Journal articles on the topic 'Family medicine Australia Econometric models'

The aim of the work was to model the mechanism of the influence of an exogenous resource variable on the predicted indicator of the national development goal, in which one model was selected from an infinite family of hypothetical resource allocation models within a year, reflecting the uncertainty inherent in soft computing. The study of problems based on small sample data in the age of big data is substantiated by the fact that there are a number of longitudinal tasks of longterm research in which, after 5–6 years of testing any methods, it is necessary to obtain data on their effectiveness and predictability in general. At the same time, the data slice occurs strictly at the end of the year as a control and summary measurement. In such cases, special econometric specifications of models are required that take into account the "physics" of relationships. This situation is similar to the situation in mechanics, when small data are compensated by the laws of motion and play the role of initial data in the Cauchy problem for differential equations – when the law itself is known and does not need to be estimated using big data.

Background: Successful Family Medicine practices and academic programmes are found in western countries, Australia, Singapore, Cuba and among other non-western countries. Documenting the enablers and challenges of different contexts would, it is hoped, inform current and future process of developing academic and practice programmes in Family Medicine in countries where the discipline is starting. Methods: A qualitative study was undertaken that conducted a focused literature review and in-depth interviews of key informants on the early development of the Family Medicine in Kenya. All interviews were audio recorded. Pattern matching, explanation building, time-series analysis and logic models were used in analysis. Results: Representatives of Kenyan and foreign organisations worked well as a team to write and implement the first curriculum of Family Medicine. The challenges include lack of teachers; starting a graduate programme in medical schools that did not have one and starting these health services delivery departments in a system that did not have any. Conclusions: The main enablers of the evolution of Family Medicine in Kenya include committed partnerships and teamwork among Kenyan and non-Kenyan stakeholders. The challenges include the lack of Kenyan teachers of the programme and the introduction of a new discipline. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: /10.1080/20786190.2016.12481420

Background Meta-analysis of systematically reviewed studies on interventions is the cornerstone of evidence based medicine. In the following, we will introduce the common-beta beta-binomial (BB) model for meta-analysis with binary outcomes and elucidate its equivalence to panel count data models. Methods We present a variation of the standard “common-rho” BB (BBST model) for meta-analysis, namely a “common-beta” BB model. This model has an interesting connection to fixed-effect negative binomial regression models (FE-NegBin) for panel count data. Using this equivalence, it is possible to estimate an extension of the FE-NegBin with an additional multiplicative overdispersion term (RE-NegBin), while preserving a closed form likelihood. An advantage due to the connection to econometric models is, that the models can be easily implemented because “standard” statistical software for panel count data can be used. We illustrate the methods with two real-world example datasets. Furthermore, we show the results of a small-scale simulation study that compares the new models to the BBST. The input parameters of the simulation were informed by actually performed meta-analysis. Results In both example data sets, the NegBin, in particular the RE-NegBin showed a smaller effect and had narrower 95%-confidence intervals. In our simulation study, median bias was negligible for all methods, but the upper quartile for median bias suggested that BBST is most affected by positive bias. Regarding coverage probability, BBST and the RE-NegBin model outperformed the FE-NegBin model. Conclusion For meta-analyses with binary outcomes, the considered common-beta BB models may be valuable extensions to the family of BB models.

The COVID-19 pandemic has introduced to mild the risks of deadly epidemic-prone illnesses sweeping our globalized planet. The pandemic is still going strong, with additional viral variations popping up all the time. For the close to future, the international response will have to continue. The molecular tests for SARS-CoV-2 detection may lead to False-negative results due to their genetic similarity with other coronaviruses, as well as their ability to mutate and evolve. Furthermore, the clinical features caused by SARS-CoV-2 seem to be like the symptoms of other viral infections, making identification even harder. We constructed seven hidden Markov models for each coronavirus family (SARS-CoV2, HCoV-OC43, HCoV-229E, HCoV-NL63, HCoV-HKU1, MERS-CoV, and SARS-CoV), using their complete genome to accurate diagnose human infections. Besides, this study characterized and classified the SARS-CoV2 strains according to their different geographical regions. We built six SARS-CoV2 classifiers for each world's continent (Africa, Asia, Europe, North America, South America, and Australia). The dataset used was retrieved from the NCBI virus database. The classification accuracy of these models achieves 100% in differentiating any virus model among others in the Coronavirus family. However, the accuracy of the continent models showed a variable range of accuracies, sensitivity, and specificity due to heterogeneous evolutional paths among strains from 27 countries. South America model was the highest accurate model compared to the other geographical models. This finding has vital implications for the management of COVID-19 and the improvement of vaccines.

ObjectivesAsthma is one of the greatest health burdens, yet contributors to asthma symptom trajectories are understudied in Australian children. We aimed to assess the trajectories of asthma symptom and their associations with several family environmental factors during the childhood period in Australia.DesignSecondary analysis from a cross-sequential cohort study.SettingNationwide representative data from the ‘Longitudinal Study of Australian Children (LSAC)’.ParticipantsParticipants from the LSAC birth cohort.Outcome measuresAsthma symptom trajectory groups.MethodsAsthma symptom presenting as wheezing, family environmental factors and sociodemographic data (2004–2018) were obtained from the LSAC. Group-based trajectory modelling was applied to identify asthma symptom trajectories and multivariable logistic regression models were used to assess the associations between these and environmental factors.ResultsOf 5107 children in the LSAC cohort, 3846 were included in our final analysis. We identified three distinct asthma symptom trajectories from age 0/1 year to 14/15 years: ‘low/no’ (69%), ‘transient high’ (17%) and ‘persistent high’ (14%). Compared with the ‘low/no’ group, children exposed to ‘moderate and declining’ (relative risk ratio (RRR): 2.22, 95% CI 1.94 to 2.54; RRR: 1.26, 95% CI 1.08 to 1.46) and ‘high and persistent’ prevalence of maternal smoking (RRR: 1.41, 95% CI 1.23 to 1.60; RRR: 1.26, 95% CI 1.10 to 1.44) were at increased risk of being classified into the ‘transient high’ and ‘persistent high’ trajectories of asthma symptom. Persistently bad external dwelling conditions (RRR: 1.27, 95% CI 1.07 to 1.51) were associated with ‘transient high’ trajectory while ‘moderate and increasing’ conditions of cluttered homes (RRR: 1.37, 95% CI 1.20 to 1.56) were associated with ‘persistent high’ trajectory of asthma symptom. Exposure to tobacco smoke inside the house also increased the risk of being in the ‘persistent high’ trajectory group (RRR: 1.30, 95% CI 1.12 to 1.50).ConclusionPoor home environment increased the risk of asthma symptom during childhood. Improving home environment and reducing exposure to tobacco smoke may facilitate a favourable asthma symptom trajectory during childhood.

ObjectivesAsthma is one of the greatest health burdens, yet contributors to asthma symptom trajectories are understudied in Australian children. We aimed to assess the trajectories of asthma symptom and their associations with several family environmental factors during the childhood period in Australia.DesignSecondary analysis from a cross-sequential cohort study.SettingNationwide representative data from the ‘Longitudinal Study of Australian Children (LSAC)’.ParticipantsParticipants from the LSAC birth cohort.Outcome measuresAsthma symptom trajectory groups.MethodsAsthma symptom presenting as wheezing, family environmental factors and sociodemographic data (2004–2018) were obtained from the LSAC. Group-based trajectory modelling was applied to identify asthma symptom trajectories and multivariable logistic regression models were used to assess the associations between these and environmental factors.ResultsOf 5107 children in the LSAC cohort, 3846 were included in our final analysis. We identified three distinct asthma symptom trajectories from age 0/1 year to 14/15 years: ‘low/no’ (69%), ‘transient high’ (17%) and ‘persistent high’ (14%). Compared with the ‘low/no’ group, children exposed to ‘moderate and declining’ (relative risk ratio (RRR): 2.22, 95% CI 1.94 to 2.54; RRR: 1.26, 95% CI 1.08 to 1.46) and ‘high and persistent’ prevalence of maternal smoking (RRR: 1.41, 95% CI 1.23 to 1.60; RRR: 1.26, 95% CI 1.10 to 1.44) were at increased risk of being classified into the ‘transient high’ and ‘persistent high’ trajectories of asthma symptom. Persistently bad external dwelling conditions (RRR: 1.27, 95% CI 1.07 to 1.51) were associated with ‘transient high’ trajectory while ‘moderate and increasing’ conditions of cluttered homes (RRR: 1.37, 95% CI 1.20 to 1.56) were associated with ‘persistent high’ trajectory of asthma symptom. Exposure to tobacco smoke inside the house also increased the risk of being in the ‘persistent high’ trajectory group (RRR: 1.30, 95% CI 1.12 to 1.50).ConclusionPoor home environment increased the risk of asthma symptom during childhood. Improving home environment and reducing exposure to tobacco smoke may facilitate a favourable asthma symptom trajectory during childhood.

ObjectiveEven as genomic medicine is implemented globally, there remains a lack of rigorous, national assessments of physicians’ current genomic practice and continuing genomics education needs. The aim of this study was to address this gap.DesignA cross-sectional survey, informed by qualitative data and behaviour change theory, to assess the current landscape of Australian physicians’ genomic medicine practice, perceptions of proximity and individual preparedness, and preferred models of practice and continuing education. The survey was advertised nationally through 10 medical colleges, 24 societies, 62 hospitals, social media, professional networks and snowballing.Results409 medical specialists across Australia responded, representing 30 specialties (majority paediatricians, 20%), from mainly public hospitals (70%) in metropolitan areas (75%). Half (53%) had contacted their local genetics services and half (54%) had ordered or referred for a gene panel or exome/genome sequencing test in the last year. Two-thirds (67%) think genomics will soon impact their practice, with a significant preference for models that involved genetics services (p<0.0001). Currently, respondents mainly perform tasks associated with pretest family history taking and counselling, but more respondents expect to perform tasks at all stages of testing in the future, including tasks related to the test itself, and reporting results. While one-third (34%) recently completed education in genomics, only a quarter (25%) felt prepared to practise. Specialists would like (more) education, particularly on genomic technologies and clinical utility, and prefer this to be through varied educational strategies.ConclusionsThis survey provides data from a breadth of physician specialties that can inform models of genetic service delivery and genomics education. The findings support education providers designing and delivering education that best meet learner needs to build a competent, genomic-literate workforce. Further analyses are underway to characterise early adopters of genomic medicine to inform strategies to increase engagement.

This interpretative study examines the complexities of lesbian parents’ experiences in organized youth sport programs. Specifically, it seeks to understand youth sport as a potential site for social change that facilitates a sense of inclusive community for diverse family structures. Using thematic analysis, the author examines perspectives of nine participants from Australia, Canada, and the United States. Emphasis is placed on how the lesbian parents (a) negotiate heightened visibility, sexual stigma, and parental judgment; (b) foster social relationships through participation, volunteerism, and positive role models; and (c) create shared understanding toward building an inclusive sport culture. The findings call attention to the importance of intentional and unintentional acts (by families as well as sport organizations) that create a sense of community and an inclusive organizational culture. The connection of lesbian parents’ experiences to broader concepts, such as sexual stigma and transformative services, are also examined within the context of youth sport.

This paper discusses a small study that was undertaken in a palliative care unit (PCU) to demonstrate reasons for the lengthy patient turnover time after the death of a patient. The study arose from a managerial challenge about the PCU's efficiency in comparison to other settings of care. While Palliative care services in Australia are loosely funded on a per diem rate, casemix funding models for inpatient services in other settings reward efficiency in terms of length of stay (1). The aim of the study was to undertake a post-death survey, from the nursing perspective, of activities and the time required to deliver follow-up care, as required, to the deceased patient and his/her family. Details of the post-death episode for all patients who died in the PCU over two time periods were collected using a newly designed tool. This paper does not argue for the incorporation of post-death nursing work as a measure of efficiency or quality; rather, it is a demonstration of the type of work and the time involved in carrying out post-death work. This nursing work is an essential but hidden and generally unacknowledged element of palliative care and, not surprisingly, there is a dearth of literature describing the role of the nurse in providing care of the family and others after the patient has died. This project has provided important information about the factors that Protract after-death care, and gives some insight into the role of the nurse after a death occurs in a PCU.

Background and Objectives: There is an ongoing shortage of primary care physicians in the United States. Medical schools are under pressure to address this threat to the nation’s health by producing more primary care graduates, including family physicians. Our objective was to identify institutional characteristics associated with more medical students choosing primary care. Methods: We conducted a systematic literature review with narrative synthesis to identify medical school characteristics associated with increased numbers or proportions of primary care graduates. We included peer-reviewed, published research from the United States, Canada, Australia, and New Zealand. The existing literature on characteristics, including institutional geography, funding and governance, mission, and research emphasis, was analyzed and synthesized into summary statements. Results: Ensuring a strong standing of the specialty of family medicine and creating an atmosphere of acceptance of the pursuit of primary care as a career are likely to increase an institution’s percentage of medical students entering primary care. Training on regional campuses or providing primary care experiences in rural settings also correlates with a larger percentage of graduates entering primary care. A research-intensive culture is inversely correlated with primary care physician production among private, but not public, institutions. The literature on institutional financial incentives is not of high enough quality to make a firm statement about influence on specialty choice. Conclusions: To produce more primary care providers, medical schools must create an environment where primary care is supported as a career choice. Medical schools should also consider educational models that incorporate regional campuses or rural educational settings.

Trichosanthes tricuspidata Lour., also known as T. palmata Roxb, T. bracteata Lam., T. puber Blume, and Modecca bracteata, is a vine belonging to the Cucurbitaceae family (English name: redball snake gourd). Distributed in China, South and East Asia, and tropical Australia, it has been traditionally used as a medicinal plant for its antifever, laxative, anthelmintic properties and for migraine treatment. In this paper, we examined the effects of Trichosanthes tricuspidata Lour. ethanol extract (Tt-ME) in vitro and in vivo. To confirm the effects of Tt-ME on inflammatory responses, we conducted experimental analyses including level of nitric oxide (NO) production, RT-PCR, and immunoblotting and using a HCl/EtOH-induced gastritis animal model. Tt-ME attenuated the release of NO and decreased mRNA levels of inducible NO synthase (iNOS), TNF-α, and IL-6 in lipopolysaccharide- (LPS-) induced macrophages in a concentration-dependent manner. Tt-ME time-dependently suppressed nuclear translocation of nuclear factor kappa B (NF-κB) subunits p50 and p65, activator protein (AP-1) subunits c-Fos and c-Jun, and STAT3 transcriptional activity by inhibiting nuclear translocation of p50, p65, c-Fos, c-Jun, and STAT3. Tt-ME significantly downregulated NF-κB, MAPK, and JAK2 signaling by targeting Syk, Src, and IRAK1 protein kinases. Furthermore, matrix metalloproteinase-9 (MMP-9) expression and cell migration were observed to be downregulated by Tt-ME in LPS-activated macrophages. In vivo studies on Tt-ME also produced similar trends in Hcl/EtOH-induced gastritis mouse models by inhibiting proinflammatory cytokines and the inflammatory signaling pathway. Our results strongly suggest that Tt-ME exerted anti-inflammatory activity in LPS-stimulated macrophages and mouse models of acute inflammatory disease.

Objective There is a paucity of research on the quality of evidence relating to primary care workforce models. Thus, the aim of the present study was to evaluate the quality of evidence on diabetes primary care workforce models in Australia. Methods The National Health and Medical Research Council of Australia’s (National Health and Medical Reseach Council; 2000, 2001) frameworks for evaluating scientific evidence and economic evaluations were used to assess the quality of studies involving primary care workforce models for diabetes care involving Australian adults. A search of medical databases (MEDLINE, AMED, RURAL, Australian Indigenous HealthInfoNet and The Cochrane Institute), journals for diabetes care (Diabetes Research and Clinical Practice, Diabetes Care, Diabetic Medicine, Population Health Management, Rural and Remote Health, Australian Journal of Primary Health, PLoS Medicine, Medical Journal of Australia, BMC Health Services Research, BMC Public Health, BMC Family Practice) and Commonwealth and state government health websites was undertaken to acquire Australian studies of diabetes workforce models published 2005–13. Various diabetes workforce models were examined, including ‘one-stop shops’, pharmacy care, Aboriginal services and telephone-delivered interventions. The quality of evidence was evaluated against several criteria, including relevance and replication, strength of evidence, effect size, transferability and representativeness, and value for money. Results Of the14 studies found, four were randomised controlled trials and one was a systematic review (i.e. Level II and I (best) evidence). Only three provided a replicable protocol or detailed intervention delivery. Eleven lacked a theoretical framework. Twelve reported significant improvements in clinical (patient) outcomes, commonly HbA1c, cholesterol and blood pressure; only four reported changes in short- and long-term outcomes (e.g. quality of life). Most studies used a small or targeted population. Only two studies assessed both benefits and costs of their intervention compared with usual care and cost effectiveness. Conclusions More rigorous studies of diabetes workforce models are needed to determine whether these interventions improve patient outcomes and, if they do, represent value for money. What is known about the topic? Although health systems with strong primary care orientations have been associated with enhanced access, equity and population health, the primary care workforce is facing several challenges. These include a mal-distribution of resources (supply side) and health outcomes (demand side), inconsistent support for teamwork care models, and a lack of enhanced clinical inter-professional education and/or training opportunities. These challenges are exacerbated by an ageing health workforce and general population, as well as a population that has increased prevalence of chronic conditions and multi-morbidity. Although several policy directions have been advocated to address these challenges, there is a lack of high-quality evidence about which primary care workforce models are best (and which models represent better value for money than current practice) and what the health effects are for patients. What does this paper add? This study demonstrated several strengths and weaknesses of Australian diabetes models of care studies. In particular, only five of the 14 studies assessed were designed in a way that enabled them to achieve a Level II or I rating (and hence the ‘best’ level of evidence), based on the NHMRC’s (2000, 2001) frameworks for assessing scientific evidence. The majority of studies risked the introduction of bias and thus may have incorrect conclusions. Only a few studies described clearly what the intervention and the comparator were and thus could be easily replicated. Only two studies included cost-effectiveness studies of their interventions compared with usual care. What are the implications for practitioners? Although there has been an increase in the number of primary care workforce models implemented in Australia, there is a need for more rigorous research to assess whether these interventions are effective in producing improved health outcomes and represent better value for money than current practice. Researchers and policymakers need to make decisions based on high-quality evidence; it is not obvious what effect the evidence is having on primary care workforce reform.

