Multimorbidity, or the presence of more than one long-term condition in the one person, is a major issue in health care in Australia and internationally. Multimorbidity impacts on people’s quality of life and increases the cost of providing health care, and this is especially true for people living with mental-physical multimorbidity. Lack of integrated care is compounded by single disease guidelines not meeting the needs of many of the people living with multimorbidity or the clinicians who support them. Interventions to support people living with multimorbidity to achieve better health and well-being are needed. Expert consensus guidelines recommend that interventions are person-centred, focused on health behaviour change and can be integrated into routine care. Collaborative care, characterised by multidisciplinary involvement, development of an evidence-based management plan, patient review and monitoring and enhanced interprofessional communication offers the most promising framework for meeting the needs of people living with multimorbidity. Yet operationalising the principles of collaborative care, the ‘how’ of delivering that care, remains an area for further research. Motivational interviewing (MI) is a person-centred communication style to support behaviour change and may offer an effective approach to communication in interventions for multimorbidity thereby supporting the delivery of collaborative care for people living with mental-physical multimorbidity. The overall aim of this thesis is to examine the applicability and potential of motivational interviewing in the further development of collaborative care for people living with multimorbidity. This PhD research project is a multimethod investigation conducted in two phases. To address the aim of the thesis, the first phase of the research program investigated the existing application of MI in health care settings, by disease and clinician type, through a systematic review of systematic reviews, as well as a secondary observational analysis of the communication and MI skills used in routine primary care practice. This first phase of the thesis provides support for the potential of MI in health care settings across a range of chronic conditions, both mental and physical, and delivered by a range of clinicians. Observational analysis provided insights into the clinical skills to target in intervention development, specifically about the use of MI skills to promote engagement and to elicit individual perspectives, so as to tailor intervention and information provision. Embedded within a research group undertaking a randomised controlled trial of stepped care to address depression severity in primary care, the second phase of this thesis includes the development of an MI-informed model of collaborative care, with intervention mechanisms identified from the synthesis of theory, the available best practice clinical guidelines, and primary care nurse perspectives. The resultant model of care was then trialled in the Target-D randomised controlled trial and used in the intervention arm with those experiencing severe symptoms. The findings of a multimethod realist evaluation of this new collaborative care intervention include that MI skills contribute to engagement, individual focus and behaviour change empowerment as key mechanisms. In addition, this approach to collaborative care is supported by tailored flexibility, structured clinical practice resources, and interprofessional collaboration. The findings of this PhD can inform the further development of primary care interventions for people living with mental-physical multimorbidity.

Background: Indonesia has a high maternal mortality rate due to hypertensive disorders of pregnancy (HDP), but limited guidelines for HDP management are available in primary care settings. Recommendations for improving HDP management in Indonesian primary care have been identified from a review of HDP international guidelines. Adopting the recommendations into practice in the form of management pathways can potentially change the providers’ practice and subsequently improve care for HDP women. Aim: To improve HDP management in Indonesia by developing a set of HDP management pathways for primary care and determining the acceptability and feasibility of the pathways in practice. Methods: This study applied a mixed-methods design guided by the Medical Research Council (MRC), the Practical Robust Implementation and Sustainability Model (PRISM), and symbolic interactionism approach. It consisted of three consecutive phases: Phase 1 (exploratory interviews); Phase 2 (pathway development); and Phase 3 (acceptability and feasibility study). Phase 1 involved key stakeholders in Indonesia and asked their views and experiences of HDP management in primary care. Phase 2 applied three-round Delphi survey to achieve experts’ consensus on HDP recommendations and develop HDP pathways in primary care, and in Phase 3, the pathways were implemented in three public primary care clinics (Pusat Kesehatan Masyarakat (Puskesmas)) in Yogyakarta to determine their acceptability and feasibility in practice. The pathway implementation was evaluated using clinical audit data and triangulation of observation, interviews and focus groups (FGs) with primary care providers, patients, obstetricians and a health officer. Results: Twenty-four stakeholders participated in Phase 1. The primary care providers mainly referred HDP women to hospitals with limited performed managements before and after the referrals. The HDP management was also challenged by providers’ limited confidence, fragmented continuity of care, and certain beliefs in the community. The participants also raised the possibility of developing surveillance procedures for HDP women, particularly to improve coordination between Puskesmas and private primary care clinics. In Phase 2, 52 experts were recruited to participate in a three-round Delphi survey, and 48, 45, and 37 of them completed the first, second, and third-round survey respectively. Of the 125 tested statements, 115 achieved consensus and were used to develop the HDP pathways, consisting of (i) an HDP diagnosis flowchart, (ii) an HDP management pathway and (iii) an HDP surveillance pathway in primary care. In Phase 3, 55 providers and 61 patients participated in the study, and 48 of them participated in evaluation interviews/FGs. Primary care provider participants attempted to apply recommendations in the pathways and said that the pathways were able to improve their practice. Implementation barriers were also identified, which were mainly related to hierarchical relationships, professional boundaries, and limited clinical resources in primary care. Conclusion: A set of HDP management pathways for Indonesian primary care have been developed and shown to be acceptable and feasible in practice. The pathways can be used for improving the quality of HDP management and have the potentials for more extensive implementation in primary care. Further research is needed to minimise the identified implementation barriers of the pathways before their scale-up study in primary care settings.

