced by these understandings. Knowledge of these explanatory models and belief systems can inform the enhancement of existing mental health services, as well as provide fresh opportunities for the development of new services and programs with greater appeal and perceived relevance for this population. Fifteen participants between 18-25 years of age from a CALD migrant background and residing in Melbourne, Australia engaged with ‘photo-interviewing’ to express personal mental distress narratives. They each created up to 20 photographs that represented their mental health and distress experiences, and discussed the meaning of these photographs within the setting of an open qualitative interview. This method encouraged rich descriptions, reflective interpretation, and a storied expression of their lived experiences. The interview transcripts were analysed for themes that were relevant to how they identified, explained, and responded to these mental distress experiences. A variety of colloquial and psychological terms were used interchangeably to identify mental distress, as well as temporally situated accounts that did not utilise signifying terminology. Mental distress was explained as the result of disruptions to self-identity, social identity, and established social connections. ‘Self-identity’ referred to idealised concepts of the self that participants had either lost, aspired to attain, or sought to escape; whilst ‘social identity’ referred to their value and status amongst peers, family, and the broader community. These notions of identity were influenced by archetypal social roles and values embedded within their cultural background, and were subject to challenges from their interactions with Australian society. Separation from trusted social connections due to their migration journey resulted in disruptions to their informal support networks and their established social identities. The participants favoured self-directed actions and receiving informal social support over the engagement of formal support services. These actions were directed towards the restoration of a spoiled identity and a sense of social belonging. These findings suggest that young people from a CALD migrant background would benefit from multidisciplinary support interventions that address concerns related to disrupted identities, promote post-migration social inclusion, and build upon the capacity of informal social supports to facilitate their engagement with formal mental health services.

Gestational diabetes mellitus (GDM) is a condition characterised by elevated blood glucose that occurs in pregnancy and affects 11-15% of pregnant women. Tightly maintaining blood glucose levels (BGL) within target in GDM is associated with better maternal and foetal outcomes. In contrast poorly controlled hyperglycaemia is associated with adverse outcomes such as higher rates of caesarean delivery, macrosomia, foetal shoulder dystocia and admission of the new-born to a special care nursery or neonatal intensive care unit. At least 50% of women with GDM need insulin to maintain glycaemic levels within target. In the early stages of insulin commencement, women with GDM often require intensive monitoring, frequent advice and support for insulin titration. This can be difficult to manage in pregnant women who are often faced with other competing demands, including work and caring for a young family, which contribute to the challenges of managing GDM. Further, the need for intensive support, together with inconsistent attendance for appointments, contribute to difficulties with managing GDM through the out-patient setting. Telemedicine has previously been shown to enhance patient self-monitoring and enabling provision of accurate and timely data transmission and sharing between patients and clinicians. Use of telemedicine potentially enabled efficient communication with timely response by clinicians in addressing urgent situations where BGLs are outside the desired target range. As a result, telemedicine may provide an innovative approach to streamline GDM management given the intensity of support and demand for insulin-treated GDM services and burden to GDM patients to attend appointments for ongoing monitoring and support. My PhD study involved a complex intervention and as a result drew from elements of the three theoretical frameworks. First the Medical Research Council (MRC) Framework which guides the development and evaluation of complex interventions which draws attention to the steps to follow, i.e. intervention piloting and then proceeding to the exploratory phase which was the mainstay for my study. The second was the Normalisation Process Theory (NPT) which emphasises translating and embedding complex interventions in practice, noting the TeleGDM study was implemented in real practice. The third framework was the Telehealth Evaluation Framework which provides a guide to the elements to consider in order to standardise the evaluation of telehealth interventions. My PhD project aimed to explore the impact of telemedicine on the management of insulin-treated GDM at Northern Health (NH). The project which is described in detail in this thesis consisted of: i) A background literature review including a systematic literature review and meta-analysis of telemedicine for GDM management; ii) Piloting the protocol at one of the campuses of NH. The pilot was aimed at gaining insights into the flow of the recruitment process and getting feedback on the chosen telemedicine system, before proceeding to an exploratory randomised controlled trial (RCT) stage; iii) An exploratory RCT comparing an adjunct telemedicine intervention to usual care in the management of insulin-treated