Background: Despite a fast-paced environment, the emergency clinician has a duty to meet the palliative patient’s needs. Despite suggested models and interventions, this remains challenging in practice. Aim: To raise awareness of these challenges by exploring the experience of palliative care patients and their families and informal carers attending the emergency department, and of the clinicians caring for them. Design: Qualitative systematic literature review and thematic synthesis. Search terms related to the population (palliative care patients, family carers, clinicians), exposure (the emergency department) and outcome (experience). The search was international but restricted to English and used a qualitative filter. Title, abstracts and, where retrieved, full texts were reviewed independently by two reviewers against predefined inclusion criteria arbitrated by a third reviewer. Studies were appraised for quality but not excluded on that basis. Data sources: MEDLINE [1946-], Embase[1947-], CINAHL [1981-] and PsycINFO [1987-] with a bibliography search. Results: 19 papers of 16 studies were included from Australia ( n = 5), the United Kingdom ( n = 5), and United States ( n = 9) representing 482 clinical staff involved in the emergency department (doctors, nurses, paramedics, social workers, technicians), 61 patients and 36 carers. Nine descriptive themes formed three analytic themes: ‘Environment and Purpose’, ‘Systems of Care and Interdisciplinary Working’ and ‘Education and Training’. Conclusion: In the included studies, provision of emergency palliative care is a necessary purpose of the emergency department. Failure to recognise this, gain the necessary skills or change to systems better suited to its delivery perpetuates poor implementation of palliative care in this environment.

ObjectiveDespite needs, people with advanced non-malignant respiratory disease are infrequently referred to palliative care services. Integrated models of palliative care and respiratory service delivery have been advocated to address this inequity of access. This study mapped current ambulatory palliative care service provision for patients with advanced non-malignant respiratory disease in Australia and New Zealand. MethodsAn online survey was distributed to the palliative care physician membership of the Australian and New Zealand Society of Palliative Medicine. Information was sought regarding access to specific breathlessness and integrated respiratory and palliative care services, and their operation. Data were described using descriptive statistics. ResultsIn all, 133 respondents (93 from Australia, 40 from New Zealand; representing 55 Australian and 26 New Zealand discrete sites) with complete data were available for analysis. More than half the respondents reported seeing patients with advanced non-malignant respiratory disease frequently (56/97; 58%), and 18 of 81 services (22%) reported having breathlessness or integrated respiratory and palliative care services caring for this patient group. Such services were mostly staffed by respiratory and palliative care doctors and nurses and based in the clinic environment, with limited support available outside this setting. Of the 63 respondents without existing breathlessness or integrated services, 49 (78%) expressed interest in their establishment, with limited resources cited as the most common barrier. ConclusionsThere is limited availability of integrated respiratory and palliative care or specialised breathlessness services in Australia and New Zealand despite widespread support by palliative care physicians. This study provides a snapshot to inform strategic service development. What is known about the topic?People with advanced respiratory disease have very significant morbidity with complex needs equivalent to, and in many cases more intense than, people with end-stage lung cancer; they also have significant mortality. Yet, these people frequently do not access palliative care services. The establishment of integrated respiratory and palliative care services has been advocated as an effective means to overcome the barriers to palliative care access. Such services have demonstrated improved patient and family-reported outcomes, as well as service-level improvements. What does this paper add?This paper maps the availability of integrated respiratory palliative care services in Australia and New Zealand. We reveal that although most palliative care physicians report seeing patients with advanced respiratory disease in practice, just one-fifth of services report having an integrated service approach. There was high interest and enthusiasm for such services (78%), but resources limited their establishment. What are the implications for practitioners?Palliative care services recognise the needs of patients with advanced respiratory disease and the benefits of integrated respiratory and palliative care services to address these needs, but scarcity of resources limits the ability to respond accordingly. This study provides a snapshot of current service level to inform strategic development.

IntroductionAdvances in the care of patients with single-ventricle congenital heart disease have led to a new generation of individuals living with a Fontan circulation. For people with Fontan physiology, physical, psychological and neurodevelopmental challenges are common. The objective of this study is to describe and develop a deeper understanding of the factors that contribute to quality of life (QOL) among children, adolescents and adults living with a Fontan circulation across Australia and New Zealand, their parents and siblings.Methods and AnalysisThis article presents the protocol for the Australian and New Zealand Fontan Registry (ANZFR) QOL Study, a cross-sectional, population-based study designed to examine QOL among people of all ages with a Fontan circulation, their parents and siblings. Study eligibility criteria includes (1) individuals with a Fontan circulation aged ≥6 years, at least 12 months post-Fontan procedure and enrolled in the ANZFR; (2) parents of individuals enrolled in the ANZFR; and (3) siblings aged ≥6 years of an individual enrolled in the ANZFR. A novel, online research platform is used to distribute personalised assessments tailored to participant age and developmental stage. A suite of validated psychometric self-report and parent-proxy report instruments capture potential correlates and predictors of QOL, including symptoms of psychological distress, personality attributes, coping and cognitive appraisals, family functioning, healthcare experiences and costs, access to emotional support and socioeconomic factors. Clinical characteristics are captured via self-report and parent-proxy report, as well as the ANZFR. Descriptive analyses and multilevel models will be used to examine QOL across groups and to investigate potential explanatory variables.Ethics and DisseminationApproval has been obtained from all relevant Human Research Ethics Committees (HRECs), including the Sydney Children’s Hospitals Network and the Royal Children’s Hospital Melbourne HRECs. Study findings will be published in peer-reviewed journals and presented at national and international meetings and seminars.

IntroductionShort interpregnancy interval (IPI) has been linked to adverse pregnancy outcomes. WHO recommends waiting at least 2 years after a live birth and 6 months after miscarriage or induced termination before conception of another pregnancy. The evidence underpinning these recommendations largely relies on data from low/middle-income countries. Furthermore, recent epidemiological investigations have suggested that these studies may overestimate the effects of IPI due to residual confounding. Future investigations of IPI effects in high-income countries drawing from large, population-based data sources are needed to inform IPI recommendations. We aim to assess the impact of IPIs on maternal and child health outcomes in high-income countries.Methods and analysisThis international longitudinal retrospective cohort study will include more than 18 million pregnancies, making it the largest study to investigate IPI in high-income countries. Population-based data from Australia, Finland, Norway and USA will be used. Birth records in each country will be used to identify consecutive pregnancies. Exact dates of birth and clinical best estimates of gestational length will be used to estimate IPI. Administrative birth and health data sources with >99% coverage in each country will be used to identify maternal sociodemographics, pregnancy complications, details of labour and delivery, birth and child health information. We will use matched and unmatched regression models to investigate the impact of IPI on maternal and infant outcomes, and conduct meta-analysis to pool results across countries.Ethics and disseminationEthics boards at participating sites approved this research (approval was not required in Finland). Findings will be published in peer-reviewed journals and presented at international conferences, and will inform recommendations for optimal IPI in high-income countries. Findings will provide important information for women and families planning future pregnancies and for clinicians providing prenatal care and giving guidance on family planning.

IntroductionSARS-CoV-2, a highly contagious severe acute respiratory syndrome, has spread to most countries in the world and resulted in a change to practice patterns for the assessment and diagnosis of people with voice disorders. Many services are transitioning to telehealth models to maintain physical distancing measures and conserve personal protective equipment used by healthcare workers during laryngoscopy examinations. The speech–language pathology primary contact (SLPPC) assessment for patients referred to ear, nose and throat (ENT) services in Australia has been shown to reduce waiting times for assessment while streamlining access to ENT assessment and allied health practitioner treatment pathways.Methods and analysisA prospective observational cohort study will see patients in a newly developed telehealth model which uses the principles from a usual care SLPPC assessment protocol. Participants will be offered an initial telehealth assessment (speech–language pathology primary contact telehealth (SLPPC-T)) prior to being prioritised for a face-to-face laryngoscopy assessment to complete the diagnostic process. The telehealth assessment will collect sociodemographic information, personal and family medical history, key symptoms, onset and variability of symptoms, red-flag signs or symptoms for laryngeal malignancy, and clinical voice assessment data for auditory–perceptual and acoustic analysis. The study outcomes include (1) association of signs, symptoms and specific voice measures collected during SLPPC-T with voice disorder classification provided after laryngoscopy; (2) degree of concordance between voice disorder classification after SLPPC-T and after laryngoscopy; (3) health service and patient-related costs and health outcomes of the SLPPC-T; (4) patient and stakeholder views and beliefs about the SLPPC-T process.Ethics and disseminationEthical approval has been granted prior to commencement of the study enrolment by the Gold Coast Hospital and Health Service Human Research Ethics Committee (reference number HREC/2020/QGC/62832). Results will be shared through the publication of articles in peer-reviewed medical journals and presentation at national and international scientific meetings.Trial registration numberACTRN12621000427875.

Abstract STUDY QUESTION Can exome sequencing identify new genetic causes of globozoospermia? SUMMARY ANSWER Exome sequencing in 15 cases of unexplained globozoospermia revealed deleterious mutations in seven new genes, of which two have been validated as causing globozoospermia when knocked out in mouse models. WHAT IS KNOWN ALREADY Globozoospermia is a rare form of male infertility characterised by round-headed sperm and malformation of the acrosome. Although pathogenic variants in DPY19L2 and SPATA16 are known causes of globozoospermia and explain up to 70% of all cases, genetic causality remains unexplained in the remaining patients. STUDY DESIGN, SIZE, DURATION After pre-screening 16 men for mutations in known globozoospermia genes DPY19L2 and SPATA16, exome sequencing was performed in 15 males with globozoospermia or acrosomal hypoplasia of unknown aetiology. PARTICIPANTS/MATERIALS, SETTING, METHOD Targeted next-generation sequencing and Sanger sequencing was performed for all 16 patients to screen for single-nucleotide variants and copy number variations in DPY19L2 and SPATA16. After exclusion of one patient with DPY19L2 mutations, we performed exome sequencing for the 15 remaining subjects. We prioritised recessive and X-linked protein-altering variants with an allele frequency of &lt;0.5% in the population database GnomAD in genes with an enhanced expression in the testis. All identified candidate variants were confirmed in patients and, where possible, in family members using Sanger sequencing. Ultrastructural examination of semen from one of the patients allowed for a precise phenotypic characterisation of abnormal spermatozoa. MAIN RESULTS AND ROLE OF CHANCE After prioritisation and validation, we identified possibly causative variants in eight of 15 patients investigated by exome sequencing. The analysis revealed homozygous nonsense mutations in ZPBP and CCDC62 in two unrelated patients, as well as rare missense mutations in C2CD6 (also known as ALS2CR11), CCIN, C7orf61 and DHNA17 and a frameshift mutation in GGN in six other patients. All variants identified through exome sequencing, except for the variants in DNAH17, were located in a region of homozygosity. Familial segregation of the nonsense variant in ZPBP revealed two fertile brothers and the patient’s mother to be heterozygous carriers. Paternal DNA was unavailable. Immunohistochemistry confirmed that ZPBP localises to the acrosome in human spermatozoa. Ultrastructural analysis of spermatozoa in the patient with the C7orf61 mutation revealed a mixture of round heads with no acrosomes (globozoospermia) and ovoid or irregular heads with small acrosomes frequently detached from the sperm head (acrosomal hypoplasia). LIMITATIONS, REASONS FOR CAUTION Stringent filtering criteria were used in the exome data analysis which could result in possible pathogenic variants remaining undetected. Additionally, functional follow-up is needed for several candidate genes to confirm the impact of these mutations on normal spermatogenesis. WIDER IMPLICATIONS OF THE FINDINGS Our study revealed an important role for mutations in ZPBP and CCDC62 in human globozoospermia as well as five new candidate genes. These findings provide a more comprehensive understanding of the genetics of male infertility and bring us closer to a complete molecular diagnosis for globozoospermia patients which would help to predict the success of reproductive treatments. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by The Netherlands Organisation for Scientific Research (918–15-667); National Health and Medical Research Council of Australia (APP1120356) and the National Council for Scientific Research (CONICET), Argentina, PIP grant 11220120100279CO. The authors have nothing to disclose.

Abstract STUDY QUESTION What is the impact of the poly(ADP-ribose) polymerase (PARP) inhibitor, olaparib, alone or in combination with chemotherapy on the ovary in mice? SUMMARY ANSWER Olaparib treatment, when administered alone, depletes primordial follicle oocytes, but olaparib does not exacerbate chemotherapy-mediated ovarian follicle loss in mice. WHAT IS KNOWN ALREADY The ovary contains a finite number of oocytes stored within primordial follicles, which give rise to all mature ovulatory oocytes. Unfortunately, they are highly sensitive to exogenous DNA damaging insults, such as cytotoxic cancer treatments. Members of the PARP family of enzymes are central to the repair of single-strand DNA breaks. PARP inhibitors have shown promising clinical efficacy in reducing tumour burden, by blocking DNA repair capacity. Olaparib is a PARP1/2 inhibitor recently FDA-approved for treatment of BRCA1 and BRCA2 mutation carriers with metastatic breast cancer. It is currently being investigated as an adjunct to standard treatment at an earlier stage, potentially curable, BRCA1- and BRCA2-associated breast cancer which affects reproductive age women. Despite this, there is no preclinical or clinical information regarding the potential impacts of olaparib on the ovary or on female fertility. Unfortunately, it may be many years before clinical data on fertility outcomes for women treated with PARP inhibitors becomes available, highlighting the importance of rigorous preclinical research using animal models to establish the potential for new cancer therapies to affect the ovary in humans. We aimed to comprehensively determine the impact of olaparib alone, or following chemotherapy, on the ovary in mice. STUDY DESIGN, SIZE, DURATION On Day 0, mice (n = 5/treatment group) were administered a single intraperitoneal dose of cyclophosphamide (75 mg/kg/body weight), doxorubicin (10 mg/kg), carboplatin (80 mg/kg), paclitaxel (7.5 mg/kg) or vehicle control. From Days 1 to 28, mice were administered subcutaneous olaparib (50 mg/kg) or vehicle control. This regimen is proven to reduce tumour burden in preclinical mouse studies and is also physiologically relevant for women. PARTICIPANTS/MATERIALS, SETTING, METHODS Adult female wild-type C57BL6/J mice at peak fertility (8 weeks) were administered a single intraperitoneal dose of chemotherapy, or vehicle, then either subcutaneous olaparib or vehicle for 28 days. Vaginal smears were performed on each animal for 14 consecutive days from Days 15 to 28 to monitor oestrous cycling. At 24 h after final treatment, ovaries were harvested for follicle enumeration and immunohistochemical analysis of primordial follicle remnants (FOXL2 expressing granulosa cells), DNA damage (γH2AX) and analysis of apoptosis by TUNEL assay. Serum was collected to measure circulating anti-Müllerian hormone (AMH) concentrations by ELISA. MAIN RESULTS AND THE ROLE OF CHANCE Olaparib significantly depleted primordial follicles by 36% compared to the control (P &lt; 0.05) but had no impact on other follicle classes, serum AMH, corpora lutea number (indicative of ovulation) or oestrous cycling. Primordial follicle remnants were rarely detected in control ovaries but were significantly elevated in ovaries from mice treated with olaparib alone (P &lt; 0.05). Similarly, DNA damage denoted by γH2AX foci was completely undetectable in primordial follicles of control animals but was observed in ∼10% of surviving primordial follicle oocytes in mice treated with olaparib alone. These observations suggest that functional PARPs are essential for primordial follicle oocyte maintenance and survival. Olaparib did not exacerbate chemotherapy-mediated follicle depletion in the wild-type mouse ovary. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION This study was performed in mice, so the findings may not translate to women and further studies utilizing human ovarian tissue and sera samples should be performed in the future. Only one long-term time point was analysed, therefore olaparib-mediated follicle damage should be assessed at more immediate time points in the future to support our mechanistic findings. WIDER IMPLICATIONS OF THE FINDINGS Olaparib dramatically depleted primordial follicles and this could be attributed to loss of intrinsic PARP-mediated DNA repair mechanisms. Importantly, diminished ovarian reserve can result in premature ovarian insufficiency and infertility. Notably, the extent of follicle depletion might be enhanced in BRCA1 and BRCA2 mutation carriers, and this is the subject of current investigations. Together, our data suggest that fertility preservation options should be considered for young women prior to olaparib treatment, and that human studies of this issue should be prioritized. STUDY FUNDING/COMPETING INTEREST(S) This work was made possible through Victorian State Government Operational Infrastructure Support and Australian Government NHMRC IRIISS. This work was supported by funding from the National Health and Medical Research Council (NHMRC); (K.J.H. #1050130) (A.L.W. #1120300). K.A.P. is a National Breast Cancer Foundation Fellow (Australia—PRAC-17-004). K.A.P. is the Breast Cancer Trials (Australia) Study Chair for the OlympiA clinical trial sponsored by AstraZeneca, the manufacturer of olaparib. All other authors declare no competing financial or other interests.