Young women are more likely than older women to be subjected to abuse from an intimate partner, though they rarely seek professional help. Instead, they most often disclose the abuse to their friends. In many cases, friends also witness or notice signs of intimate partner violence (IPV). Thus, friends may be critically important sources of support for young women. Yet there is limited research on how young women perceive the responses of friends, and no study appears to have examined how friends perceive responding to IPV. This hinders the ability of health and welfare professionals to develop effective interventions to guide friends on how to support young women experiencing IPV. To address this gap, the aim of this PhD study was to explore the interactions between young women experiencing IPV and their friends from the perspectives of both young women and friends. The study was underpinned by a feminist socio-constructionist epistemology and influenced by narrative methodologies. In-depth interviews were held with eight young women who had experienced IPV. Separate interviews were undertaken with 13 young people who had been a friend of a young woman who had experienced IPV. A thematic narrative analysis of the stories told by interview participants identified that the interactions between young women and friends in relation to IPV had often ended in disappointment, with friends narrating frustration and helplessness, and young women describing feeling misunderstood and judged. A further analysis of the young women’s interviews was undertaken using the Listening Guide method to explore how friends’ responses to the IPV shaped young women’s self-perceptions. The analysis identified that when friends had expected them to leave the abusive relationship but they had been unable to do so, the young women perceived themselves as weak or stupid. However, when friends had recognised the challenges they faced in ending the abuse, it had a transformative impact on how young women perceived themselves. Finally, a thematic analysis of the interviews with friend participants found that the dynamics, emotions and conflicting expectations associated with friendship had influenced how friends perceived their role and created tensions in deciding how to respond to IPV. Through using different qualitative methods, the study provides a rich, multi-layered understanding of the interactions between young women experiencing IPV and their friends, and the individual, relational and sociocultural factors that influence their interactions. The findings reveal that the ways in which friends respond to IPV can have significant implications for how young women perceive themselves. For friends, offering support can be challenging and can affect the dynamics of the friendship and their own wellbeing. Dominant cultural narratives about responses to IPV, as well as the expectations and emotions associated with friendship appear to be key factors that shape friends’ responses. Together, the study’s findings offer valuable information for the development of interventions for friends of young women experiencing IPV. Such interventions can equip friends to offer effective help and can also support them with the significant impacts and dilemmas they may face in responding to IPV.