GDM. The study primarily looked at impact on service utilisation, i.e. outpatient GDM clinic appointments. Other outcomes included a range of maternal and foetal/new-born clinical outcomes, patient and clinician satisfaction and service provider costs; and iv) A mixed methods outcome and process evaluation of the exploratory RCT. Ninety-four patients and five CDE-RNs participated in my study. The findings showed that telemedicine support in the management of GDM produced health service and clinical outcomes similar to usual care. Adjunct telemedicine support had no significant impact on the number of face-to-face outpatient GDM clinic appointments, foetal biometrics, rates of caesarean deliveries, macrosomia, large for gestational age, admission of new-borns to the special care nursery, birth-weight or costs. The intervention had the advantage of significantly reducing the time for patients to achieve optimum glycaemic control, an important outcome in GDM management. Importantly, while not superior to usual care in terms of health service use, telemedicine did not compromise the quality and safety of care in terms of foetal and maternal outcomes. Uptake of the intervention, as reflected by the volume of GDM self-monitoring data entered into the telemedicine system by patients, showed that patients using this approach shared less data with clinicians, when compared to the usual care method of handwritten data. There was greater usage of the telemedicine system to share data in first four weeks of the intervention. Statistically, there was no difference between the intervention and control on health service provider costs. However, limitations of scaling up the intervention notwithstanding, there was potentially for a significant cost saving from a health service perspective. Themes from patient interviews showed that telemedicine as a concept, may be acceptable among patients, facilitated proactive self-management, and enabled personalised feedback. Some patients suggested telemedicine could potentially reduce face-to-face clinic attendances, thus, saving them travel time or allow them to balance work and ongoing GDM care. These views were possibly from a self-selected group of patients who engaged more with using the telemedicine system element of the intervention. Patients who engaged less with using the system were reluctant to participate in interviews. As clinicians involved in performing the clinical aspects of the study, Credentialed Diabetes Education-Registered Nurses (CDE-RNs) had mixed responses regarding telemedicine. For instance, some expressed views that telemedicine may be a supplement usual care, rather than an alternative substitute. They also cited the telemedicine system’s technical design, and lack of integration with existing ehealth systems as the negatives of telemedicine, as these factors resulted in increased work to use the system, adversely impacting on workflow and productivity. In conclusion, while my study was exploratory, telemedicine support for GDM showed no impact on service utilisation and provider costs. Telemedicine produced similar maternal and foetal clinical outcomes as usual care, suggesting no added risk to clinical quality of care, but with the possibility of a shorter time to insulin dose stabilisation. Further research in telemedicine using, user-friendly technological platforms that are fit for purpose, and including robust health economic evaluation in GDM is still needed.

Gender diverse young people are a marginalised population with specific health care needs. Studies suggest that these needs are not being met by their general practitioners (GPs), but existing research focuses on gender diverse adults or non-Australian populations. The experiences of Australian gender diverse young people with GPs have not been studied in depth. Thirty-seven young gender diverse people shared their experiences with GPs. Many had negative experiences with GPs, with a majority of non-binary people having had mostly negative experiences. Participants’ experiences were positively impacted by GPs showing respect for gender diverse people, GPs being knowledgeable about gender diversity, a positive and friendly attitude from GPs, a welcoming clinic environment in which gender diverse patients were called by their chosen names, and GPs treating gender diverse patients like autonomous individuals. Negative experiences were characterised by GPs being uninformed or misinformed about gender diversity, GPs being insulting or demeaning, clinics requiring that patients be known by their birth names and assigned genders, GPs and staff misgendering gender diverse patients, and GPs attributing gender diversity to mental illness or vice versa. This study was conducted through an online survey, asking open-ended questions which provided answers suitable for qualitative analysis. Answers were analysed through thematic analysis, using a framework based on that of phenomenology. The recommendations put forth are that GPs must be educated on gender diversity; paperwork and computer systems should be able to accept input of genders other than male and female; GPs should respect gender diverse patients as individuals who know themselves; clinic waiting rooms should be welcoming and staff educated about gender diversity; GPs should not assume that gender diversity causes or is caused by mental illness; and GPs should believe, listen to, and respect the input of gender diverse patients. Further study on this topic could focus on the experiences of gender diverse Indigenous people, people born outside of Australia, or people living in regional areas; or on the experience of gender diverse people with other healthcare practitioners.