Abstract STUDY QUESTION What are the success rates for women returning to ART treatment in the hope of having a second ART-conceived child. SUMMARY ANSWER The cumulative live birth rate (LBR) for women returning to ART treatment was between 50.5% and 88.1% after six cycles depending on whether women commenced with a previously frozen embryo or a new ovarian stimulation cycle and the assumptions made regarding the success rates for women who dropped-out of treatment. WHAT IS KNOWN ALREADY Previous studies have reported the cumulative LBR for the first ART-conceived child to inform patients about their chances of success. However, most couples plan to have more than one child to complete their family and, for that reason, patients commonly return to ART treatment after the birth of their first ART-conceived child. To our knowledge, there are no published data to facilitate patient counseling and clinical decision-making regarding the success rates for these patients. STUDY DESIGN, SIZE, DURATION A population-based cohort study with 35 290 women who commenced autologous (using their own oocytes) ART treatment between January 2009 and December 2013 and achieved their first treatment-dependent live birth from treatment performed during this period. These women were then followed up for a further 2 years of treatment to December 2015, providing a minimum of 2 years and a maximum of 7 years of treatment follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS Cycle-specific LBR and cumulative LBR were calculated for up to six complete ART cycles (one ovarian stimulation and all associated transfers). Three cumulative LBR were calculated based on the likelihood of success in women who dropped-out of treatment (conservative, optimal and inverse probability-weighted (IPW)). A multivariable logistic regression model was used to predict the chance of returning to ART treatment for a second ART-conceived child, and a discrete time logistic regression model was used to predict the chance of achieving a second ART-conceived child up to a maximum of six complete cycles. The models were adjusted for patient characteristics and previous and current treatment characteristics. MAIN RESULTS AND THE ROLE OF CHANCE Among the women who had their first ART-conceived live birth, 15 325 (43%) returned to treatment by December 2015. LBRs were consistently better in women who recommenced treatment with a previously frozen embryo, compared to women who underwent a new ovarian stimulation cycle. After six complete cycles, plus any surplus frozen embryos, the cumulative LBR was between 60.9% (95% CI: 60.0–61.8%) (conservative) and 88.1% (95% CI: 86.7–89.5%) (optimal) [IPW 87.2% (95% CI: 86.2–88.2%)] for women who recommenced treatment with a frozen embryo, compared to between 50.5% (95% CI: 49.0–52.0%) and 69.8% (95% CI: 67.5–72.2%) [IPW 68.1% (95% CI: 67.3–68.9%)] for those who underwent a new ovarian stimulation cycle. The adjusted odds of a second ART-conceived live birth decreased for women ≥35 years, who waited at least 3 years before returning to treatment, or who required a higher number of ovarian stimulation cycles or double embryo transfer to achieve their first child. LIMITATIONS, REASONS FOR CAUTION Our estimates do not fully account for a number of individual prognostic factors, including duration of infertility, BMI and ovarian reserve. WIDER IMPLICATIONS OF THE FINDINGS This is the first study to report success rates for women returning to ART treatment to have second ART-conceived child. These age-specific success rates can facilitate individualized counseling for the large number of patients hoping to have a second child using ART treatment. STUDY FUNDING/COMPETING INTEREST(S) No funding was received to undertake this study. R. Paul and O. Fitzgerald have nothing to declare. D. Lieberman reports being a fertility specialist and receiving non-financial support from MSD and Merck outside the submitted work. C. Venetis reports being a fertility specialist and receiving personal fees and non-financial support from MSD, personal fees and non-financial support from Merck Serono and Beisins and non-financial support from Ferring outside the submitted work. G.M. Chambers reports being a paid employee of the University of New South Wales, Sydney (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The Fertility Society of Australia (FSA) contracts UNSW to prepare the Australian and New Zealand Assisted Reproductive Technology Database (ANZARD) annual report series and benchmarking reports. TRIAL REGISTRATION NUMBER NA.

Government responses to COVID-19 have dramatically altered the social quality of daily circumstances. Consequently, theoretical questions about social cohesion require recalibration as we explore new models of social quality. Central to this article is trust, one of the fundamental tenets of social cohesion. We present data from interviews with 40 women in midlife (45–64 years) regarding their everyday experiences of “life in lockdown” during the pandemic. Key themes focus on women’s (dis)trust in individuals (e.g., politicians, public health experts, family, themselves) and systems (e.g., politics, medicine, the media). This study provides insights into the differential impact of the pandemic in shaping public trust and hence social cohesion—in authority, institutions, and “each other”—with important lessons for how future efforts can rebuild trust in post-pandemic times.

Objective: Many refugees experience prolonged separation from family members, which research suggests has adverse effects on mental health and post-displacement outcomes in refugee populations. We examine mental health differences in refugees separated and not separated from their families, and key post-migration factors and cultural mechanisms that may underlie this impact. Methods: A sample of 1085 refugees resettled in Australia, of which 23.3% were separated from all of their immediate family, took part in an online battery of survey measures indexing pre- and post-migration refugee experiences, mental health symptoms, disability and individualistic/collectivistic self-identity. Family separation was used as a predictor of mental health outcomes in a series of linear regressions, and the separated and non-separated groups were compared in multigroup path analysis models to examine group-specific indirect effects. Results: The separated group reported greater exposure to pre-migration potentially traumatic events and higher levels of post-migration living difficulties compared to the non-separated group. Family separation predicted higher post-traumatic stress and depression symptoms, but not disability, after controlling for potentially traumatic event exposure, age and sex. Path analyses revealed distinct indirect effects for separated and non-separated groups. Principally, higher collectivistic self-identity was associated with elevated post-traumatic stress, depression and disability symptoms via social-related post-migration living difficulties such as isolation and loneliness in the separated group; whereas collectivism was linked with increased depression symptoms via economic-related post-migration living difficulties in the non-separated group. Conclusion: These findings indicate that family separation powerfully influences mental health outcomes, but that its effect may be mediated by the type of post-migration stress experienced in the settlement environment and culturally bound differences in how the sense of self is interconnected with family.

Abstract Background Poor oral health among children is socially patterned and poorly understood. To optimise interventions aimed at reducing the persistent socioeconomic gap in health, we need to understand its shaping mechanisms. We examined if homeownership modifies the widely recognised association between household income and child oral health. Methods Data were analysed on 3,344 children from the Longitudinal Study of Australian Children. Multivariable regression models tested associations between tertiles of household income and dental decay and tooth loss. Effect modification by homeownership was tested on both additive and multiplicative scales. Models were adjusted for demographic variables, area of residence and family characteristics. Results For dental decay and tooth loss, children in households in the lower tertiles of income had worse oral health than children in the highest. Additive interaction was weakly supported in our models. The relative effect of income on oral health was greater for homeowners than renters for dental decay (medium household income 0.65 (95%CI: 0.44; 0.98) and low household income 0.82 (95%CI: 0.58; 1.15)) and tooth loss (medium household income 0.25 (95%CI: 0.09; 0.68) and low household income 0.41 (95%CI: 0.17; 0.97)). Conclusions Low-income children have poorer oral health outcomes. Although children of homeowners have better oral health than children of renters, income inequality is higher among the homeowner’s group. Current rent assistance programs for low-income families in Australia may minimise income-related inequalities on a relative scale. Key messages Our findings shed light on the potential of equalising policies in reducing income-related oral health inequalities.

BackgroundPatients with advanced hepatocellular carcinoma (HCC) have specific palliative care needs owing to the influence of the disease on abdominal pain, jaundice, bleeding, appetite, ascites, liver function and hepatic encephalopathy. This research would help develop care models and identify knowledge gaps in the field.AimsTo identify the palliative care needs and experiences of patients with advanced HCC.MethodsCINAHL, EMBASE and MEDLINE were used to search English literature from January 1998 to March 2022 for ‘Palliative care’ and ‘Hepatocellular cancer’ using precise inclusion and exclusion criteria.ResultsThe retrieves identified 2710 records, including 33 studies used in our research. Two additional studies were grey items. Among 35 studies, 13 studies were performed in Asia, 11 studies in North America, 8 studies in Europe and 3 studies in Australia. Quantitative investigations were mostly descriptive or observational. Eight studies were conducted on a national scale, while two were in specific regions. 20 studies were conducted by a single institution. 22 studies focused only on patients, 2 on family caregivers and 2 on healthcare professionals. 2 more studies concentrated on patients and family caregivers, while 6 concentrated on patients and healthcare professionals.ConclusionsThis scoping study illustrates the complexity of advanced HCC treatment and challenges in modern healthcare systems. Formulating appropriate referral criteria, integrating and coordinating care, and assessing care contents are crucial. To enhance the treatment of patients with advanced HCC, it is important to understand the relationships between research and service design across teams, disciplines and care settings.

Objective Stigma towards mental illness has been described in many health professions at the undergraduate level, but not in the discipline of paramedicine. The objective of this research was to describe levels of stigma towards people with mental illness as self-reported by undergraduate paramedicine students in Australia, Finland, New Zealand and South Africa. Design Using a cross-sectional design, an online survey was administered consisting of a validated instrument measuring self-reported stigma levels. Setting Four undergraduate paramedicine university programs in Australia, New Zealand, Finland and South Africa. Method The Opening Minds Scale for Health Providers (OMS-HC) is a validated, 20-item instrument measuring self-reported stigma. The 20 OMS-HC items were summed and generalised linear models with log link and Poisson family were used to examine associated factors. Results The overall level of self-reported stigma across students from all countries was 53, on a scale ranging from 20 (‘least stigmatised’) to 100 (‘most stigmatised’). Compared with the Australian cohort, total stigma scores increased significantly by 8% in New Zealand (p=0.01), 15% (p<0.001), and 18% in South Africa (p=0.002). Subscale analysis revealed high scores for social distance as a construct of stigma more broadly. Conclusion The findings provide an important baseline that can be used by paramedicine programs to inform development of mental healthcare curricula seeking to reduce stigma during the formative undergraduate years of professional development. The findings can be applied in a teaching and learning setting as source material to stimulate discussion and promote student self-reflection in a range of teaching activities.

Abstract Background The effects of problem gambling are wide-ranging, affecting many aspects of health and negatively impacting the person who gambles, their family and friends, and their community. People experiencing problem gambling have low rates of help-seeking and perceive many barriers to treatment, although evidence suggests that encouragement and support from friends and family can increase rates of help-seeking. Mental Health First Aid Australia’s Conversations About Gambling course aims to teach members of the public evidence-based strategies for recognising and responding to signs of problem gambling in a person they know. Methods This research evaluated the effects of the Conversations About Gambling course on participants’ knowledge, confidence, stigmatising attitudes, intended helping behaviour and actual helping behaviour towards a person experiencing problem gambling. Participants from Australia completed surveys before the course, immediately after the course and six months later. Changes over time (pre-course to post-course, and pre-course to 6-month follow-up) were assessed with linear mixed models. Descriptive statistics and content analyses of open-ended questions pertaining to participants’ satisfaction with the course were also produced. Results Between 2018 and 2020, 166 participants were recruited into this study. At 6-month follow-up 87 participants (52.4%) provided data. Participants’ knowledge about gambling and gambling problems, confidence, desire for social distance and intentions to help a person experiencing problem gambling significantly improved from pre-course to post-course, and from pre-course to 6-month follow-up. The quality of some actions taken to support a person they knew who was experiencing problem gambling also improved from pre-course to 6-month follow-up, in line with the teachings of the course. Participants perceived the course to be highly acceptable. Conclusions The results of this initial evaluation of Mental Health First Aid Australia’s Conversations About Gambling course suggest that it is an effective and acceptable educational intervention for those who wish to support a person experiencing problem gambling.

AbstractMental illness heightens risk of medical emergencies, emergency hospitalisation, and readmissions. Innovations for integrated medical–psychiatric care within paediatric emergency settings may help adolescents with acute mental disorders to get well quicker and stay well enough to remain out of hospital. We assessed models of integrated acute care for adolescents experiencing medical emergencies related to mental illness (MHR). We conducted a systematic review by searching MEDLINE, PsychINFO, Embase, and Web of Science for quantitative studies within paediatric emergency medicine, internationally. We included populations aged 8–25 years. Our outcomes were length of hospital stay (LOS), emergency hospital admissions, and rehospitalisation. Limits were imposed on dates: 1990 to June 2021. We present a narrative synthesis. This study is registered on PROSPERO: 254,359. 1667 studies were screened, 22 met eligibility, comprising 39,346 patients. Emergency triage innovations reduced admissions between 4 and 16%, including multidisciplinary staffing and training for psychiatric assessment (F(3,42) = 4.6, P < 0.05, N = 682), and telepsychiatry consultations (aOR = 0.41, 95% CI 0.28–0.58; P < 0.001, N = 597). Psychological therapies delivered in emergency departments reduced admissions 8–40%, including psychoeducation (aOR = 0.35, 95% CI 0.17–0.71, P < 0.01, N = 212), risk-reduction counselling for suicide prevention (OR = 2.78, 95% CI 0.55–14.10, N = 348), and telephone follow-up (OR = 0.45, 95% CI 0.33–0.60, P < 0.001, N = 980). Innovations on acute wards reduced readmissions, including guided meal supervision for eating disorders (P = 0.27), therapeutic skills for anxiety disorders, and a dedicated psychiatric crisis unit (22.2 vs 8.5% (P = 0.008). Integrated pathway innovations reduced readmissions between 8 and 37% including family-based therapy (FBT) for eating disorders (X2(1,326) = 8.40, P = 0.004, N = 326), and risk-targeted telephone follow-up or outpatients for all mental disorders (29.5 vs. 5%, P = 0.03, N = 1316). Studies occurred in the USA, Canada, or Australia. Integrated care pathways to psychiatric consultations, psychological therapies, and multidisciplinary follow-up within emergency paediatric services prevented lengthy and repeat hospitalisation for MHR emergencies. Only six of 22 studies adjusted for illness severity and clinical history between before- and after-intervention cohorts and only one reported socio-demographic intervention effects.

Abstract Background Non-surgical multidisciplinary management is often the first pathway of care for patients with chronic low back pain (LBP). This study explores if patient characteristics recorded at the initial service examination have an association with a poor response to this pathway of care in an advanced practice physiotherapist-led tertiary service. Methods Two hundred and forty nine patients undergoing non-surgical multidisciplinary management for their LBP across 8 tertiary public hospitals in Queensland, Australia participated in this prospective longitudinal study. Generalised linear models (logistic family) examined the relationship between patient characteristics and a poor response at 6 months follow-up using a Global Rating of Change measure. Results Overall 79 of the 178 (44%) patients completing the Global Rating of Change measure (28.5% loss to follow-up) reported a poor outcome. Patient characteristics retained in the final model associated with a poor response included lower Formal Education Level (ie did not complete school) (Odds Ratio (OR (95% confidence interval)) (2.67 (1.17–6.09), p = 0.02) and higher self-reported back disability (measured with the Oswestry Disability Index) (OR 1.33 (1.01–1.77) per 10/100 point score increase, p = 0.046). Conclusions A low level of formal education and high level of self-reported back disability may be associated with a poor response to non-surgical multidisciplinary management of LBP in tertiary care. Patients with these characteristics may need greater assistance with regard to their comprehension of health information, and judicious monitoring of their response to facilitate timely alternative care if no benefits are attained.