Abstract: Patient-Generated Health Data (PGHD) collected from innovative medical and consumer wearable technologies are enabling healthcare to shift from inside clinical settings to outside of them through Remote Patient Monitoring (RPM) initiatives. RPM enables continuous monitoring of patients while they are mobile outside the clinical environment and has the potential to empower patients in their health self-management and improve their clinical outcomes. However, PGHD are being collected on an ongoing basis under the patient’s or caregiver’s responsibilities in rapidly changing circumstances during the patient’s daily life. This poses risks to the quality of PGHD and, in turn, reduces their trustworthiness and fitness for use in clinical practice. This issue is limiting the use of such data in RPM, to project-oriented and short-term services that are not incorporated into clinical workflows as part of routine clinical practices. Although there are Data Quality Management (DQM) guidelines for the clinical data routinely collected inside clinical settings, no systematic approach exists to assure the quality of PGHD, whether captured from medical or consumer wearables, so that these data offer the basis for safe patient care. This thesis aimed to address this problem, using a socio-technical health informatics lens to investigate cow can DQM assure that PGHD from medical or consumer wearables are fit for use in clinical care. Following a recognised guideline development process, using five qualitative studies, this thesis developed a DQM guideline for PGHD that stakeholders can use to enhance the value of these data in routine clinical practice. PGHD stakeholders who have experience in RPM were involved in two studies: first, in-depth interviews to identify DQM challenges; and second, a workshop to co-design potential solutions to meet the needs and expectations of stakeholder groups. Next, findings from these two studies, along with results from a preliminary and updated literature review, and a policy review, were interpreted to construct the guideline. The resulting DQM guideline for PGHD comprised 19 recommendations across seven aspects of data quality: accessibility, accuracy, completeness, consistency, interpretability, relevancy, and timeliness. The guideline explicitly addressed the needs of key PGHD stakeholders - patients and clinicians - and it implied that there must be collaboration among all stakeholders, to meet these needs. The final qualitative study in this thesis validated the guideline by seeking experts’ opinion on its likely contribution to the safety and quality of care in RPM. Using the Delphi method, the guideline was distributed via an online survey among international health informatics and health information experts. There was consensus that the guideline’s recommendations are essential to delivering safe and high-quality RPM services. The increasing proliferation of PGHD from health wearables in RPM requires a systematic approach to enable the reliability of these data for use in clinical care. This thesis provided early, significant steps toward practising DQM of PGHD for incorporation into routine clinical practices.

In most countries, who should be screened for colorectal cancer (CRC) is determined by age and family history of disease. Risk prediction models add genomic and/or lifestyle risk factors and are able to predict CRC risk more precisely. If these models were implemented within current population screening programs, more cancers could be detected by screening fewer people, as people at elevated risk are more effectively identified. Behavioural interventions for screening participation could also be targeted, increasing uptake of screening and reducing risky health behaviours. Measures of clinical utility evaluate how useful a model is to direct clinical interventions and to assess associated implementation aspects. This PhD sought to answer the research question: what is the clinical utility of two CRC risk prediction models, one incorporating genomic risk factors, the other lifestyle factors, for tailored population CRC screening in Australia? The first study (Chapter 2) compared the risk stratification and potential clinical impact of the two risk predication models, separately and together, across a range of implementation scenarios in the context of Australian population CRC screening. Use of a genomic and/or lifestyle risk prediction model identified additional people at increased risk that would benefit from colonoscopy, and those at lower risk who could potentially delay screening. Category-based scenarios of broad risk groups provided good balance between number of screens and cancers detected. These findings provide a modelling framework for risk-stratified CRC screening to further model impact on mortality and cost-effectiveness. The second study (Chapters 3 to 6) consisted of 150 general practice patients aged 45-74 recruited sequentially from four practices. After a brief discussion that could be replicated in general practice about the implications of a genomic risk test for CRC, each participant was offered the test. Risk results and tailored screening recommendations were given to those who chose to do the test. In-depth interviews were also conducted with a subset of sixteen participants. Uptake of the genomic test was high (84%), indicating acceptability. Qualitative data revealed that the decision to do the genomic test was easy for most and participants had few reservations about taking the test. 73% of participants made an informed choice about the test. A minority of participants did not understand the implications of the test so did not make an informed decision and a few had concerns about its possible implications so chose not to do it. Based on responses to a series of validated questionnaires, there was minimal psychosocial impact of the genomic test. There was limited evidence that genomic testers were more likely to complete their CRC screening compared to non-testers, but some mediators of screening behaviour were altered in genomic testers. The genomic results promoted screening and/or discussion with GPs regarding screening but only for some. Results from this study have been used to strengthen the behavioural impact of genomic results presentation and discussion before trialling its effect on screening behaviour in a newly funded RCT. There is clinical utility of two CRC risk prediction models for targeting CRC population screening in Australia. Genomic testing for this purpose is acceptable and could be feasible within general practice, suggesting patients can make informed choices regarding testing in this setting and with little risk of adverse psychosocial impacts from testing. Further work is underway to refine and test this intervention that aims not only to recommend the right CRC screening based on risk but encourage adherence to those recommendations. This thesis has contributed significantly to the literature on risk-stratified CRC screening and concludes by summarising how it may be implemented in practice.