Research in the general practice setting is essential to ensure the clinical care provided is effective and evidence-based. To facilitate general practice-based research, studies must be designed in ways that accommodate practice routine. Furthermore, intervention studies need to be managed at the practice level to ensure uptake and implementation. The practice manager is central to the administration and oversight of general practice organisation and routine. However, there is a paucity of research evidence about this role, and no current literature on practice managers’ contributions to research intervention trial facilitation and implementation in the general practice setting. This study investigated the practice manager’s role in facilitating the implementation of an intervention as part of a clinical trial in Australian general practice. This research was a sub-study of the Australian Chlamydia Control Effectiveness Pilot (ACCEPt). ACCEPt was a randomised controlled trial that measured whether a multifaceted intervention designed to increase annual chlamydia testing reduced the transmission and associated complications of chlamydia among 16 – 29 year-old general practice attendees. Using a qualitative thematic methodology, 23 semi-structured interviews were conducted with practice managers during the ACCEPt intervention phase. “The practice managers' role in facilitating and implementing the ACCEPt intervention was explored, along with the barriers and enablers to the conduct of general practice-based research.” The findings of this study suggest practice managers are key to establishing, facilitating and managing research interventions at the general practice level. The participating practice managers described their central positions within the structure of the organisation as pivotal to directly liaising with GPs on research matters, delegating tasks and maintaining the profile of research in general practices. Managers had the capacity to embed non-clinical tasks into their current workloads, which they saw as crucial to sustaining trials and limiting the impact of research on practice routine. New perspectives from practice managers suggest the main enabler to research uptake and sustainability in the practice is the practice manager’s involvement. They reported daily routine and the rigid scheduling of GPs’ appointment times as the main barrier. This is the first Australian study of the role of the practice manager in facilitating intervention studies in general practice. While this study fills a gap in the literature about practice managers and their contribution to general practice-based research uptake, it also highlights the need for further examination of this role, specifically a broader systematic investigation of practice managers’ contribution to managing intervention studies at the practice level. Furthermore, exploration of the training needs of practice managers is required to identify education that would maximise their potential to contribute to research.

In Victoria, rural patients with colorectal cancer have poorer outcomes than urban counterparts. To date, research and policy initiatives have focused on addressing potential variation in cancer treatment. However, pre-treatment delays may also be important. Policy change is required to reduce disparities for rural patients with cancer. Determining potential models of rural cancer care and understanding the policymaking process could enhance the success of future policies to address geographic cancer disparities. The overarching aim of the research program was to develop evidence to inform potential health system policies to reduce outcome disparities for colorectal cancer patients in rural Victoria. There were three research objectives: 1. Compare rural and urban patient pathways and experiences to diagnosis and treatment for those with colorectal and breast cancer in Victoria; 2. Identify potential models of rural cancer care that could inform future policies; and 3. Understand how large-scale health service policies in cancer care develop and are implemented. The research used a multi-phase, mixed methods design in five studies. The first phase examined rural and urban patient pathways to colorectal or breast cancer diagnosis and treatment in two studies. Breast cancer patients were included as a comparison group since outcomes are equivalent for women across Victoria. In the first study, interviews with 43 patients showed that rural and urban patients with either cancer experienced relatively similar pathways, though some had difficulty accessing GPs and longer time to specialist referral. Qualitative results informed hypotheses tested in a quantitative study of time intervals to treatment. Survey data from 922 patients with colorectal (n=433) and breast cancer (n=489), 621 GPs and 370 specialists were supplemented with cancer registry data. In quantile regression analyses, the time from first symptom or screening test to treatment was significantly longer for rural than urban patients with colorectal cancer, but not breast cancer. This was likely driven by longer diagnostic intervals for rural patients with colorectal cancer. In the second phase, patient interview data were re-analysed to explore experiences of choice of cancer treatment provider. Although most patients had limited involvement in choosing a provider, decision-making considerations were more complex for rural than urban patients. Studies in the final phase were a scoping review of rural cancer models of care and an interview study with 13 local and international key informants regarding the policymaking process. Across 47 reviewed articles, telehealth models were most common. Navigator and alternative provider models were identified for the pre-treatment period, but very few studies measured time to cancer care, and none assessed clinical cancer outcomes. Developing and implementing cancer policies at national or state-level was found to involve specific change mechanisms, such as stakeholder collaboration and evidence-use, influenced by the physical, political and temporal context. Based on these results, it is recommended that policies to address rural–urban inequities in colorectal cancer patient outcomes in Victoria focus on the diagnostic interval. Initiatives such as GP endoscopy, waiting time reporting or diagnostic centres should be investigated, acknowledging the potential impact of context in policy-change. The current research provides a baseline to assess the impact of future policies, and a starting-point for further research to understand policy development and implementation in cancer care.