Abstract Background While direct effects of occupational exposures on an individual’s respiratory health are evident, a new paradigm is emerging on the possible effects of pre-conception occupational exposure on respiratory health in offspring. We aimed to study the association between parental occupational exposure starting before conception and asthma in their offspring (at 0–15 years of age). Methods We studied 3985 offspring participating in the Respiratory Health in Northern Europe, Spain and Australia (RHINESSA) generation study. Their mothers or fathers (n = 2931) previously participated in the European Community Respiratory Health Survey (ECRHS). Information was obtained from questionnaires on parental job history pre- and post-conception which was linked to an asthma-specific job-exposure matrix (JEM). We assessed the association between parental occupational exposure and offspring asthma, applying logistic regression models, clustered by family and adjusted for study centre, offspring sex, parental characteristics (age, asthma onset, place of upbringing, smoking) and grandparents’ level of education. Results Parental occupational exposure to microorganisms, pesticides, allergens or reactive chemicals pre-conception or both pre- and post-conception was not related to offspring asthma; in general, subgroup analyses confirmed this result. However, maternal exposure both pre- and post-conception to allergens and reactive chemicals was associated with increased odds for early-onset asthma in offspring (0–3 years of age); odds ratio 1.70 (95% CI: 1.02–2.84) and 1.65 (95% CI: 0.98–2.77), respectively. Conclusions This study did not find evidence that parental occupational exposure, defined by an asthma JEM before conception only or during pre- and post-conception vs non-exposed, was associated with offspring asthma.

Introduction Most developed countries, including Australia, have a strong focus on national, state and local strategies for emergency management and response in the face of disasters and crises. This framework can include coping with catastrophic dislocation, service disruption, injury or loss of life in the face of natural disasters such as major fires, floods, earthquakes or other large-impact natural events, as well as dealing with similar catastrophes resulting from human actions such as bombs, biological agents, cyber-attacks targeting essential services such as communications networks, or other crises affecting large populations. Emergency management frameworks for crisis and disaster response are distinguished by their focus on the domestic context for such events; that is, how to manage and assist the ways in which civilian populations, who are for the most part inexperienced and untrained in dealing with crises and disasters, are able to respond and behave in such situations so as to minimise the impacts of a catastrophic event. Even in countries like Australia that demonstrate a strong public commitment to cultural pluralism and social cohesion, ethno-cultural diversity can be seen as a risk or threat to national security and values at times of political, natural, economic and/or social tensions and crises. Australian government policymakers have recently focused, with increasing intensity, on “community resilience” as a key element in countering extremism and enhancing emergency preparedness and response. In some sense, this is the result of a tacit acknowledgement by government agencies that there are limits to what they can do for domestic communities should such a catastrophic event occur, and accordingly, the focus in recent times has shifted to how governments can best help people to help themselves in such situations, a key element of the contemporary “resilience” approach. Yet despite the robustly multicultural nature of Australian society, explicit engagement with Australia’s cultural diversity flickers only fleetingly on this agenda, which continues to pursue approaches to community resilience in the absence of understandings about how these terms and formations may themselves need to be diversified to maximise engagement by all citizens in a multicultural polity. There have been some recent efforts in Australia to move in this direction, for example the Australian Emergency Management Institute (AEMI)’s recent suite of projects with culturally and linguistically diverse (CALD) communities (2006-2010) and the current Australia-New Zealand Counter-Terrorism Committee-supported project on “Harnessing Resilience Capital in Culturally Diverse Communities to Counter Violent Extremism” (Grossman and Tahiri), which I discuss in a longer forthcoming version of this essay (Grossman). Yet the understanding of ethno-cultural identity and difference that underlies much policy thinking on resilience remains problematic for the way in which it invests in a view of the cultural dimensions of community resilience as relic rather than resource – valorising the preservation of and respect for cultural norms and traditions, but silent on what different ethno-cultural communities might contribute toward expanded definitions of both “community” and “resilience” by virtue of the transformative potential and existing cultural capital they bring with them into new national and also translocal settings. For example, a primary conclusion of the joint program between AEMI and the Australian Multicultural Commission is that CALD communities are largely “vulnerable” in the context of disasters and emergency management and need to be better integrated into majority-culture models of theorising and embedding community resilience. This focus on stronger national integration and the “vulnerability” of culturally diverse ethno-cultural communities in the Australian context echoes the work of scholars beyond Australia such as McGhee, Mouritsen (Reflections, Citizenship) and Joppke. They argue that the “civic turn” in debates around resurgent contemporary nationalism and multicultural immigration policies privileges civic integration over genuine two-way multiculturalism. This approach sidesteps the transculturational (Ortiz; Welsch; Mignolo; Bennesaieh; Robins; Stein) aspects of contemporary social identities and exchange by paying lip-service to cultural diversity while affirming a neo-liberal construct of civic values and principles as a universalising goal of Western democratic states within a global market economy. It also suggests a superficial tribute to cultural diversity that does not embed diversity comprehensively at the levels of either conceptualising or resourcing different elements of Australian transcultural communities within the generalised framework of “community resilience.” And by emphasising cultural difference as vulnerability rather than as resource or asset, it fails to acknowledge the varieties of resilience capital that many culturally diverse individuals and communities may bring with them when they resettle in new environments, by ignoring the question of what “resilience” actually means to those from culturally diverse communities. In so doing, it also avoids the critical task of incorporating intercultural definitional diversity around the concepts of both “community” and “resilience” used to promote social cohesion and the capacity to recover from disasters and crises. How we might do differently in thinking about the broader challenges for multiculturalism itself as a resilient transnational concept and practice? The Concept of Resilience The meanings of resilience vary by disciplinary perspective. While there is no universally accepted definition of the concept, it is widely acknowledged that resilience refers to the capacity of an individual to do well in spite of exposure to acute trauma or sustained adversity (Liebenberg 219). Originating in the Latin word resilio, meaning ‘to jump back’, there is general consensus that resilience pertains to an individual’s, community’s or system’s ability to adapt to and ‘bounce back’ from a disruptive event (Mohaupt 63, Longstaff et al. 3). Over the past decade there has been a dramatic rise in interest in the clinical, community and family sciences concerning resilience to a broad range of adversities (Weine 62). While debate continues over which discipline can be credited with first employing resilience as a concept, Mohaupt argues that most of the literature on resilience cites social psychology and psychiatry as the origin for the concept beginning in the mid-20th century. The pioneer researchers of what became known as resilience research studied the impact on children living in dysfunctional families. For example, the findings of work by Garmezy, Werner and Smith and Rutter showed that about one third of children in these studies were coping very well despite considerable adversities and traumas. In asking what it was that prevented the children in their research from being negatively influenced by their home environments, such research provided the basis for future research on resilience. Such work was also ground-breaking for identifying the so-called ‘protective factors’ or resources that individuals can operationalise when dealing with adversity. In essence, protective factors are those conditions in the individual that protect them from the risk of dysfunction and enable recovery from trauma. They mitigate the effects of stressors or risk factors, that is, those conditions that predispose one to harm (Hajek 15). Protective factors include the inborn traits or qualities within an individual, those defining an individual’s environment, and also the interaction between the two. Together, these factors give people the strength, skills and motivation to cope in difficult situations and re-establish (a version of) ‘normal’ life (Gunnestad). Identifying protective factors is important in terms of understanding the particular resources a given sociocultural group has at its disposal, but it is also vital to consider the interconnections between various protective mechanisms, how they might influence each other, and to what degree. An individual, for instance, might display resilience or adaptive functioning in a particular domain (e.g. emotional functioning) but experience significant deficits in another (e.g. academic achievement) (Hunter 2). It is also essential to scrutinise how the interaction between protective factors and risk factors creates patterns of resilience. Finally, a comprehensive understanding of the interrelated nature of protective mechanisms and risk factors is imperative for designing effective interventions and tailored preventive strategies (Weine 65). In short, contemporary thinking about resilience suggests it is neither entirely personal nor strictly social, but an interactive and iterative combination of the two. It is a quality of the environment as much as the individual. For Ungar, resilience is the complex entanglements between “individuals and their social ecologies [that] will determine the degree of positive outcomes experienced” (3). Thinking about resilience as context-dependent is important because research that is too trait-based or actor-centred risks ignoring any structural or institutional forces. A more ecological interpretation of resilience, one that takes into a person’s context and environment into account, is vital in order to avoid blaming the victim for any hardships they face, or relieving state and institutional structures from their responsibilities in addressing social adversity, which can “emphasise self-help in line with a neo-conservative agenda instead of stimulating state responsibility” (Mohaupt 67). Nevertheless, Ungar posits that a coherent definition of resilience has yet to be developed that adequately ‘captures the dual focus of the individual and the individual’s social ecology and how the two must both be accounted for when determining the criteria for judging outcomes and discerning processes associated with resilience’ (7). Recent resilience research has consequently prompted a shift away from vulnerability towards protective processes — a shift that highlights the sustained capabilities of individuals and communities under threat or at risk. Locating ‘Culture’ in the Literature on Resilience However, an understanding of the role of culture has remained elusive or marginalised within this trend; there has been comparatively little sustained investigation into the applicability of resilience constructs to non-western cultures, or how the resources available for survival might differ from those accessible to western populations (Ungar 4). As such, a growing body of researchers is calling for more rigorous inquiry into culturally determined outcomes that might be associated with resilience in non-western or multicultural cultures and contexts, for example where Indigenous and minority immigrant communities live side by side with their ‘mainstream’ neighbours in western settings (Ungar 2). ‘Cultural resilience’ considers the role that cultural background plays in determining the ability of individuals and communities to be resilient in the face of adversity. For Clauss-Ehlers, the term describes the degree to which the strengths of one’s culture promote the development of coping (198). Culturally-focused resilience suggests that people can manage and overcome stress and trauma based not on individual characteristics alone, but also from the support of broader sociocultural factors (culture, cultural values, language, customs, norms) (Clauss-Ehlers 324). The innate cultural strengths of a culture may or may not differ from the strengths of other cultures; the emphasis here is not so much comparatively inter-cultural as intensively intra-cultural (VanBreda 215). A culturally focused resilience model thus involves “a dynamic, interactive process in which the individual negotiates stress through a combination of character traits, cultural background, cultural values, and facilitating factors in the sociocultural environment” (Clauss-Ehlers 199). In understanding ways of ‘coping and hoping, surviving and thriving’, it is thus crucial to consider how culturally and linguistically diverse minorities navigate the cultural understandings and assumptions of both their countries of origin and those of their current domicile (Ungar 12). Gunnestad claims that people who master the rules and norms of their new culture without abandoning their own language, values and social support are more resilient than those who tenaciously maintain their own culture at the expense of adjusting to their new environment. They are also more resilient than those who forego their own culture and assimilate with the host society (14). Accordingly, if the combination of both valuing one’s culture as well as learning about the culture of the new system produces greater resilience and adaptive capacities, serious problems can arise when a majority tries to acculturate a minority to the mainstream by taking away or not recognising important parts of the minority culture. In terms of resilience, if cultural factors are denied or diminished in accounting for and strengthening resilience – in other words, if people are stripped of what they possess by way of resilience built through cultural knowledge, disposition and networks – they do in fact become vulnerable, because ‘they do not automatically gain those cultural strengths that the majority has acquired over generations’ (Gunnestad 14). Mobilising ‘Culture’ in Australian Approaches to Community Resilience The realpolitik of how concepts of resilience and culture are mobilised is highly relevant here. As noted above, when ethnocultural difference is positioned as a risk or a threat to national identity, security and values, this is precisely the moment when vigorously, even aggressively, nationalised definitions of ‘community’ and ‘identity’ that minoritise or disavow cultural diversities come to the fore in public discourse. The Australian evocation of nationalism and national identity, particularly in the way it has framed policy discussion on managing national responses to disasters and threats, has arguably been more muted than some of the European hysteria witnessed recently around cultural diversity and national life. Yet we still struggle with the idea that newcomers to Australia might fall on the surplus rather than the deficit side of the ledger when it comes to identifying and harnessing resilience capital. A brief example of this trend is explored here. From 2006 to 2010, the Australian Emergency Management Institute embarked on an ambitious government-funded four-year program devoted to strengthening community resilience in relation to disasters with specific reference to engaging CALD communities across Australia. The program, Inclusive Emergency Management with CALD Communities, was part of a wider Australian National Action Plan to Build Social Cohesion, Harmony and Security in the wake of the London terrorist bombings in July 2005. Involving CALD community organisations as well as various emergency and disaster management agencies, the program ran various workshops and agency-community partnership pilots, developed national school education resources, and commissioned an evaluation of the program’s effectiveness (Farrow et al.). While my critique here is certainly not aimed at emergency management or disaster response agencies and personnel themselves – dedicated professionals who often achieve remarkable results in emergency and disaster response under extraordinarily difficult circumstances – it is nevertheless important to highlight how the assumptions underlying elements of AEMI’s experience and outcomes reflect the persistent ways in which ethnocultural diversity is rendered as a problem to be surmounted or a liability to be redressed, rather than as an asset to be built upon or a resource to be valued and mobilised. AEMI’s explicit effort to engage with CALD communities in building overall community resilience was important in its tacit acknowledgement that emergency and disaster services were (and often remain) under-resourced and under-prepared in dealing with the complexities of cultural diversity in emergency situations. Despite these good intentions, however, while the program produced some positive outcomes and contributed to crucial relationship building between CALD communities and emergency services within various jurisdictions, it also continued to frame the challenge of working with cultural diversity as a problem of increased vulnerability during disasters for recently arrived and refugee background CALD individuals and communities. This highlights a common feature in community resilience-building initiatives, which is to focus on those who are already ‘robust’ versus those who are ‘vulnerable’ in relation to resilience indicators, and whose needs may require different or additional resources in order to be met. At one level, this is a pragmatic resourcing issue: national agencies understandably want to put their people, energy and dollars where they are most needed in pursuit of a steady-state unified national response at times of crisis. Nor should it be argued that at least some CALD groups, particularly those from new arrival and refugee communities, are not vulnerable in at least some of the ways and for some of the reasons suggested in the program evaluation. However, the consistent focus on CALD communities as ‘vulnerable’ and ‘in need’ is problematic, as well as partial. It casts members of these communities as structurally and inherently less able and less resilient in the context of disasters and emergencies: in some sense, as those who, already ‘victims’ of chronic social deficits such as low English proficiency, social isolation and a mysterious unidentified set of ‘cultural factors’, can become doubly victimised in acute crisis and disaster scenarios. In what is by now a familiar trope, the description of CALD communities as ‘vulnerable’ precludes asking questions about what they do have, what they do know, and what they do or can contribute to how we respond to disaster and emergency events in our communities. A more profound problem in this sphere revolves around working out how best to engage CALD communities and individuals within existing approaches to disaster and emergency preparedness and response. This reflects a fundamental but unavoidable limitation of disaster preparedness models: they are innately spatially and geographically bounded, and consequently understand ‘communities’ in these terms, rather than expanding definitions of ‘community’ to include the dimensions of community-as-social-relations. While some good engagement outcomes were achieved locally around cross-cultural knowledge for emergency services workers, the AEMI program fell short of asking some of the harder questions about how emergency and disaster service scaffolding and resilience-building approaches might themselves need to change or transform, using a cross-cutting model of ‘communities’ as both geographic places and multicultural spaces (Bartowiak-Théron and Crehan) in order to be more effective in national scenarios in which cultural diversity should be taken for granted. Toward Acknowledgement of Resilience Capital Most significantly, the AEMI program did not produce any recognition of the ways in which CALD communities already possess resilience capital, or consider how this might be drawn on in formulating stronger community initiatives around disaster and threats preparedness for the future. Of course, not all individuals within such communities, nor all communities across varying circumstances, will demonstrate resilience, and we need to be careful of either overgeneralising or romanticising the kinds and degrees of ‘resilience capital’ that may exist within them. Nevertheless, at least some have developed ways of withstanding crises and adapting to new conditions of living. This is particularly so in connection with individual and group behaviours around resource sharing, care-giving and social responsibility under adverse circumstances (Grossman and Tahiri) – all of which are directly relevant to emergency and disaster response. While some of these resilient behaviours may have been nurtured or enhanced by particular experiences and environments, they can, as the discussion of recent literature above suggests, also be rooted more deeply in cultural norms, habits and beliefs. Whatever their origins, for culturally diverse societies to achieve genuine resilience in the face of both natural and human-made disasters, it is critical to call on the ‘social memory’ (Folke et al.) of communities faced with responding to emergencies and crises. Such wellsprings of social memory ‘come from the diversity of individuals and institutions that draw on reservoirs of practices, knowledge, values, and worldviews and is crucial for preparing the system for change, building resilience, and for coping with surprise’ (Adger et al.). Consequently, if we accept the challenge of mapping an approach to cultural diversity as resource rather than relic into our thinking around strengthening community resilience, there are significant gains to be made. For a whole range of reasons, no diversity-sensitive model or measure of resilience should invest in static understandings of ethnicities and cultures; all around the world, ethnocultural identities and communities are in a constant and sometimes accelerated state of dynamism, reconfiguration and flux. But to ignore the resilience capital and potential protective factors that ethnocultural diversity can offer to the strengthening of community resilience more broadly is to miss important opportunities that can help suture the existing disconnects between proactive approaches to intercultural connectedness and social inclusion on the one hand, and reactive approaches to threats, national security and disaster response on the other, undermining the effort to advance effectively on either front. This means that dominant social institutions and structures must be willing to contemplate their own transformation as the result of transcultural engagement, rather than merely insisting, as is often the case, that ‘other’ cultures and communities conform to existing hegemonic paradigms of being and of living. In many ways, this is the most critical step of all. A resilience model and strategy that questions its own culturally informed yet taken-for-granted assumptions and premises, goes out into communities to test and refine these, and returns to redesign its approach based on the new knowledge it acquires, would reflect genuine progress toward an effective transculturational approach to community resilience in culturally diverse contexts.References Adger, W. Neil, Terry P. Hughes, Carl Folke, Stephen R. Carpenter and Johan Rockström. “Social-Ecological Resilience to Coastal Disasters.” Science 309.5737 (2005): 1036-1039. ‹http://www.sciencemag.org/content/309/5737/1036.full> Bartowiak-Théron, Isabelle, and Anna Corbo Crehan. “The Changing Nature of Communities: Implications for Police and Community Policing.” Community Policing in Australia: Australian Institute of Criminology (AIC) Reports, Research and Policy Series 111 (2010): 8-15. Benessaieh, Afef. “Multiculturalism, Interculturality, Transculturality.” Ed. A. Benessaieh. Transcultural Americas/Ameriques Transculturelles. Ottawa: U of Ottawa Press/Les Presses de l’Unversite d’Ottawa, 2010. 11-38. Clauss-Ehlers, Caroline S. “Sociocultural Factors, Resilience and Coping: Support for a Culturally Sensitive Measure of Resilience.” Journal of Applied Developmental Psychology 29 (2008): 197-212. Clauss-Ehlers, Caroline S. “Cultural Resilience.” Encyclopedia of Cross-Cultural School Psychology. Ed. C. S. Clauss-Ehlers. New York: Springer, 2010. 324-326. Farrow, David, Anthea Rutter and Rosalind Hurworth. Evaluation of the Inclusive Emergency Management with Culturally and Linguistically Diverse (CALD) Communities Program. Parkville, Vic.: Centre for Program Evaluation, U of Melbourne, July 2009. ‹http://www.ag.gov.au/www/emaweb/rwpattach.nsf/VAP/(9A5D88DBA63D32A661E6369859739356)~Final+Evaluation+Report+-+July+2009.pdf/$file/Final+Evaluation+Report+-+July+2009.pdf>.Folke, Carl, Thomas Hahn, Per Olsson, and Jon Norberg. “Adaptive Governance of Social-Ecological Systems.” Annual Review of Environment and Resources 30 (2005): 441-73. ‹http://arjournals.annualreviews.org/doi/pdf/10.1146/annurev.energy.30.050504.144511>. Garmezy, Norman. “The Study of Competence in Children at Risk for Severe Psychopathology.” The Child in His Family: Children at Psychiatric Risk. Vol. 3. Eds. E. J. Anthony and C. Koupernick. New York: Wiley, 1974. 77-97. Grossman, Michele. “Resilient Multiculturalism? Diversifying Australian Approaches to Community Resilience and Cultural Difference”. Global Perspectives on Multiculturalism in the 21st Century. Eds. B. E. de B’beri and F. Mansouri. London: Routledge, 2014. Grossman, Michele, and Hussein Tahiri. Harnessing Resilience Capital in Culturally Diverse Communities to Counter Violent Extremism. Canberra: Australia-New Zealand Counter-Terrorism Committee, forthcoming 2014. Grossman, Michele. “Cultural Resilience and Strengthening Communities”. Safeguarding Australia Summit, Canberra. 23 Sep. 2010. ‹http://www.safeguardingaustraliasummit.org.au/uploader/resources/Michele_Grossman.pdf>. Gunnestad, Arve. “Resilience in a Cross-Cultural Perspective: How Resilience Is Generated in Different Cultures.” Journal of Intercultural Communication 11 (2006). ‹http://www.immi.se/intercultural/nr11/gunnestad.htm>. Hajek, Lisa J. “Belonging and Resilience: A Phenomenological Study.” Unpublished Master of Science thesis, U of Wisconsin-Stout. Menomonie, Wisconsin, 2003. Hunter, Cathryn. “Is Resilience Still a Useful Concept When Working with Children and Young People?” Child Family Community Australia (CFA) Paper 2. Melbourne: Australian Institute of Family Studies, 2012.Joppke, Christian. "Beyond National Models: Civic Integration Policies for Immigrants in Western Europe". West European Politics 30.1 (2007): 1-22. Liebenberg, Linda, Michael Ungar, and Fons van de Vijver. “Validation of the Child and Youth Resilience Measure-28 (CYRM-28) among Canadian Youth.” Research on Social Work Practice 22.2 (2012): 219-226. Longstaff, Patricia H., Nicholas J. Armstrong, Keli Perrin, Whitney May Parker, and Matthew A. Hidek. “Building Resilient Communities: A Preliminary Framework for Assessment.” Homeland Security Affairs 6.3 (2010): 1-23. ‹http://www.hsaj.org/?fullarticle=6.3.6>. McGhee, Derek. The End of Multiculturalism? Terrorism, Integration and Human Rights. Maidenhead: Open U P, 2008.Mignolo, Walter. Local Histories/Global Designs: Coloniality, Subaltern Knowledges, and Border Thinking. Princeton: Princeton U P, 2000. Mohaupt, Sarah. “Review Article: Resilience and Social Exclusion.” Social Policy and Society 8 (2009): 63-71.Mouritsen, Per. "The Culture of Citizenship: A Reflection on Civic Integration in Europe." Ed. R. Zapata-Barrero. Citizenship Policies in the Age of Diversity: Europe at the Crossroad." Barcelona: CIDOB Foundation, 2009: 23-35. Mouritsen, Per. “Political Responses to Cultural Conflict: Reflections on the Ambiguities of the Civic Turn.” Ed. P. Mouritsen and K.E. Jørgensen. Constituting Communities. Political Solutions to Cultural Conflict, London: Palgrave, 2008. 1-30. Ortiz, Fernando. Cuban Counterpoint: Tobacco and Sugar. Trans. Harriet de Onís. Intr. Fernando Coronil and Bronislaw Malinowski. Durham, NC: Duke U P, 1995 [1940]. Robins, Kevin. The Challenge of Transcultural Diversities: Final Report on the Transversal Study on Cultural Policy and Cultural Diversity. Culture and Cultural Heritage Department. Strasbourg: Council of European Publishing, 2006. Rutter, Michael. “Protective Factors in Children’s Responses to Stress and Disadvantage.” Annals of the Academy of Medicine, Singapore 8 (1979): 324-38. Stein, Mark. “The Location of Transculture.” Transcultural English Studies: Fictions, Theories, Realities. Eds. F. Schulze-Engler and S. Helff. Cross/Cultures 102/ANSEL Papers 12. Amsterdam and New York: Rodopi, 2009. 251-266. Ungar, Michael. “Resilience across Cultures.” British Journal of Social Work 38.2 (2008): 218-235. First published online 2006: 1-18. In-text references refer to the online Advance Access edition ‹http://bjsw.oxfordjournals.org/content/early/2006/10/18/bjsw.bcl343.full.pdf>. VanBreda, Adrian DuPlessis. Resilience Theory: A Literature Review. Erasmuskloof: South African Military Health Service, Military Psychological Institute, Social Work Research & Development, 2001. Weine, Stevan. “Building Resilience to Violent Extremism in Muslim Diaspora Communities in the United States.” Dynamics of Asymmetric Conflict 5.1 (2012): 60-73. Welsch, Wolfgang. “Transculturality: The Puzzling Form of Cultures Today.” Spaces of Culture: City, Nation World. Eds. M. Featherstone and S. Lash. London: Sage, 1999. 194-213. Werner, Emmy E., and Ruth S. Smith. Vulnerable But Invincible: A Longitudinal Study of\ Resilience and Youth. New York: McGraw Hill, 1982. NotesThe concept of ‘resilience capital’ I offer here is in line with one strand of contemporary theorising around resilience – that of resilience as social or socio-ecological capital – but moves beyond the idea of enhancing general social connectedness and community cohesion by emphasising the ways in which culturally diverse communities may already be robustly networked and resourceful within micro-communal settings, with new resources and knowledge both to draw on and to offer other communities or the ‘national community’ at large. In effect, ‘resilience capital’ speaks to the importance of finding ‘the communities within the community’ (Bartowiak-Théron and Crehan 11) and recognising their capacity to contribute to broad-scale resilience and recovery.I am indebted for the discussion of the literature on resilience here to Dr Peta Stephenson, Centre for Cultural Diversity and Wellbeing, Victoria University, who is working on a related project (M. Grossman and H. Tahiri, Harnessing Resilience Capital in Culturally Diverse Communities to Counter Violent Extremism, forthcoming 2014).