Australia’s Indigenous populations experience high rates of family violence but are less likely to access support than non-Indigenous peoples. Mainstream family violence responses have rarely been informed by Indigenous perspectives, and as a result are often not embraced. Although online family violence resources have been well received by non-Indigenous communities, their acceptability to Indigenous peoples has yet to be determined. This thesis engaged with an Indigenous Australian community to understand their perceptions of help-seeking behaviours for family violence and respond to the barriers experienced when pursuing support. Further, this thesis explored the potential for technology as an acceptable resource for those impacted by Indigenous family violence, and what elements an online resource would need have for it to be engaging and usable. To address these aims, a series of methods were used. Firstly, a scoping review was undertaken to identify the help-seeking barriers experienced by Indigenous peoples globally. Then, Community-Based Participatory Research (CBPR) methods were used for addressing the localised help-seeking barriers and exploring the acceptability and elements of online resources for Indigenous family violence. Following a Canadian framework for collaborative research developed with Indigenous peoples, the CBPR methods began by working closely with an Indigenous population on a community-identified need. After establishing trust and seeking approval for the research, an Aboriginal Community Advisory Group was formed and guiding principles for the collaborative research were established. Then, working with the Aboriginal Community Advisory Group, appropriate CBPR methods for addressing the aims of the research were identified. To understand the local perspectives on help-seeking behaviours for Indigenous family violence, interviews took place with fourteen Indigenous women and nine men. These interviews also explored the potential for online family violence resources for Indigenous peoples. Findings from the interviews were then complemented with a round of focus groups where the use of technology for responding to family violence was discussed. Finally, to enhance the likelihood of developing an online resource that was engaging and acceptable to Indigenous peoples, a further round of focus groups and Aboriginal Community Advisory Group deliberations informed the understanding of the elements needed in an appropriate resource. These methods also led to the co-design of an online resource for the Indigenous community involved in the research. This thesis presents the findings in three peer-reviewed articles and a model of suggested elements for online Indigenous family violence resources that can be adapted for other communities. The findings suggest that Indigenous peoples avoid accessing formalised services for family violence because of the substantial barriers they experience such as shame, racism, and fear. One key original contribution to knowledge is that Indigenous peoples perceived online responses for family violence to be acceptable and anticipate that many barriers to support can be addressed through the use of technology. Other significant and new understandings include that Indigenous peoples want co-designed family violence resources that facilitate healing through connection to culture, community and country. This thesis provides evidence that systematic change is required to prioritise the respectful treatment of Indigenous peoples accessing support for family violence. Implications at the practice level include that service providers need cultural training – informed by Indigenous knowledge – to provide culturally safe care so Indigenous peoples can overcome fear and access support. Technology has a role to play in providing accessible support for Indigenous family violence survivors in the practice space. Finally, research implications include opportunities to expand knowledge on the link between culture and healing. Using CBPR methods, non-Indigenous research teams can work respectfully with Indigenous knowledge holders to highlight their voices and create appropriate and useful solutions for community-driven needs.

Sexual violence is a major global public health issue. There are strong associations between sexual violence victimisation and mental illness, with one in three women presenting at mental health services have experienced domestic violence, including sexual violence. Women often report feeling disempowered and re-victimised while in psychiatric inpatient units, especially in mixed-gender wards. The biomedical model has been the dominant model of care in psychiatric inpatient units. Recent years have seen a global movement towards gender-sensitive and trauma-informed models of care for those with mental illness. To date, there is limited extant research focused on understanding health professionals' experiences and practices of these care models. This research aimed to understand how trauma-informed care or gender-sensitive care is experienced and enacted by health professionals’ for women victim-survivors of sexual violence across acute psychiatric inpatient units. To address this aim, the research was divided into two phases and four research questions. The first phase answered research questions one and two through a scoping review of the literature. The first research question explored health professionals' experiences of providing trauma-informed care in acute psychiatric inpatient settings. The second research question explored health professionals' awareness of the gendered impacts of trauma and how this impacts the care provided. The second phase included a qualitative case study, including stakeholder interviews, observations, and document analysis. The second phase answered research questions three and four. The third research question explored health professionals' perceptions of providing care for women who are victim-survivors of sexual violence in psychiatric inpatient units. The fourth research question explored health professionals' experiences in providing care for women who are victim-survivors of sexual violence in psychiatric inpatient units. The researcher also conducted a policy review of current mental health and violence against women policy and procedures to understand the context of health professionals' experiences and practices. The findings of these studies are presented in three peer-reviewed published articles. The findings suggest that trauma-informed and gender-sensitive care are inconsistently understood and enacted in practice. A more comprehensive care model, which is gender-trauma and-violence informed, is suggested to address the identified barriers in acute psychiatric inpatient units. This research contributes to improving care provision for women who are victim-survivors of sexual violence during their admissions to psychiatric inpatient units.