Crisis helplines were established in the 1950s to provide an immediate telephone response to anyone in an acute crisis. They now operate around the world, and Lifeline is recognised as one of Australia’s largest national crisis helpline services. A disproportionate number of calls to crisis helplines come from frequent users, who make multiple calls over an extended period of time. It has long been thought that frequent users are isolated individuals who call about non-crisis related issues; however, this assumption has never been investigated. Service providers struggle in knowing how to respond to frequent users while still addressing the needs of other callers. An evidence-based approach is required. AIM: The aim of this thesis was to investigate the socio-demographic characteristics of frequent users of crisis helplines and the factors driving their frequent use. Specifically, it answered the research questions: 1. What is the socio-demographic profile of frequent users of crisis helplines? 2. What are the reasons for frequent users’ continued use of crisis helplines and how do they differ to those of other callers? 3. What are the health service use patterns of frequent users of crisis helplines? METHODS: Three studies were conducted to address the research questions. Study 1, a brief survey of callers to Lifeline, investigated the socio-demographic characteristics of frequent users and differences in their reasons for calling compared with episodic and one-off callers. Quantitative analyses were conducted using ordered logistic regression. Study 2 involved interviews with Lifeline frequent users. Inductive thematic analysis was used to generate common themes to understand why some users may call crisis helplines frequently. Study 3, a longitudinal analysis of data from the diamond study, examined the relationship between frequent use of crisis helplines and health service use patterns over time. Crisis helpline use was measured at 3, 6, 9, and 12 months and analysed using ordered logistic regression. RESULTS: Compared to other callers, frequent users were more socially isolated individuals and lacked people to turn to in moments of despair. They had come to rely on crisis helplines for support; although, this was not the only factor driving them to call. They also reported disabling and chronic mental health issues, physical illnesses, and ongoing crises. The circumstances under which they called varied, but there was evidence to suggest that the current service model was not meeting their long-term needs and may in fact reinforce their calling behaviour. Frequent users also visited the general practitioner, psychiatrist, psychologist, and the emergency department at rates higher than other callers; yet, they were less satisfied with their access to these services. CONCLUSIONS: Frequent users have a genuine need for crisis support, yet, they use crisis helplines in a manner different from their intended use. They account for a substantial number of callers to crisis helplines and service providers may benefit from recognising frequent users as a legitimate group of service users. This might have implications to how counsellors approach these users and may require a change in the operation of crisis helplines.

Background: Diabetes and periodontal diseases are common chronic diseases in the community. Diabetes, particularly if sub-optimally managed, is associated with an increased prevalence and severity of periodontal diseases, and severe periodontal disease adversely effects glycemic control. Studies have demonstrated that treating periodontal diseases may help improve a person’s glycemic control. Thus, understanding the association between diabetes and oral health has important implications for people with diabetes and the healthcare professionals that assist with their management. Despite the bidirectional relationship between diabetes and oral health, overseas studies have reported low levels of oral health knowledge and sub-optimal self-care behaviours in people with diabetes and few studies have explored this in Australia. Preventing and managing the chronic complications that arise from diabetes requires a multidisciplinary approach. However, research indicates that there are gaps in the knowledge of medical and oral health professionals with regards to the link between oral health and diabetes. Little is known about how oral health is incorporated into the clinical practice of healthcare providers assisting people with the management of their diabetes in Australia and the extent of collaboration between medical and oral health professionals. Aim: To investigate oral health knowledge and behaviours of adults with diabetes. Additionally, to explore the oral health knowledge of healthcare professionals that provide self-management support, health education and treatment interventions to adults with diabetes. Methods: A mixed methods study comprised of: (1) Online survey of adults with type 1 and type 2 diabetes. The survey results were analysed using STATA software and the findings summarised using descriptive statistics. (2) Qualitative study in which semi-structured interviews were conducted with 10 healthcare professionals: three dentists, two general practitioners (GPs), two dental hygienists and three diabetes educators. Interviews were audio recorded, transcribed verbatim and analysed thematically. Results: 154 people with diabetes completed the survey. A significant proportion (20%) of people with diabetes were unsure if diabetes could worsen their oral health. Many did not report oral self-care behaviours consistent with recommendations for people with diabetes, for instance 41% did not brush twice a day, 49% did not floss daily and 33% did not visit a dentist annually. Three main themes emerged from the interview study. (1) Healthcare professionals reported uncertainty about the relationship between diabetes and oral health, and were unclear about the bidirectional nature of this association. (2) Healthcare professionals do not routinely discuss the link between oral health and diabetes with people with diabetes. (3) Medical and oral healthcare professionals do not actively communicate and collaborate in the management of people with diabetes. Conclusions: Adults with diabetes are in a high-risk group for oral diseases and yet a significant proportion report being uncertain about the relationship between diabetes and oral health and practice less than ideal oral self-care behaviours. Medical and oral healthcare professionals are a primary source of information for people with diabetes. Therefore they require a clear understanding of the bidirectional links between oral diseases and diabetes so that they may provide patient education, support oral self-care and diabetes self-care and preform timely treatment interventions. Using the Chronic Care Model (CCM) as an organising framework, interventions can be instituted at a patient, healthcare professional and healthcare system level in order to improve diabetes care and health outcomes for people with diabetes.