Abstract Background Women from migrant and refugee backgrounds who live in high-income countries are at increased risk of adverse perinatal outcomes, including mental health issues, preterm birth and maternal and infant mortality. There is a need to implement and evaluate models of care to meet their specific needs in order to improve health outcomes, their experiences of care, and overcome barriers to access. In Sydney, Australia, a unique model of care was implemented to support women and families from migrant and refugee backgrounds to access health and community-based services through the continuum of pregnancy to the early parenting period. This model of care is known as the Cross Cultural Workers (CCWs) in Maternity and Child and Family Health Service (the CCW Service). The aim of this study was to explore the perceptions of service providers regarding the CCW Service and identify recommendations for improvement. Methods A mixed-methods study was conducted consisting of surveys and face to face semi-structured interviews. Service providers were recruited from hospital-based maternity and community-based services. Survey data were analysed descriptively. Interviews were analysed using qualitative content analysis. Results Sixty-nine service providers completed surveys and 19 were interviewed. The CCW Service was highly regarded by service providers who perceived it to be critical in improving care for women from migrant and refugee backgrounds. The overarching theme from the interviews was the ability of the CCW Service to act as a ‘bridge to health’ through the provision of culturally responsive care. There were three main categories; supporting access to health and community-based services, improving the healthcare experience, and organisational factors, including part-time hours, capacity, heavy workloads and confusion/lack of clarity regarding the CCW role, which affected CCWs’ capacity to optimally support service providers in providing culturally responsive care. These limitations meant CCWs were not able to meet demand, and fully operationalise the model. Conclusion Service providers perceived the CCW model to be a culturally responsive model of care tailored to the needs of women and families from migrant and refugee backgrounds, that reduces barriers to access, and has the potential to improve perinatal outcomes, and women's experience and satisfaction with care.

IntroductionCommunity paramedicine (CP) is an emerging model of care which expands paramedic scopes of practice to collaboratively support primary healthcare delivery in underserviced and disadvantaged communities. CP is a patient-centred holistic approach focussed on improving health outcomes, with success heavily reliant on integrative partnerships. This research aimed to identify key stakeholder perspectives about the value of CP in rural Australia.MethodsA workshop was conducted using a modified soft system methodology (SSM) that asked participants to consider the value of CP from the perspective of five key stakeholder groups. The 50 participants consisted of paramedics and volunteer ambulance officers, paramedic service executives, paramedic educators, Medicare Local representatives and a general practitioner. Participants were randomly allocated to five stakeholder groups: paramedic profession; Minister for Health and Ageing; consumers, chief executive and executive management team of an ambulance service; and healthcare professionals. The application of SSM placed the five groups into three broad categories of stakeholders: customers, actors, and owners.‘Customers’ in this context are patients, families and carers. ‘Actors’ are paramedics and volunteer ambulance officers, and ambulance service executives. The ‘owners’ are the Office of the Minister and those with the power to facilitate or block initiatives. Participants were allocated 15 minutes to brainstorm the question: “What can a community paramedic do for you to improve rural health provision?” Group views were verbally shared with all workshop participants and video recorded for analysis.ResultsThe ‘customers’ asked about CP from patient, family and carer perspectives, and were highly engaged with questions about how, when and where CP could operate. The paramedic and volunteer ambulance officer group of ‘actors’ battled to move beyond their emergency response mindset to articulate a clear CP vision. The executive management team responded from a strategic and risk management perspective focussing on patient safety and corporate image. They identified the need to form stakeholder partnerships. The ‘owners’ representing the Office of the Minister focussed on the holistic and wellness benefits of CP. The health professional group anticipated the CP role could provide collaborative care and support doctors.ConclusionsThe findings suggest many participants had a limited understanding of CP, which creates a barrier for implementation. Key benefits identified included a reduction in financial and physical burdens on the rural healthcare sector and improved outcomes for consumers. Active participation of stakeholders in the process of introducing CP programs, where people are comfortable questioning current practices and encouraged to explore new concepts and innovations, would enable a shared understanding of program aims and expectations. For paramedic services to expand service delivery models in rural Australia community participation and engagement with stakeholders is essential. They and paramedics must be willing to embrace meaningful and collaborative partnerships with patients, broader health networks, social services, politicians and researchers, and be prepared to step away from their traditional ‘command and control’ culture to co-design innovative paramedic models. SSM was a worthwhile approach to stakeholder engagement that has the potential to improve implementation of community paramedic programs through improved inclusion and the valuing of stakeholder perspectives.

Objective: To identify the prevalence and predictors of (a) thoughts of suicide or self-harm among healthcare workers during the COVID-19 pandemic and (b) help-seeking among those healthcare workers with thoughts of suicide or self-harm. Method: Analysis of data from the Australian COVID-19 Frontline Healthcare Workers Study, an online survey of healthcare workers conducted during the second wave of the COVID-19 pandemic in Australia. Outcomes of interest were thoughts of suicide or self-harm as measured through the Patient Health Questionnaire for depression and help-seeking behaviours. Results: Overall, 819 (10.5%) of 7795 healthcare workers reported thoughts of suicide or self-harm over a 2-week period. Healthcare workers with these thoughts experienced higher rates of depression, anxiety, post-traumatic stress disorder and burnout than their peers. In multivariable models, the odds of suicide or self-harm thoughts were higher among workers who had friends or family infected with COVID-19 (odds ratio = 1.24, 95% confidence interval = [1.06, 1.47]), were living alone (odds ratio = 1.32, 95% confidence interval = [1.06, 1.64]), younger (⩽30 years cf. >50 years; odds ratio = 1.70, 95% confidence interval = 1.36-2.13), male (odds ratio = 1.81, 95% confidence interval = [1.49, 2.20]), had increased alcohol use (odds ratio = 1.58, 95% confidence interval = [1.35, 1.86]), poor physical health (odds ratio = 1.62, 95% confidence interval = [1.36, 1.92]), increased income worries (odds ratio = 1.81, 95% confidence interval = [1.54, 2.12]) or prior mental illness (odds ratio = 3.27, 95% confidence interval = [2.80, 3.82]). Having dependent children was protective (odds ratio = 0.75, 95% confidence interval = [0.61, 0.92]). Fewer than half (388/819) of the healthcare workers who reported thoughts of suicide or self-harm sought professional support. Healthcare workers with thoughts of suicide or self-harm were more likely to seek support if they were younger (⩽30 years cf. >50 years; odds ratio = 1.78, 95% confidence interval = [1.13, 2.82]) or had prior mental health concerns (odds ratio = 4.47, 95% confidence interval = [3.25, 6.14]). Conclusion: One in 10 Australian healthcare workers reported thoughts of suicide or self-harm during the pandemic, with certain groups being more vulnerable. Most healthcare workers with thoughts of suicide or self-harm did not seek professional help. Strong and sustained action to protect the safety of healthcare workers, and provide meaningful support, is urgently needed.