GPimED: Can a one- hour on-line learning module improve early diagnosis and management of Eating Disorders by General Practice Trainees? PROBLEM STATEMENT Eating disorders are a serious and potentially life-threatening group of illnesses within the community. The literature shows that diagnosis and management of these illnesses are inadequately covered during medical school and subsequent General Practice training. This can result in a delay in diagnosis and appropriate referral thus significantly contributing to patient morbidity and mortality plus increased financial burden on the community. The literature demonstrates that patients with ED present repeatedly to General Practice (GP) with a myriad of signs and symptoms There is often delay in diagnosis due to varied reasons. The literature also finds that this delay coupled with lack of appropriate management can greatly exacerbate the morbidity and potential mortality. For example, within this group of disorders, Anorexia Nervosa (AN) has the highest mortality rate of any psychiatric illness with suicide rates 32 times higher than the general population and a mortality rate of 10%. General Practitioners (GPs) are often time poor and lack the knowledge to adequately manage patients with ED Online education for GPs is becoming more popular as it is cost effective, convenient and allows rural and remote GPs access to educational material they might not otherwise be able to access if it is available only via face to face delivery AIM The aim of this study is to determine whether a one-hour online learning module developed to upskill General Practitioners in the recognition and management of Eating Disorders improves the performance of GP trainees. SIGNFICANCE This study will shed light on the effectiveness of online education in upskilling GP trainees and if the ED module is successful, it may lead to improved treatment of patients with evolving or established eating disorders in the General Practice setting. It will potentially reduce the rates of delayed diagnosis resulting in improved outcomes. The literature indicates that patients with an ED present up to 5 times more frequently to primary care than demographically matched peers. General Practice is thus ideally placed to recognize these patients, to make a timely diagnosis and initiate appropriate investigation, management and referrals. The literature also indicates when diagnosis and appropriate intervention occurs within the first three years of the disorder developing, there is a greater than 40% chance of complete recovery. On November 1st 2019, the Federal Government initiated $110 million in extra funding for increased support for patients with a serious ED. This support can only be accessed if the patient as an Eating Disorder Plan completed is be done by the GP who has performed appropriate screening and provided the requisite history, examination and investigations. METHODS The trial design was a randomized, parallel-group study. Participants were recruited from the Victorian General Practice Training Consortia MCCC and EVGPT. The comparator was a general Youth Mental health module. Baseline surveys including demographic details plus a clinical case designed to assess baseline competence in recognising a probable eating disorder case and management thereafter. Following randomisation to either the ED module arm (intervention) or control arm, follow up surveys were completed after 6 weeks, quantitative evaluation was conducted using clinical scenarios presented as case studies in the format of Key Feature Problems (KFPs) which are a component of the FRACGP examination. RESULTS Despite our best efforts, there were only small number of recruits- 15 respondents with 8 completing all components of the study. Despite the small sample, there was measurable improvement in many parameters assessed cross both arms of the trial. In particular, an increase in the identification of ED as a differential diagnosis and improved referrals to health professionals considered integral to the evidence based best practice multidisciplinary team approach to ED management.

Domestic and family violence (DFV) is a major health and social issue in Australia and across the globe. It affects people of all ages and walks of life, predominantly women and children. DFV is associated with a range of harms and impacts, and more frequent utilisation of health services is one. Consequently, health professionals find themselves at the frontline of responding to the health sequelae of violence and trauma in the family. However, healthcare is a gendered profession, where the majority of employees are women. How commonly DFV affects Australian women working in healthcare, and what, if any, association there is between a health professional’s personal experience of DFV and their clinical care of patients accessing healthcare for DFV, is not known. An additional gap in the evidence-base is understanding the needs and perspectives of both survivor health professionals and key stakeholders about the role of the healthcare workplace in supporting survivor staff, not just patients. To address these research gaps, the aim of this PhD study was to investigate the prevalence, clinical care impacts and workplace implications of DFV against an Australian population of women nurses, doctors and allied health professionals. This study utilised a combined methodological approach to collect both quantitative and qualitative data. The first phase of the project was a descriptive, cross-sectional survey of health professionals at a large Australian tertiary maternity hospital, in which 471 health professional women participated (45.0% response rate). Phase two followed, and individual and group interviews were conducted with 18 hospital managers and other key stakeholders. The original contributions of this thesis to new knowledge was the finding that DFV was common in the lives of the health professional women in this study: intimate partner violence (IPV) had affected one in ten (11.5%, 43) women during the last 12-months, and one third (33.6%, 146) of women since the age of sixteen. Sexual violence by an intimate partner was reported by 12.1% (51) of health professional women. Overall, just under half (45.2%, 212) of the participating health professional women had experienced IPV or violence from another family member (including childhood witnessing of DFV) across the life course. The second original finding of this study was that a health professional’s experience of DFV appeared to facilitate clinical care of survivor patients. Specifically, exposure to DFV was positively associated with preparedness to care for survivor patients through greater uptake of professional DFV training, more sensitive attitudes about survivors and more frequent access of information with which to resource survivor patients. The final original knowledge contribution was how hospital workplaces can best support their survivor staff, drawing on the perspectives and experiences of both survivor health professional women (n=93) and hospital managers (n=18). Survivors wanted their workplace to understand that DFV had affected them and to support both their individual needs and recovery as well as their professional capacity to respond to survivor patients. Managers recognised the imperative of a hospital workplace to ensure the availability of multifaceted support for survivor staff, and suggested mechanisms for this. Safety emerged as a key barrier to a more supportive workplace for survivor staff; participants were clear that occupational violence could render a workplace physically unsafe, and fear or uncertainty about how a disclosure of DFV would be responded to affected feelings of emotional safety. The findings of this thesis are presented across three publications. The results indicate that the cumulative trauma burden in Australian health professional women’s lives is high. That burden is added to by the risk of vicarious trauma that all health professionals face in a role where listening to patient histories of trauma and violence is routine. However, the survivors in this study did not present as enduringly vulnerable; on the contrary, they self-reported an informed and sensitive readiness to respond to patients with whom they have DFV in common. This research indicates the efficacy of a trauma and violence-informed framework to underscore and strengthen a recovery-orientated hospital response towards both survivor staff and patients.

Background Type 2 diabetes is a leading health priority of the 21st century. Type 2 diabetes management is complex for both practitioners and patients, made more so because diabetes rarely occurs on its own. Indeed, multimorbidity (the co-occurrence of two or more chronic conditions in an individual) is the norm in diabetes. Multimorbidity, brings about many challenges including difficulties in managing the competing demands of multiple conditions. This can result in reduced adherence to complicated therapeutic regimens. This in turn could lead to suboptimal glycaemia which has been shown to be associated with poorer health outcomes such as the development of downstream complications and increased mortality. Currently, there is no universally accepted measure of multimorbidity. The literature has suggested that the type as well as number of conditions are both important when considering multimorbidity. It has been suggested that multiple conditions in those with type 2 diabetes should be categorised as concordant (diabetes-related) or discordant (unrelated). While the associations between multimorbidity, glycaemia (HbA1c) and all-cause mortality in people with type 2 diabetes has been studied to some extent, significant gaps remain in the existing literature. In particular, the effects of different patterns of multimorbidity including concordant and discordant conditions have not been studied extensively. Similarly, little is known about the relationships between multimorbidity and emerging novel glycaemic measures, such as glycaemic variability and time-in-range. These new ways of understanding glycaemia may be important independent risk factors for developing complications in people with type 2 