Abstract Background TransformUs was a four-arm school-based intervention to increase physical activity and reduce sedentary behaviour among primary school children. Pedagogical and environmental strategies targeted the classroom, school grounds and family setting. The aims of this study were to evaluate program fidelity, dose, appropriateness, satisfaction and sustainability, and associations between implementation level and outcomes among the three intervention arms. Methods At baseline, 18-months (mid-intervention) and 30-months (post-intervention), teachers, parents and children completed surveys, and children wore GT3X ActiGraph accelerometers for 8 days at each time point to determine physical activity and sedentary time. Implementation data were pooled across the three intervention groups and teachers were categorised by level of implementation: (i) ‘Low’ (< 33% delivered); (ii) ‘Moderate’ (33–67% delivered); and (iii) ‘High’ (> 67% delivered). Linear and logistic mixed models examined between group differences in implementation, and the association with children’s physical activity and sedentary time outcomes. Qualitative survey data were analysed thematically. Results Among intervention recipients, 52% (n = 85) of teachers, 29% (n = 331) of parents and 92% (n = 407) of children completed baseline evaluation surveys. At 18-months, teachers delivered on average 70% of the key messages, 65% set active/standing homework, 30% reported delivering > 1 standing lesson/day, and 56% delivered active breaks per day. The majority of teachers (96%) made activity/sports equipment available during recess and lunch, and also used this equipment in class (81%). Fidelity and dose of key messages and active homework reduced over time, whilst fidelity of standing lessons, active breaks and equipment use increased. TransformUs was deemed appropriate for the school setting and positively received. Implementation level and child behavioural outcomes were not associated. Integration of TransformUs into existing practices, children’s enjoyment, and teachers’ awareness of program benefits all facilitated delivery and sustainability. Conclusions This study demonstrated that intervention dose and fidelity increased over time, and that children’s enjoyment, senior school leadership and effective integration of interventions into school practices facilitated improved intervention delivery and sustainability. Teacher implementation level and child behavioural outcomes were unrelated, suggesting intervention efficacy was achieved irrespective of implementation variability. The potential translatability of TransformUs into practice contexts may therefore be increased. Findings have informed scale-up of TransformUs across Victoria, Australia. Trial registration International Standard Randomized Controlled Trial Number ISRCTN83725066; Australian New Zealand Clinical Trials Registry Number ACTRN12609000715279. Registered 19 August 2009. Available at: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=308387&isReview=true

Fig 1: Image from a secret Rangoon fashion shoot. Photograph: Myanmar Photo Archive / Lukas Birk. Introduction NOTE: Rangoon, Burma has been known as Yangon, Myanmar, since 2006. I use Rangoon and Burma for the period prior to 2006 and Yangon and Myanmar for the period thereafter. In addition, I have removed the name of any activist currently in Myanmar due to the recent policy of executing political prisoners. On 1 February 2021, Myanmar was again plunged into political turmoil when the military illegally overthrew the country’s democratically elected government. This is the third time Myanmar, formally known as Burma, has been subject to a coup d’état; violent seizures of power took place in 1962 and in 1988-90. While those two earlier military governments met with opposition spearheaded by students and student organisations, in 2021 the military faced organised resistance through a mass Civil Disobedience Movement (CDM) initiated by government healthcare workers who refused to come to work. They were joined by private sector “strikes” and, perhaps most visible of all to western viewers, mass street demonstrations “led” by “Gen Z” activists—young people who had come of age during Myanmar’s brief decade of democracy. There is little doubt that the success of the CDM and associated protests is due to the widespread coverage and reach of social media as well as the creative communications skills of the country’s first “generation of digital natives”, who are sufficiently familiar and comfortable with social platforms to “participate and shape their identities in communication and dialogue with global digital media content” (Jordt et al. 12 ). The leveraging of global culture, including the use of English in protest signs, was notable in garnering international media coverage and so keeping Myanmar’s political plight front-of-mind with governments around the world. Yet this is not the whole story behind the effectiveness of these campaigns. As Lisa Brooten argues, contemporary networks are built on “decades of behind-the-scenes activism to build a multi-ethnic civil society” (East Asia Forum). The leading democracy activist, Min Ko Naing, aligned “veteran activists from previous generations with novice Gen Z activists”, declaring “this revolution represents a combination of Generations X, Y and Z in fighting against the military dictatorship’” (Jordt et al. 18). Similarly, the creative strategies used by 2021’s digital campaigners also build on protests by earlier generations of young, creative people. This paper looks at two creative protest across the generations. The first is “secret” fashion photography of the late 1970s collected in Lukas Birk’s Yangon Fashion 1979 – Fashion=Resistance. The second is the contemporary #100projectors campaign, a “projection project for Myanmar democracy movement against the military dictatorship” (in the interest of full disclosure, I took part in the #100projectors project). Drawing from the contemporary advertising principle of “segmentation”, the communications practice where potential consumers are divided into “subgroups … based on specific characteristics and needs” (WARC 1), as well as contemporary thinking on the “aesthetics” of “cosmopolitanism”, (Papastergiadis, Featherstone, and Christensen), I argue that contemporary creative strategies can be traced back to the creative tactics of resistance employed by earlier generations of protesters and their re-imagining of “national space and its politics” (Christensen 556) in the interstices of cosmopolitan Rangoon, Burma, and Yangon, Myanmar. #100projectors Myanmar experienced two distinct periods of military rule, the Socialist era between 1962 and 1988 under General Ne Win and the era under the State Law and Order Restoration Council – State Peace and Development Council between 1988 and 2011. These were followed by a semi-civilian era from 2011 to 2021 (Carlson 117). The coup in 2021 marks a return to extreme forms of control, censorship, and surveillance. Ne Win’s era of military rule saw a push for Burmanisation enforced through “significant cultural restrictions”, ostensibly to protect national culture and unity, but more likely to “limit opportunities for internal dissent” (Carlson 117). Cultural restrictions applied to art, literature, film, television, as well as dress. Despite these prohibitions, in the 1970s Rangoon's young people smuggled in illegal western fashion magazines, such as Cosmopolitan and Vogue, and commissioned local tailors to make up the clothes they saw there. Bell-bottoms, mini-skirts, western-style suits were worn in “secret” fashion shoots, with the models posing for portraits at Rangoon photographic studios such as the Sino-Burmese owned Har Si Yone in Chinatown. Some of the wealthier fashionistas even came for weekly shoots. Demand was so high, a second branch devoted to these photographic sessions was opened with its own stock of costumes and accessories. Copies of these head to toe fashion portraits, printed on 12 x 4 cm paper, were shared with friends and family; keeping portrait albums was a popular practice in Burma and had been since the 1920s and 30s (Birk, Burmese Photographers 113). The photos that survive this era are collected in Lukas Birk’s Yangon Fashion 1979 – Fashion=Resistance. #100projectors was launched in February 2021 by a group of young visual and video artists with the aim of resisting the coup and demanding the return of democracy. Initially a small group of projectionists or “projector fighters”, as the title suggests they plan to amplify their voices by growing their national and international network to 100. #100projectors is one of many campaigns, movements, and fundraisers devised by artists and creatives to protest the coup and advocate for revolution in Myanmar. Other notable examples, all run by Gen Z activists, include the Easter Egg, Watermelon, Flash, and Marching Shoes strikes. The Marching Shoe Strike, which featured images of flowers in shoes, representing those who had died in protests, achieved a reach of 65.2 million in country with 1.4 million interactions across digital channels (VERO, 64) and all of these campaigns were covered by the international press, including The Guardian, Reuters, The Straits Times, and VOA East Asia Pacific Session, as well as arts magazines around the world (for example Hyperallergic, published in Brooklyn). #100projectors material has been projected in Finland, Scotland, and Australia. The campaign was written about in various art magazines and their Video #7 was screened at the Bangkok Art and Culture Centre in February 2022 as part of Defiant Art: A Year of Resistance to the Myanmar Coup. At first glance, these two examples seem distant in both their aims and achievements. Fashion photos, taken in secret and shared privately, could be more accurately described as a grassroots social practice rather than a political movement. While Birk describes the act of taking these images as “a rebellion” and “an escape” in a political climate when “a pair of flowers and a pair of sunglasses might just start a revolution”, the fashionistas’ photographs seem “ephemeral” at best, or what Mina Roces describes as the subtlest form of resistance or ‘weapons of the weak’ (Scott in Roces 7). By contrast, #100projectors has all the hallmarks of a polished communications campaign. They have a logo and slogans: “We fight for light” and “The revolution must win”. There is a media plan, which includes the use of digital channels, encrypted messaging, live broadcasts, as well as in-situ projections. Finally, there is a carefully “targeted” audience of potential projectionists. It is this process of defining a target audience, based on segmentation, that is particularly astute and sophisticated. Traditionally, segmentation defined audiences based on demographics, geodemographics, and self-identification. However, in the online era segments are more likely to be based on behaviour and activities revealed in search data as well as shares, depending on preferences for privacy and permission. Put another way, as a digital subject, “you are what you choose to share” (WARC 1). The audience for #100projectors includes artists and creative people around the world who choose to share political video art. They are connected through digital platforms including Facebook as well as encrypted messaging. Yet this contemporary description of digital subjectivity, “you are what you choose to share”, also neatly describes the Yangon fashionistas and the ways in which they resist the political status quo. Photographic portraits have always been popular in Burma and so this collection does not look especially radical. Initially, the portraits seem to speak only about status, taste, and modernity. Several subjects within the collection are shown in national or ethnic dress, in keeping with the governments edict that Burma consisted of 135 ethnicities and 8 official races. In addition, there is a portrait of a soldier in full uniform. But the majority of the images are of men and women in “modern” western gear typical of the 1970s. With their wide smiles and careful poses, these men and women look like they’re performing sophisticated worldliness as well as showing off their wealth. They are cosmopolitan adepts taking part in international culture. Status is implicit in the accessories, from sunglasses to jewellery. One portrait is shot at mid-range so that it clearly features a landline phone. In 1970s Burma, this was an object out of reach for most. Landlines were both prohibitively expensive and reserved for the true elites. To make a phone call, most people had to line up at special market stalls. To be photographed with a phone, in western clothes (to be photographed at all), seems more about aspiration than anarchy. In the context of Ne Win’s Burma, however, the portraits clearly capture a form of political agency. Burma had strict edicts for dress and comportment: kissing in public was banned and Burmese citizens were obliged to wear Burmese dress, with western styles considered degenerate. Long hair, despite being what Burmese men traditionally wore prior to colonisation, was also deemed too western and consequently “outlawed” (Edwards 133). Dress was not only proscribed but hierarchised and heavily gendered; only military men had “the right to wear trousers” (Edwards 133). Public disrespect of the all-powerful, paranoid, and vindictive military (known as “sit tat” for military or army versus “Tatmadaw” for the good Myanmar army) was dangerous bordering on the suicidal. Consequently, wearing shoulder-length hair, wide bell bottoms, western-style suits, and “risqué” mini-skirts could all be considered acts of at least daring and definitely defiance. Not only are these photographs a challenge to gender constructions in a country ruled by a hyper-masculine army, but these images also question the nature of what it meant to be Burmese at a time when Burmeseness itself was rigidly codified. Recording such acts on film and then sharing the images entailed further risk. Thus, these models are, as Mina Roces puts it, “express[ing] their agency through sartorial change” (Roces 5). Fig. 2: Image from a secret Rangoon fashion shoot – illicit dress and hair. Photograph: Myanmar Photo Archive / Lukas Birk. Fig. 3: Image from a secret Rangoon fashion shoot. Photograph: Myanmar Photo Archive / Lukas Birk. Roces also notes the “challenge” of making protest visible in spaces “severely limited” under authoritarian regimes (Roces 10). Burma under the Socialist government was a particularly difficult place in which to mount any form of resistance. Consequences included imprisonment or even execution, as in the case of the student leader Tin Maung Oo. Ma Thida, a writer and human rights advocate herself jailed for her work, explains the use of creative tools such as metaphor in a famous story about a crab by the writer and journalist Hanthawaddy U Win Tin: The crab, being hard-shelled, was well protected and could not be harmed. However, the mosquito, despite being a far smaller animal, could bite the eyes of the crab, leading to the crab’s eventual death. ... Readers drew the conclusion that the socialist government of Ne Win was the crab that could be destabilized if a weakness could be found. (Thida 317) If the metaphor of a crab defeated by a mosquito held political meaning, then being photographed in prohibited fashions was a more overt way of making defiance and resistant “visible”. While that visibility seems ephemeral, the fashionistas also found a way not only to be seen by the camera in their rebellious clothing, but also by a “public” or audience of those with whom they shared their images. The act of exchanging portraits, what Birk describes as “old-school Instagram”, anticipates not only the shared selfie, but also the basis of successful contemporary social campaigns, which relied in part on networks sharing posts to amplify their message (Birk, Yangon Fashion 17). What the fashionistas also demonstrate is that an act of rebellion can also be a means of testing the limits of conformity, of the need for beauty, of the human desire to look beautiful. Acts of rebellion are also acts of celebration and so, solidarity. Fig. 4: Image from a secret Rangoon fashion shoot – illicit dress length. Photograph: Myanmar Photo Archive / Lukas Birk. Fig. 5: Image from a secret Rangoon fashion shoot – illicit trousers. Photograph: Myanmar Photo Archive / Lukas Birk. As the art critic and cultural theorist Nikos Papastergiadis writes, “the cosmopolitan imagination in contemporary art could be defined as an aesthetic of openness that engenders a global sense of inter-connectedness” (207). Inter-connectedness and its possibilities and limits shape the aesthetic imaginary of both the secret fashion shoots of 1970s Rangoon and the artists and videographers of 2021. In the videos of the #100projectors project and the fashion portraits of stylish Rangoonites, interconnection comes as a form of aesthetic blending, a conversation that transcends the border. The sitter posing in illicit western clothes in a photo studio in the heart of Rangoon, then Burma’s capital and seat of power, cannot help but point out that borders are permeable, and that national identity is temporally-based, transitory, and full of slippages. In this spot, 40-odd years earlier, Burmese nationalists used dress as a means of publicly supporting the nationalist cause (Edwards, Roces). Like the portraits, the #100projector videos blend global and local perspectives on Myanmar. Combining paintings, drawings, graphics, performance art recordings, as well as photography, the work shares the ‘instagrammable’ quality of the Easter Egg, Watermelon, and Marching Shoes strikes with their bright colours and focus on people—or the conspicuous lack of people and the example of the Silent Strike. Graphics are in Burmese as well as English. Video #6 was linked to International Women’s Day. Other graphics reference American artists such as Shepherd Fairey and his Hope poster, which was adapted to feature Aung San Suu Kyi’s face during then-President Obama’s visit in 2012. The videos also include direct messages related to political entities such as Video #3, which voiced support for the Committee Representing Pyidaungsu Hlutaw (CRPH), a group of 15 elected MPs who represented the ideals of Gen Z youth (Jordt et al., viii). This would not necessarily be understood by an international viewer. Also of note is the prevalence of the colour red, associated with Aung San Suu Kyi’s NLD. Red is one of the three “political” colours formerly banned from paintings under SLORC. The other two were white, associated with the flowers Aung Sang Suu Kyi wore in her hair, and black, symbolic of negative feelings towards the regime (Carlson, 145). The Burmese master Aung Myint chose to paint exclusively in the banned colours as an ongoing act of defiance, and these videos reflect that history. The videos and portraits may propose that culturally, the world is interconnected. But implicit in this position is also the failure of “interconnectedness”. The question that arises with every viewing of a video or Instagram post or Facebook plea or groovy portrait is: what can these protesters, despite the risks they are prepared to take, realistically expect from the rest of the world in terms of help to remove the unwanted military government? Interconnected or not, political misfortune is the most effective form of national border. Perhaps the most powerful imaginative association with both the #100projectors video projections and fashionistas portraits is the promise of transformation, in particular the transformations possible in a city like Rangoon / Yangon. In his discussion of the cosmopolitan space of the city, Christensen notes that although “digital transformations touch vast swathes of political, economic and everyday life”, it is the city that retains supreme significance as a space not easily reducible to an entity beneath the national, regional, or global (556). The city is dynamic, “governed by the structural forces of politics and economy as well as moralities and solidarities of both conservative and liberal sorts”, where “othered voices and imaginaries find presence” in a mix that leads to “contestations” (556). Both the fashionistas and the video artists of the #100projectors use their creative work to contest the ‘national’ space from the interstices of the city. In the studio these transformations of the bodies of Burmese subjects into international “citizens of the world” contest Ne Win’s Burma and reimagine the idea of nation. They take place in the Chinatown, a relic of the old, colonial Rangoon, a plural city and one of the world’s largest migrant ports, where "mobility, foreignness and cross-cultural hybridity" were essential to its make-up (Aung Thin 778). In their instructions on how to project their ideas as a form of public art to gain audience, the #100projectors artists suggest projectors get “full on creative with other ways: projecting on people, outdoor cinema, gallery projection” (#100projectors). It is this idea projection as an overlay, a doubling of the everyday that evokes the possibility of transformation. The #100projector videos screen on Rangoon bridges, reconfiguring the city, albeit temporarily. Meanwhile, Rangoon is doubled onto other cities, towns, villages, communities, projected onto screens but also walls, fences, the sides of buildings in Finland, Scotland, Australia, and elsewhere. Conclusion In this article I have compared the recent #100projectors creative campaign of resistance against the 2021 coup d’état in Myanmar with the “fashionistas” of 1970 and their “secret” photo shoots. While the #100projectors is a contemporary digital campaign, some of the creative tactics employed, such as dissemination and identifying audiences, can be traced back to the practices of Rangoon’s fashionistas of the 1970s. ­­Creative resistance begins with an act of imagination. The creative strategies of resistance examined here share certain imaginative qualities of connection, a privileging of the ‘cosmopolitan’ and ‘interconnectedness’ as well as the transformativity of actual space, with the streets of Rangoon, itself a cosmopolitan city. References @100projectors Instagram account. <https://www.instagram.com/100projectors/>. @Artphy_1 Instagram account. <https://www.instagram.com/artphy_1/>. Aung Thin, Michelle. “Sensations of Rootedness’ in Cosmopolitan Rangoon or How the Politics of Authenticity Shaped Colonial Imaginings of Home.” Journal of Intercultural Studies 41.6 (2020): 778-792. Birk, Lukas. Yangon Fashion 1979 – Fashion=Resistance. France: Fraglich Publishing, 2020. ———. Burmese Photographers. Myanmar: Goethe-Institut Myanmar, 2018. Brooten, Lisa. “Power Grab in a Pandemic: Media, Lawfare and Policy in Myanmar.” Journal of Digital Media & Policy 13.1 (2022): 9-24. ———. “Myanmar’s Civil Disobedience Movement Is Built on Decades of Struggle.” East Asia Forum, 29 Mar. 2021. 29 July 2022 <https://www.eastasiaforum.org/2021/03/29/myanmars-civil-disobedience-movement-is-built-on-decades-of-struggle/>. Carlson, Melissa. “Painting as Cipher: Censorship of the Visual Arts in Post-1988 Myanmar.” Sojourner: Journal of Social Issues in Southeast Asia 31.1 (2016): 116-72. Christensen, Miyase. “Postnormative Cosmopolitanism: Voice, Space and Politics.” The International Communication Gazette 79.6–7 (2017): 555–563. Edwards, Penny. “Dressed in a Little Brief Authority: Clothing the Body Politic in Burma.” In Mina Roces & Louise Edwards (eds), The Politics of Dress in Asia and the Americas. Brighton: Sussex Academic Press, 121–138. France24. “‘Longyi Revolution’: Why Myanmar Protesters Are Using Women’s Clothes as Protection.” 10 Mar. 2021. <https://youtu.be/ebh1A0xOkDw>. Ferguson, Jane. “Who’s Counting? Ethnicity, Belonging, and the National Census in Burma/Myanmar.” Bijdragen tot de Taal-, Land- en Volkenkunde 171 (2015): 1–28. Htun Khaing. “Salai Tin Maung Oo, Defiant at the End.” Frontier, 24 July 2017. 1 Aug. 2022 <https://www.frontiermyanmar.net/en/salai-tin-maung-oo-defiant-to-the-end>. Htun, Pwin, and Paula Bock. “Op-Ed: How Women Are Defying Myanmar’s Junta with Sarongs and Cellphones.” Los Angeles Times, 16 Mar. 2021. <https://www.latimes.com/opinion/story/2021-03-16/myanmar-military-women-longyi-protests>. Jordt, Ingrid, Tharaphi Than, and Sue Ye Lin. How Generation Z Galvanized a Revolutionary Movement against Myanmar’s 2021 Military Coup. Singapore: Trends in Southeast Asia ISEAS – Yusof Ishak Institute, 2021. Ma Thida. “A ‘Fierce’ Fear: Literature and Loathing after the Junta.” In Myanmar Media in Transition: Legacies, Challenges and Change. Eds. Lisa Brooten, Jane Madlyn McElhone, and Gayathry Venkiteswaran. Singapore: ISEAS - Yusof Ishak Institute, 2019. 315-323. Myanmar Poster Campaign (@myanmarpostercampaign). “Silent Strike on Feb 1, 2022. We do not forget Feb 1, 2021. We do not forget about the coup. And we do not forgive.” Instagram. <https://www.instagram.com/p/CZJ5gg6vxZw/>. Papastergiadias, Nikos. “Aesthetic Cosmopolitanism.” In Routledge International Handbook of Cosmopolitanism Studies. Ed. Gerard Delanty. London: Routledge, 2018. 198-210. Roces, Mina. “Dress as Symbolic Resistance in Asia.” International Quarterly for Asian Studies 53.1 (2022): 5-14. Smith, Emiline. “In Myanmar, Protests Harness Creativity and Humor.” Hyperallergic, 12 Apr. 2021. 29 July 2022 <https://hyperallergic.com/637088/myanmar-protests-harness-creativity-and-humor/>. Thin Zar (@Thinzar_313). “Easter Egg Strike.” Instagram. <https://www.instagram.com/p/CNPfvtAMSom/>. VERO. “Myanmar Communication Landscape”. 10 Feb. 2021. <https://vero-asean.com/a-briefing-about-the-current-situation-in-myanmar-for-our-clients-partners-and-friends/>. World Advertising Research Centre (WARC). “What We Know about Segmentation.” WARC Best Practice, May 2021. <https://www-warc-com.ezproxy.lib.rmit.edu.au/content/article/bestprac/what-we-know-about-segmentation/110142>.