diabetes. Aim To explore associations between multimorbidity, all-cause mortality and glycaemic outcomes, including HbA1c and novel measures of glycaemic variability and time-in-range in people with type 2 diabetes. Methods My PhD includes a systematic review and three quantitative studies of more than 150,000 people with type 2 diabetes utilising UK, Taiwan and Australian datasets. This provides a clearer picture of the implications of multimorbidity for people with type 2 diabetes in different populations from different countries, health settings, healthcare systems and of different ethnicities. Results The findings of my studies identified that multimorbidity was highly prevalent among people with type 2 diabetes. More than 80% of the 150,000 people included in my studies were found to have at least one other chronic condition in addition to type 2 diabetes. I found the associations between multimorbidity, mortality and glycaemia were mostly consistent across my studies. Increasing multimorbidity was significantly associated with increased all-cause mortality. This was the case for total count of multimorbidity, as well as counts of concordant and discordant conditions. Increasing concordant counts had the greatest effect on mortality. However, when examining the effects of individual conditions and combinations of two conditions on mortality in the UK and Taiwan cohorts, the results differed between Caucasian and ethnic Chinese populations. I also found that across my studies, all measures of multimorbidity were not associated with higher HbA1c, glycaemic variability and time-in-range. Conclusion This PhD has contributed a novel and deeper understanding of the significance of multimorbidity in people with type 2 diabetes. It has provided an insight into the effects of different patterns of multimorbidity, including concordant and discordant conditions, on important health outcomes in different cohorts of people with type 2 diabetes. My findings highlight the need for clinical guidelines to support a holistic approach to the complex care needs of those with type 2 diabetes and multimorbidity, accounting for the various conditions they be may be living with. While managing glycaemia in people with diabetes is important, it should not overshadow efforts to address multimorbidity, both concordant and discordant. It is important to consider the overall multimorbidity disease burden as a way of recalibrating and personalising our clinical focus in supporting people with diabetes. By taking a holistic approach and caring for the whole person, this could potentially reduce their annual mortality risk by reducing the overall burden of multimorbidity.

This thesis describes research into the way Australian government officials decide to allocate healthcare resources for children who live in rural and remote areas of the country. It is known that infant mortality and health outcomes are worse for these children than for urban children. Moreover, there is evidence that rural families are more likely to experience difficulties gaining access to healthcare for their children than urban families. Documents and guidelines published by federal and state health departments suggest that the allocation of healthcare resources should be guided by the principles of equity and of obtaining the greatest possible improvement of the health of the whole population for the money spent. Prima facie, these principles are mutually incompatible. Aim: This investigation was designed to answer the following questions: 1. What healthcare resources are currently available for children in rural and remote areas in Australia? 2. How do the parents of children living in rural and remote areas of NSW experience the provision of healthcare resources for their children and the consequences for their child and family of that pattern of resource provision? 3. How are healthcare resources allocated to children living in rural and remote areas and what factors are taken into consideration in making this allocation? 4. What ethical framework underpins the allocation of healthcare resources for children now? 5. What ethical framework could guide healthcare resource allocation for children in a way that best fits the needs of rural children, of their families and of government health officials? Methodology: To gain a picture of the healthcare resources available to rural children in NSW, the decision-making process which led to the current distribution of those resources and the experience of rural families in gaining access to those resources, I employed complementary qualitative and quantitative approaches. In early 2018, information on the geographic location of healthcare resources relevant to the needs of children in the Western New South Wales (NSW) Local Health District was obtained from the National Health Services Directory and compared with the location of child populations of various sizes in geographical units known as State Suburbs. To compare family experiences in gaining healthcare for their children, raw data were obtained from the NSW Health Child Population Health Survey, and the experiences of rural families in their interactions with several kinds of healthcare resource were compared with those of urban families. Elected and non-elected officials of the Australian Government Department of Health and Ageing and the NSW Ministry of Health were interviewed, and themes identified from the transcripts. From this analysis, descriptions of the aims and process of healthcare resource allocation decision-making emerged, including description of the constraints on decision-making and the role of ethical considerations. The analysis also revealed the views of decision-makers on the nature of the ethical principles which guide resource allocations.   