The autobiographical documentary film “18q – a valuable life”, is one attempt to redefine the place of disability in contemporary western society. My work presents some key moments in my life and that of my family since the birth of my youngest child, Allycia in 1995. Allycia was born with a rare genetic condition affecting the 18th chromosome resulting in her experiencing the world somewhat differently to the rest of the family. The condition, which manifests in a myriad of ways with varying levels of severity, affects individuals’ physical and intellectual development (Chromosome 18, n. pag.). While the film outlines the condition and Allycia’s medical history, the work is primarily concerned with the experiences of the family and offering an alternate story of disability as “other”. Drawing on Rosemarie Garland Thomson’s notion of shape structuring story ("Shape") and Margrit Shildrick’s discussion of becoming vulnerable as theoretical foundations, I reflect on how the making of the film has challenged my previously held views about disability and ultimately about myself. The Film & Disability “18q – a valuable life” introduces a new, previously “invisible” shape in the form of bodies coded as Chromosome 18 to the screen. The initial impulse to make the film was driven by a need to provide a media presence for a rare genetic condition known collectively as Chromosome 18 (Chromosome 18, n. pag.) where previously there was none. This impulse was fuelled by a desire to tell a different story, our story; a story about what life can be like when a child with intellectual and physical impairment is born into one’s family. This different story is, in Garland Thompson’s terms, one that “insists that shape structures story” (114) and endeavours to contribute to recasting disability “as an occasion for exuberant flourishing” (Garland Thompson 114). The categorisation and depiction of people with disability in western society’s media have been scrutinised by many writers including Mitchell and Snyder ("Representations"; "Visual"), Oliver and Norden who point out that negatively charged stereotypical representations of the disabled continue to proliferate in the mediasphere. Englandkennedy for example examines the portrayal of the new disability classification Attention Deficit Disorder and is highly critical of its representation in programs such as The Simpsons (1989-2008) and films such as Pecker (1998). She asserts, “few media representations of ADD exist and most are inaccurate; they reflect and reinforce social concerns and negative stereotypes” (117) to the detriment of the condition being better understood by their audiences. However, Englandkennedy also identifies the positive possibilities for informed media representations that offer new models and stories about disability, citing works such as Children of a Lesser God (1986) and The Bone Collector (1999) as examples of shifts in fictional story telling modes. There are also shifts in recent documentary films such as My Flesh and Blood (2004), Tarnation (2003) and Murderball (2005) which provide insightful, powerful and engaging stories about disability. I suggest however that they still rely upon the stereotypical modes identified by numerous disability studies scholars. For example, Darke’s (n. pag.) heroic mother figure and disabled outsider and victim are depicted in the extreme in My Flesh and Blood and Tarnation respectively, whilst Murderball, as powerful as it is, still constructs disability as “something” to be overcome and is celebrated via the character construction of the “super-crip” (Englandkennedy 99). These stories are vital and insightful developments in challenging and re-shaping the many stigmas associated with disability, but they remain, for the most part, inaccessible to me in terms of my place in the world as a person parenting a little girl with physical and intellectual impairment. Able to Live The opening of the film features footage of my two older children Adam and Kristina, as “normal”, active children. These idyllic images are interrupted by an image of me by Allycia’s bedside where, as an infant, she is attached to life saving machines. She is at once “othered” to her active, healthy siblings. Her survival was reliant, and remains so, albeit to a much lesser extent, upon the intrusion of machines, administering of medication and the intervention of strangers. The prospect of her dying rendered me powerless, vulnerable; I lacked the means to sustain her life. To hand over my child to strangers, knowing they would carve her tiny chest open, suspend the beating of her already frail heart and attempt to repair it, was to surrender to the unknown without guarantees; the only surety being she would cease to be if I did not. Allycia survived surgery. This triumph however, was recast in the shadow of abnormality as outlined in the film when genetic screening of her DNA revealed she had been born with a rare genetic abnormality coded as 18q23 deletion. This information meant she was missing a part of her eighteenth chromosome and the literature available at that time (in 1997) gave little cause for hope – she was physically and intellectually retarded. This news, delivered to me by a genetic counsellor, was coupled with advice to ensure my daughter enjoyed “quality of life”. The words, “rare genetic abnormality” and “retarded” succeeded in effectively “othering” Allycia to me, to my other two children and the general population. My knowledge and experience with people with genetic abnormalities was minimal and synonymous with loss, sadness, suffering and sacrifice and had little to do with quality of life. She was frail and I was confronted with the loss of a “normal” child that would surely result in the “loss” of my own life when framed within this bleak, imagined life that lay before me; her disability, her otherness, her vulnerability signalled my own. As unpalatable as it is for me to use the word monstrous with reference to my daughter, Shildrick’s work, aligning the disabled experience with the monstrous and the possibility of becoming via a refiguring of vulnerability, resonates somewhat with my encounter with my vulnerable self. Schildrick proposes that “any being who traverses the liminal spaces that evade classification takes on the potential to confound normative identity” (6). As Allycia’s mother, I find Shildrick’s assertion that the monstrous “remains excessive of any category, it always claims us, always touches us and implicates us in its own becoming” (6) is particularly pertinent. This is not to say that Schildrick’s notion of the monstrous is an unproblematic one. Indeed Kaul reminds us that: to identify disabled bodies too closely with the monstrous seems to risk leaving us out of universal, as well as particular, experience, entirely in the figurative. (11) Schildrick’s notion of the universality of vulnerability however is implicit in her reference to that which confounds and disturbs us, and it is an important one. Clearly Allycia’s arrival has claimed me, touched me; I am intimately implicated in her becoming. I could not have anticipated however the degree to which she has been intertwined with my own becoming. Her arrival, in retrospect crystallised for me Shildrick’s proposition that “we are already without boundaries, already vulnerable” (6). The film does not shy away from the difficulties confronting Allycia and my family and other members of the chromosome 18 community. I have attempted however to portray our environment and culture as contributing factors and challenge the myth of medicine as a perfect science or answer to the myriad of challenges of navigating life with a disability in contemporary society. This was a difficult undertaking as I did not want the work to degenerate into one that was reliant on blame or continued in the construction of people with disability as victims. I have been mindful of balancing the sometimes painful reality of our lives with those moments that have brought us a sense of accomplishment or delight. Part of the delight of our lives is exemplified when my sister Julie articulates the difference in Allycia’s experiences as compared to her own nine year old daughter, Lydia. Julie succeeds in valorising Allycia’s freedom to be herself by juxtaposing her own daughter’s preoccupation with “what others think” and her level of self consciousness in social contexts. Julie also highlights Lydia’s awareness of Allycia’s difference, via narration over footage of Lydia assisting Allycia, and asserts that this role of becoming a helper is a positive attribute for Lydia’s development. Able to Laugh Including humour in the film was a vital ingredient in the reframing of disability in our lives and is employed as a device to enhance the accessibility of the text to an audience. The film is quite dialogue driven in furnishing background knowledge and runs the risk at times, when characters reveal some of their more painful experiences, of degenerating into a tale of despair. Humour acts as device to lift the overall mood of the film. The humour is in part structured by my failures and incompetence – particularly in reference to my command (or rather lack) of public transport both in Australia and overseas. While the events depicted did occur – my missing a ferry and losing our way in the United States – their inclusion in the film is used as a device to show me, as the able bodied person; the adult ‘able’ mother, with flaws and all. This deliberate act endeavours to re-shape the “heroic mother” stereotype. A wistful form of humour also emerges when my vulnerability becomes apparent in a sequence where I break down and cry, feeling the burden in that moment of the first eleven years of Allycia’s life. Here Allycia as carer emerges as she uses our favourite toy to interrupt my crying, succeeding in turning my tears into a gentle smile. Her maturity and ability to connect with my sadness and the need to make me feel better are apparent and serve to challenge the status of intellectual impairment as burden. This sequence also served to help me laugh at myself in quite a different way after spending many hours confronted with the many faces that are mine during the editing process. I experienced a great deal of discomfort in front of the camera due to feelings of self-consciousness and being on display. That discomfort paled into insignificance when I then had to watch myself on the monitor and triggered a parallel journey alongside the making of the film as I continued to view myself over time. Those images showing my distress, my face contorted with tears as I struggled to maintain control made me cry for quite a while afterwards. I felt a strange empathy for myself – as if viewing someone else’s pain although it was mine, simultaneously the same and other. Chris Sarra’s “notion of a common core otherness as constituting the essence of human being” is one that resonates closely with these aspects. Sarra reinterprets Bhaskar (5) arguing that “we should regard the same as a tiny ripple on the sea of otherness”, enabling us “to enshrine the right to be other” capturing “something of the wonder and strangeness of being” (5). Over time I have become used to seeing these images and have laughed at myself. I believe becoming accustomed to seeing myself, aging as I have during these years, has been a useful process. I have become "more" comfortable with seeing that face, my face in another time. In essence I have been required to sit with my own vulnerabilities and have gained a deeper acceptance of my own fragility and in a sense, my own mortality. This idea of becoming “used to”, and more accepting of the images I was previously uncomfortable with has given me a renewed hope for our community in particular, the disability community in general. My experience I believe indicates the potential for us, as we become more visible, to be accepted in our difference. Critical to this is the need for us to be seen in the fullness of human experience, including our capacity to experience laughter and love and the delight these experiences bring to our lives and those around us. These experiences are captured exquisitely when Allycia sees her newfound chromosome 18 friends, Martin and Kathryn kissing one another. She reacts in much the same way I expect other little girls might in a similar situation. She is simultaneously “grossed out” and intrigued, much to our delight. It is a lovely spontaneous moment that says much in the space of a minute about Martin and Kathryn, and about Allycia’s and my relationship. For me there is a beauty, there is honesty and there is transparency. Able to Love My desire for this film is similar to Garland Thomson’s desire for her writing to “provide access to some elements of my community to both disabled and non disabled audiences alike” (122). I felt part of the key to making the film “work” was ensuring it remained accessible to as wide an audience as possible and began with a naive optimism that the film could defy stereotypical story lines. I discovered this accessibility I desired was reliant upon the traditions of storytelling; language, the construction of character and the telling of a journey demanded an engagement in ways we collectively identify and understand (Campbell). I found our lives at times, became stereotypical. I had moments of feeling like a victim; Allycia as a dancer could well be perceived as a “supercrip” and the very act of making a film about my daughter could be viewed as a heroic one. The process resulted in my surrendering to working within a framework that relies upon, all too often, character construction that is stereotypical. I felt despondent many times upon realising the emergence of these in the work, but held onto the belief that something new could be shown by exposing “two narrative currents which are seldom included in the usual stories we tell about disability: sexuality and community” (Garland Thompson 114). The take on sexuality is a gentle one, concerned with emerging ideologies surrounding sexuality in our community. This is a new phenomenon in terms of the “place” of sexuality and intimacy within our community. One of our parents featured in the film makes this clear when he explains that the community is watching a new romance blossom “with interest” (18q) and that this is a new experience for us as a whole. In focussing on sexuality, my intention is to provoke discussion about perceptions surrounding people categorised as intellectually impaired and their capacity to love and build intimate relationships and the possibilities this presents for the chromosome 18 community. The theme of community features significantly in the film as audiences become privy to conferences attended by, in one instance, 300 people. My intention here is to “make our mark”. There has been no significant filmic presence of Chromosome 18. The condition is rare, but when those affected by it are gathered together, a significantly “bigger picture” of is presented where previously there was none. The community is a significant support network for families and is concerned with becoming empowered by knowledge, care and advocacy. The transcendence of global and cultural boundaries becomes apparent in the film as these differences become diminished in light of our greater need to connect with each others’ experiences in life as, or with, people born with genetic difference. The film highlights the supportive, educated and joyful “shape” of our community. In presenting our community I hope too that western society’s preoccupation with normativity and ableism (Goggin) is effectively challenged. In presenting a version of life that “destabilises the system and points up its inadequacy as a model of existential relations”, I am also demonstrating what Shildrick calls “unreflected excess, that which is other than the same” (105). The most significant shift for me has been to refigure my ideas about Allycia as an adult. When I was given her medical prognosis I believed she would be my responsibility for the rest of my life. I did not hold a lot of hope for the future and could not have possibly entertained the idea that she may live independently or heaven forbid, she may enter into an intimate adult relationship; such was my experience with the physically and intellectually impaired. Thankfully I have progressed. This progression has been, in part, due to attending a Chromosome 18 conference in Boston in 2007 where we met Kathryn and Martin, a young couple in the early stages of building a relationship. This is a new phenomenon in our community. Kathryn and Martin were born with chromosome 18 deletions. Meeting them and their families has signalled new possibilities for our children and their opportunities and their right to explore intimate adult relationships. Their relationship has given me confidence to proceed with an open mind regarding Allycia’s adulthood and sexuality. Conclusion The very act of making the film was one that would inevitably render me vulnerable. Placing myself before the camera has given me a new perspective on vulnerability as a state that simultaneously disempowers and empowers me. I could argue this process has given me a better understanding of Allycia’s place in the world, but to do this is to deny our differences. Instead I believe the experience has given me a renewed perspective in embracing our differences and has also enabled me to see how much we are alike. My understanding of myself as both “able” and “othered”, and the ensuing recognition of, and encounter with, my vulnerable self have in some measure, come as a result of being continually confronted with images of myself in the editing process. But more than this, reflecting upon the years since Allycia’s birth I have come to a more intimate understanding and acceptance of myself as a consequence of knowing Allycia. Whereas my experience has been a matter of will, Allycia’s contribution is in the fact that she simply is. These experiences have given me renewed hope of acceptance of people of difference - that over time we as a society may become used to seeing the different face and the different behaviours that often accompany the experience of people living with genetic difference. References Bhaskar, R. Dialectic: The Pulse of Freedom. London: Verso, 1993. Campbell, J. The Hero's Journey: Joseph Campbell on His Life and Work. California: New World Library, 2003 Caouette, J. Tarnation. Dir. J. Caouette. DVD. 2004. Chromosome 18. "Chromosome 18 Research & Registry Society." 2008. 3 March 2008 ‹http://www.chromosome18.org/›. Darke, P. 