Findings: Comparison of geographical locations of healthcare resources with those of child populations revealed that healthcare resources needed by rural children were lacking in many localities containing substantial child populations. This evidence partly explains the findings that rural families were more likely than urban families to experience difficulty in accessing healthcare for their children, especially due to lack of resources, long delays in waiting time for scarce resources or transport difficulties in accessing them. Interviewed officials indicated that elected officials (health ministers) and members of the National and NSW Cabinets held the ultimate power to make allocation decisions, and that those decisions had budgetary and political constraints. Ethical principles appeared to play only a minor role in allocation of healthcare resources, and while equity was the principle most often mentioned, there was no agreement on whether equity of resource allocation, equity of access to resources or equity of health was the aim. Discussion and Implications: The investigation canvassed a range of metaethical principles which could inform resource allocation decision-making. It concluded that equity (and especially vertical equity) in access to healthcare resources for equal need was the principle most likely to be acceptable in Australian society and to Australian resource allocation decision-makers. At the same time, it appeared to be the most likely to improve the health and wellbeing of rural children, both absolutely and in relation to that of urban children. Despite the investigation’s identification of the value of equity of healthcare access, there is a discrepancy between the published intentions of the Australian Government Department of Health and NSW Health to allocate healthcare resources according to this principle, and the minor role which ethical principles, including equity, play in actual decision-making. Further, there is lack of certainty among officials about the goal of achieving equity (that is, whether equity in resource allocation, equity in healthcare access or equity in health should be the aim). The investigation suggests two principal reasons why the avowed aim of allocating resources to achieve equity was not, in fact, achieving equity of health or of healthcare access. One was the apparent uncertainty among officials about the aspect of health or healthcare in which equity was to be achieved. The other reason was deficiency in motivation to act on an acknowledged moral reason (to act to achieve equity). The data suggest that adoption of the motivating principles of communitarianism or compassion would be more likely to supply the motivation to act to achieve equity than the assumption that the interests of the individual should underlie all ethical principles.

BACKGROUND Urinary tract infections (UTIs) are very common in young children, but hard to diagnose, and easily missed. Diagnosis is important: if untreated UTI can cause sepsis and permanent kidney scarring. Many young children with unexplained fever must have a urine sample tested to check for potential UTI. The problem is that collecting urine samples from young pre-continent children is extremely difficult. Existing collection methods all have limitations. Standard care in Australia of waiting for a clean catch is time-consuming and often unsuccessful. Urine bags have unacceptably high contamination. Catheter and needle procedures are painful and distressing, and require expertise and equipment to perform. Suboptimal practice compromises patient care and wastes healthcare resources. AIMS & METHODS The doctoral research had the overall objective to improve non-invasive urine sample collection for young pre-continent children. Specific aims were to discover: 1. A quick, simple and effective non-invasive collection method 2. Cost-effectiveness of current and new collection methods 3. Which collection methods are practical in the primary care setting 4. Knowledge translation of findings into practice These aims were examined with the following research methodologies: 1. Two clinical trials of a novel voiding stimulation method 2. Economic evaluation of existing and new collection methods 3. Qualitative study in Australian general practice 4. Local guideline update and development of consumer resources RESULTS The novel Quick-Wee voiding stimulation method was conceptualised, using cold wet gauze to gently rub the suprapubic region. This triggers cutaneous bladder reflexes for faster and more successful urine sample collection. A pilot study (n=40) demonstrated the method was feasible. A randomised trial (n=354) demonstrated significantly higher success in collecting a urine sample within 5 minutes, and significantly higher parental and clinician satisfaction, compared to standard clean catch practice. An economic evaluation comprehensively modelled the costs and cost-effectiveness to collect a definitive sample for all common urine sample collection methods. Overall, catheterisation was the favoured collection method, Quick-Wee the favoured non-invasive method, and urine bags were the most expensive method. This is the first cost-effectiveness analysis of its kind, filling a significant evidence gap, and identifying potential cost savings. A qualitative study explored the barriers and enablers to collecting urine samples from young children in Australian general practice. Non-invasive methods were strongly favoured and invasive methods were rarely used. Key barriers included time and space constraints in clinics. Key enablers included parental motivation, education handouts and voiding stimulation methods. These important insights can inform policy, education and future research. Knowledge translation activities were undertaken including updating statewide guidelines and creating consumer resources. The Quick-Wee method is now recommended in guidelines across a range of settings internationally. CONCLUSION This body of work developed the new Quick-Wee voiding stimulation method and has shown it is more effective, more cost-effective, and more acceptable than standard care. It is gentle for children and simple for clinicians. This research has addressed key evidence gaps, contributing new knowledge to optimise investigation of UTI in young children. Findings have changed practice and been implemented in policies and guidelines internationally.