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BackgroundIn the past twenty years the discourse of the weight-centred health paradigm (WCHP) has attained almost complete dominance in the sphere of public health policy throughout the developed English speaking world. The national governments of Australia and many countries around the world have responded to what is perceived as an ‘epidemic of obesity’ with public health policies and programs explicitly focused on reducing and preventing obesity through so called ‘lifestyle’ behaviour change. Weight-related public health initiatives have been subjected to extensive critique based on ideological, ethical and empirical grounds (Solovay; Oliver; Gaesser; Gard; Monaghan, Colls and Evans; Wright; Rothblum and Solovay; Saguy; Rich, Monaghan and Aphramor; Bacon and Aphramor; Brown). Many scholars have raised concerns about the stigmatising and harmful effects of the WCHP (Aphramor; Bacon and Aphramor; O'Dea; Tylka et al.), and in particular the inequitable distribution of such negative impacts on women, people who are poor, and people of colour (Campos). Weight-based stigma is now well recognised as a pervasive and insidious form of stigma (Puhl and Heuer). Weight-based discrimination (a direct result of stigma) in the USA has a similar prevalence rate to race-based discrimination, and discrimination for fatter and younger people in particular is even higher (Puhl, Andreyeva and Brownell). Numerous scholars have highlighted the stigmatising discourse evident in obesity prevention programs and policies (O'Reilly and Sixsmith; Pederson et al.; Nuffield Council on Bioethics; ten Have et al.; MacLean et al.; Carter, Klinner, et al.; Fry; O'Dea; Rich, Monaghan and Aphramor). The ‘war on obesity’ can therefore be regarded as a social determinant of poor health (O'Hara and Gregg). Focusing on overweight and obese people is not only damaging to people’s health, but is ineffective in addressing the broader social and economic issues that create health and wellbeing (Cohen, Perales and Steadman; MacLean et al.; Walls et al.). Analyses of the discourses used in weight-related public health initiatives have highlighted oppressive, stigmatizing and discriminatory discourses that position body weight as pathological (O'Reilly; Pederson et al.), anti-social and a threat to the viable future of society (White). There has been limited analysis of discourses in Australian social marketing campaigns focused on body weight (Lupton; Carter, Rychetnik, et al.).Social Marketing CampaignsIn 2006 the Australian, State and Territory Governments funded the Measure Up social marketing campaign (Australian Government Department of Health and Ageing "Measure Up"). As the name suggests Measure Up focuses on the measurement of health through body weight and waist circumference. Campaign resources include brochures, posters, a tape measure, a 12 week planner, a community guide and a television advertisement. Campaign slogans are ‘The more you gain, the more you have to lose’ and ‘How do you measure up?’Tomorrow People is the component of Measure Up designed for Indigenous Australians (Australian Government Department of Health and Ageing "Tomorrow People"). Tomorrow People resources focus on healthy eating and physical activity and include a microsite on the Measure Up website, booklet, posters, print and radio advertisements. The campaign slogan is ‘Tomorrow People starts today. Do it for our kids. Do it for our culture.’ In 2011, phase two of the Measure Up campaign was launched (Australian Government Department of Health and Ageing "Swap It, Don't Stop It"). The central premise of Swap It, Don’t Stop It is that you ‘can lose your belly without losing all the things you love’ by making ‘simple’ swaps of behaviours related to eating and physical activity. The campaign’s central character Eric is made from a balloon, as are all of the other characters and visual items used in the campaign. Eric claims thatover the years my belly has ballooned and ballooned. It’s come time to do something about it — the last thing I want is to end up with some cancers, type 2 diabetes and heart disease. That’s why I’ve become a Swapper! What’s a swapper? It’s simple really. It just means swapping some of the things I’m doing now for healthier choices. That way I can lose my belly, without losing all the things I love. It’s easy! The campaign has produced around 30 branded resource items including brochures, posters, cards, fact sheets, recipes, and print, radio, television and online advertisements. All resources include references to Eric and most also include the image of the tape measure used in the Measure Up campaign. The Swap It, Don’t Stop It campaign also includes resources specifically directed at Indigenous Australians including two posters from the generic campaign with a dot painting motif added to the background. MethodologyThe epistemological position in this project was constructivist (Crotty) and the theoretical perspective was critical theory (Crotty). Multimedia critical discourse analysis (Machin and Mayr) was the methodology used to examine the social marketing campaigns and identify the discourses within them. Critical discourse analysis (CDA) focuses on critiquing text for evidence of power and ideology. CDA is used to reveal the ideas, absences and assumptions, and therefore the power interests buried within texts, in order to bring about social change. As a method, CDA has a structured three dimensional approach involving textual practice analysis (for lexicon) at the core, within the context of discursive practice analysis (for rhetorical and lexical strategies particularly with respect to claims-making), which falls within the context of social practice analysis (Jacobs). Social practice analysis explores the role played by power and ideology in supporting or disturbing the discourse (Jacobs; Machin and Mayr). Multimodal CDA (MCDA) uses a broad definition of text to include words, pictures, symbols, ideas, themes or any message that can be communicated (Machin and Mayr). Analysis of the social marketing campaigns involved examining the vocabulary, grammar, sentence structure, visuals and overall structure of the text for textual, discursive and social practices.Results and DiscussionIndividual ResponsibilityThe discourse of individual responsibility is strongly evident in the campaigns. In this discourse, it is ultimately the individual who is held responsible for their body weight and their health. The individual responsibility discourse is signified by the discursive practice of using epistemic (related to the truth or certainty) and deontic (compelling or instructing) modality words, particularly modal verbs and modal adverbs. High modality epistemic words are used to convince the reader of the certainty of statements and to portray the statement-maker as authoritative. High modality deontic words are used to instil power and authority in the instructions.The extensive use of high modality epistemic and deontic words is demonstrated in the following paragraph assembled from various campaign materials: Ultimately (epistemic modality adverb) individuals must take responsibility (deontic modality verb) for their own health, including their and weight. Obesity is caused (epistemic modality verb) by an imbalance in energy intake (from diet) (epistemic modality verb) and expenditure (from activity) (epistemic modality verb). Individually (epistemic modality adverb) we make decisions (epistemic modality verb) about how much we eat (epistemic modality verb) and how much activity we undertake (epistemic modality verb). Each of us can control (epistemic modality) our own weight by controlling (deontic modality) what we eat (deontic modality verb) and how much we exercise (deontic modality verb). To correct (deontic modality verb) the energy imbalance, individuals need to develop (deontic modality verb) a healthy lifestyle by making changes (deontic modality verb) to correct (deontic modality verb) their dietary habits and increase (deontic modality verb) their activity levels. The verbs must, control, correct, develop, change, increase, eat and exercise are deontic modality verbs designed to instruct or compel the reader.These discursive practices result in the clear message that individuals can and must control, correct and change their eating and physical activity, and thereby control their weight and health. The implication of the individualist discourse is that individuals, irrespective of their genes, life-course, social position or environment, are charged with the responsibility of being more self-surveying, self-policing, self-disciplined and self-controlled, and therefore healthier. This is consistent with the individualist orientation of neoliberal ideology, and has been identified in various critiques of obesity prevention public health programs that centralise the self-responsible subject (Murray; Rich, Monaghan and Aphramor) and the concept of ‘healthism’, the moral obligation to pursue health through healthy behaviours or healthy lifestyles (Aphramor and Gingras; Mansfield and Rich). The hegemonic Western-centric individualist discourse has also been critiqued for its role in subordinating or silencing other models of health and wellbeing including Aboriginal or indigenous models, that do not place the individual in the centre (McPhail-Bell, Fredericks and Brough).Obesity Causes DiseaseEpistemic modality verbs are used as a discursive practice to portray the certainty or probability of the relationship between obesity and chronic disease. The strength of the epistemic modality verbs is generally moderate, with terms such as ‘linked’, ‘associated’, ‘connected’, ‘related’ and ‘contributes to’ most commonly used to describe the relationship. The use of such verbs may suggest recognition of uncertainty or at least lack of causality in the relationship. However this lowered modality is counterbalanced by the use of verbs with higher epistemic modality such as ‘causes’, ‘leads to’, and ‘is responsible for’. For example:The other type is intra-abdominal fat. This is the fat that coats our organs and causes the most concern. Even though we don’t yet fully understand what links intra-abdominal fat with chronic disease, we do know that even a small deposit of this fat increases the risk of serious health problems’. (Swap It, Don’t Stop It Website; italics added)Thus the prevailing impression is that there is an objective, definitive, causal relationship between obesity and a range of chronic diseases. The obesity-chronic disease discourse is reified through the discursive practice of claims-making, whereby statements related to the problem of obesity and its relationship with chronic disease are attributed to authoritative experts or expert organisations. The textual practice of presupposition is evident with the implied causal relationship between obesity and chronic disease being taken for granted and uncontested. Through the textual practice of lexical absence, there is a complete lack of alternative views about body weight and health. Likewise there is an absence of acknowledgement of the potential harms arising from focusing on body weight, such as increased body dissatisfaction, disordered eating, and, paradoxically, weight gain.Shame and BlameBoth Measure Up and Swap It, Don’t Stop It include a combination of written/verbal text and visual images that create a sense of shame and blame. In Measure Up, the central character starts out as young, slim man, and as he ages his waist circumference grows. When he learns that his expanding waistline is associated with an increased risk of chronic disease, his facial expression and body language convey that he is sad, dejected and fearful. In the still images, this character and a female character are positioned looking down at the tape measure as they measure their ‘too large’ waists. This position and the looks on their faces suggest hanging their heads in shame. The male characters in both campaigns specifically express shame about “letting themselves go” by unthinkingly practicing ‘unhealthy’ behaviours. The characters’ clothing also contribute to a sense of shame. Both male and female characters in Measure Up appear in their underwear, which suggests that they are being publicly shamed. The clothing of the Measure Up characters is similar to that worn by contestants in the television program The Biggest Loser, which explicitly uses shame to ‘motivate’ contestants to lose weight. Part of the public shaming of contestants involves their appearance in revealing exercise clothing for weigh-ins, which displays their fatness for all to see (Thomas, Hyde and Komesaroff). The stigmatising effects of this and other aspects of the Biggest Loser television program are well documented (Berry et al.; Domoff et al.; Sender and Sullivan; Thomas, Hyde and Komesaroff; Yoo). The appearance of the Measure Up characters in their underwear combined with their head position and facial expressions conveys a strong, consistent message that the characters both feel shame and are deserving of shame due to their self-inflicted ‘unhealthy’ behaviours. The focus on ‘healthy’ and ‘unhealthy’ behaviours contributes to accepted and contested health identities (Fry). The ‘accepted health identity’ is represented as responsible and aspiring to and pursuing good health. The ‘contested health identity’ is represented as unhealthy, consuming too much food, and taking health risks, and this identity is stigmatised by public health programs (Fry). The ‘contested health identity’ represents the application to public health of Goffman’s ‘spoiled identity’ on which much stigmatisation theorising and research has been based (Goffman). As a result of both lexical and visual textual practices, the social marketing campaigns contribute to the construction of the ‘accepted health identity’ through discourses of individual responsibility, choice and healthy lifestyle. Furthermore, they contribute to the construction of the spoiled or ‘contested health identity’ through discourses that people are naturally unhealthy and need to be frightened, guilted and shamed into stopping ‘unhealthy’ behaviours and adopting ‘healthy’ behaviours. The ‘contested health identity’ constructed through these discourses is in turn stigmatised by such discourses. Thus the campaigns not only risk perpetuating stigmatisation through the reinforcement of the health identities, but possibly extend it further by legitimising the stigma associated with such identities. Given that these campaigns are conducted by the Australian Government, the already deeply stigmatising social belief system receives a significant boost in legitimacy by being positioned as a public health belief system perpetrated by the Government. Fear and AlarmIn the Measure Up television advertisement the main male character’s daughter, who has run into the frame, abruptly stops and looks fearful when she hears about his increased risk of disease. Using the discursive practice of claims-making, the authoritative external source informs the man that the more he gains (in terms of his waist circumference), the more he has to lose. The clear implication is that he needs to be fearful of losing his health, his family and even his life if he doesn’t reduce his waist circumference. The visual metaphor of a balloon is used as the central semiotic trope in Swap It, Don’t Stop It. The characters and other items featuring in the visuals are all made from twisting balloons. Balloons themselves may not create fear or alarm, unless one is unfortunate to be afflicted with globophobia (Freed), but the visual metaphor of the balloon in the social marketing campaign had a range of alarmist meanings. At the population level, rates and/or costs of obesity have been described in news items as ‘ballooning’ (Body Ecology; Stipp; AFP; Thien and Begawan) with accompanying visual images of extremely well-rounded bodies or ‘headless fatties’ (Cooper). Rapid or significant weight gain is referred to in everyday language as ‘ballooning weight’. The use of the balloon metaphor as a visual device in Swap It, Don’t Stop It serves to reinforce and extend these alarmist messages. Further, there is no attempt in the campaigns to reduce alarm by including positive or neutral photographs or images of fat people. This visual semiotic absence – a form of cultural imperialism (Young) – contributes to the invisibilisation of ‘real life’ fat people who are not ashamed of themselves. Habermas suggests that society evolves and operationalises through rational communication which includes the capacity to question the validity of claims made within communicative action (Habermas The Structural Transformation of the Public Sphere; Habermas The Theory of Communicative Action: Reason and the Rationalisation of Society). However the communicative action taken by the social marketing campaigns analysed in this study presents claims as uncontested facts and is therefore directorial about the expectations of individuals to take more responsibility for themselves, adopt certain behaviours and reduce or prevent obesity. Habermas argues that the lack or distortion of rational communication erodes relationships at the individual and societal levels (Habermas The Theory of Communicative Action: Reason and the Rationalisation of Society; Habermas The Structural Transformation of the Public Sphere). The communicative actions represented by the social marketing campaigns represents a distortion of rational communication and therefore erodes the wellbeing of individuals (for example through internalised stigma, shame, guilt, body dissatisfaction, weight preoccupation, disordered eating and avoidance of health care), relationships between individuals (for example through increased blame, coercion, stigma, bias, prejudice and discrimination) and society (for example through stigmatisation of groups in the population on the basis of their body size and increased social and health inequity). Habermas proposes that power differentials work to distort rational communication, and that it is these distortions in communication that need to be the focal point for change (Habermas The Theory of Communicative Action: Reason and the Rationalisation of Society; Habermas The Theory of Communicative Action: The Critique of Functionalist Reason; Habermas The Structural Transformation of the Public Sphere). Through critical analysis of the discourses used in the social marketing campaigns, we identified that they rely on the power, authority and status of experts to present uncontested representations of body weight and ‘appropriate’ health responses to it. In identifying the discourses present in the social marketing campaigns, we hope to focus attention on and thereby disrupt the distortions in the practical knowledge of the weight-centred health paradigm in order to contribute to systemic reorientation and change.ConclusionThrough the use of textual, discursive and social practices, the social marketing campaigns analysed in this study perpetuate the following concepts: everyone should be alarmed about growing waistlines and ‘ballooning’ rates of ‘obesity’; individuals are to blame for excess body weight, due to ignorance and the practice of ‘unhealthy behaviours’; individuals have a moral, parental, familial and cultural responsibility to monitor their weight and adopt ‘healthy’ eating and physical activity behaviours; such behaviour changes are easy to make and will result in weight loss, which will reduce risk of disease. 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