Dissertations / Theses on the topic 'Torres Strait Islander health'

Compared to males in almost any social group in all affluent nations, Australia's Aboriginal and Torres Strait Islander men suffer from substantially more serious illnesses and early death. To date, research done by or in collaboration with Indigenous communities has revealed the extent of the problems that arise from diabetes, heart disease, hypertension, cancers, respiratory diseases, psychological disorders, accidental injuries, violence and other causes. Reproductive health, however, rarely has been studied among Indigenous men. To date, research in this field has been limited mainly to studies of sexually transmitted infections. No data has been published on Aboriginal men's symptoms of prostate disease or erectile dysfunction, nor has the clinical screening and treatment of these disorders among these men been assessed. In-depth search of the worldwide web demonstrated that little information on these issues was available from other Indigenous populations. It does appear that Indigenous men in Australia, New Zealand and North America are less likely than European-ancestry men to die from prostate cancer, or for living cases to be recorded on cancer registries. This may arise because Indigenous men genuinely have a lower risk, or because they are not captured by official statistics, or because they do not live long enough to develop severe prostate disease. We also know very little about other reproductive health problems such as sexual dysfunction and specifically erectile difficulties. One reason for our scant knowledge is that research mainly relies on self-report of sensitive information. The aim of the research study was to improve the understanding of sexual and reproductive health problems experienced by Indigenous men. This is best gathered by Aboriginal males who are inside the culture of middleaged and older Indigenous men, but until now this has not been attempted. In this study we adopted the World Health Organization (WHO) definitions for Reproductive and Sexual Health (WHO, 2001). Thus, we consider reproductive system disorders (prostate disease, erectile dysfunction) and related health care-seeking, and also men's perceptions about a "satisfying and safe sexual life". The methodology was framed within an Aboriginal and Torres Strait Islander research protocol that advocates respect for cultural, social and community customs. A mixed method design combined qualitative inquiry (4 focus groups and 18 in-depth interviews) and quantitative survey (n=301) involving men living in remote, rural and urban communities (Tiwi Islands, Darwin and north and south-east Queensland). Survey data were compared to recently published self-reports from 5990 randomly selected men aged over 40 years in Australia (Holden et al., 2005, The Lancet, 366, 218-224. The qualitative interviews revealed that most men were silent about reproductive health. They were unwilling to reveal their inner feelings to wives or partners, and they were unwilling to discuss such issues with doctors and other health care workers. Men's reaction to sexual difficulties included shame, denial, substance abuse and occasionally violence. On a positive note many men said they want to learn about it, so they understand how to cope with such problems. The Indigenous men reported symptoms of erectile dysfunction at least as much as non-Indigenous men in other Australian studies. Bivariate analysis showed that erectile dysfunction was correlated with many health and lifestyle variable. However multivariate analysis revealed that only three factors significantly predicted ED: presence of chronic disease, presence of pain when working, and living in a remote geographic location The quantitative survey data indicate that Indigenous men have more symptoms of prostate disease than non-Indigenous men. The syndrome appears to be poorly managed in clinical practice (e.g. rates of PSA testing and digital-rectal examination are only one-third the rate reported by non-Aboriginal men, despite equivalent likelihood of GP visits). The research study adds to the literature by providing better insight and depth into the issues impacting on Aboriginal and Torres Strait Islander males experiencing reproductive and sexual health difficulties. It also provides a platform to undertake comprehensive research with Aboriginal and Torres Strait Islander men to explore a wider spectrum of questions in this important but neglected area. Implications for education of primary healthcare workers and community-based awareness campaigns for Indigenous males are discussed. Most of all, this study revealed "layers" of silence around sexual and reproductive health of Indigenous men. This includes silence in the scientific establishments in health services, and in the community. It is hoped that this study puts the voices of the men forward to help to break down this silence.

Compared to males in almost any social group in all affluent nations, Australia's Aboriginal and Torres Strait Islander men suffer from substantially more serious illnesses and early death. To date, research done by or in collaboration with Indigenous communities has revealed the extent of the problems that arise from diabetes, heart disease, hypertension, cancers, respiratory diseases, psychological disorders, accidental injuries, violence and other causes. Reproductive health, however, rarely has been studied among Indigenous men. To date, research in this field has been limited mainly to studies of sexually transmitted infections. No data has been published on Aboriginal men's symptoms of prostate disease or erectile dysfunction, nor has the clinical screening and treatment of these disorders among these men been assessed. In-depth search of the worldwide web demonstrated that little information on these issues was available from other Indigenous populations. It does appear that Indigenous men in Australia, New Zealand and North America are less likely than European-ancestry men to die from prostate cancer, or for living cases to be recorded on cancer registries. This may arise because Indigenous men genuinely have a lower risk, or because they are not captured by official statistics, or because they do not live long enough to develop severe prostate disease. We also know very little about other reproductive health problems such as sexual dysfunction and specifically erectile difficulties. One reason for our scant knowledge is that research mainly relies on self-report of sensitive information. The aim of the research study was to improve the understanding of sexual and reproductive health problems experienced by Indigenous men. This is best gathered by Aboriginal males who are inside the culture of middleaged and older Indigenous men, but until now this has not been attempted. In this study we adopted the World Health Organization (WHO) definitions for Reproductive and Sexual Health (WHO, 2001). Thus, we consider reproductive system disorders (prostate disease, erectile dysfunction) and related health care-seeking, and also men's perceptions about a "satisfying and safe sexual life". The methodology was framed within an Aboriginal and Torres Strait Islander research protocol that advocates respect for cultural, social and community customs. A mixed method design combined qualitative inquiry (4 focus groups and 18 in-depth interviews) and quantitative survey (n=301) involving men living in remote, rural and urban communities (Tiwi Islands, Darwin and north and south-east Queensland). Survey data were compared to recently published self-reports from 5990 randomly selected men aged over 40 years in Australia (Holden et al., 2005, The Lancet, 366, 218-224. The qualitative interviews revealed that most men were silent about reproductive health. They were unwilling to reveal their inner feelings to wives or partners, and they were unwilling to discuss such issues with doctors and other health care workers. Men's reaction to sexual difficulties included shame, denial, substance abuse and occasionally violence. On a positive note many men said they want to learn about it, so they understand how to cope with such problems. The Indigenous men reported symptoms of erectile dysfunction at least as much as non-Indigenous men in other Australian studies. Bivariate analysis showed that erectile dysfunction was correlated with many health and lifestyle variable. However multivariate analysis revealed that only three factors significantly predicted ED: presence of chronic disease, presence of pain when working, and living in a remote geographic location The quantitative survey data indicate that Indigenous men have more symptoms of prostate disease than non-Indigenous men. The syndrome appears to be poorly managed in clinical practice (e.g. rates of PSA testing and digital-rectal examination are only one-third the rate reported by non-Aboriginal men, despite equivalent likelihood of GP visits). The research study adds to the literature by providing better insight and depth into the issues impacting on Aboriginal and Torres Strait Islander males experiencing reproductive and sexual health difficulties. It also provides a platform to undertake comprehensive research with Aboriginal and Torres Strait Islander men to explore a wider spectrum of questions in this important but neglected area. Implications for education of primary healthcare workers and community-based awareness campaigns for Indigenous males are discussed. Most of all, this study revealed "layers" of silence around sexual and reproductive health of Indigenous men. This includes silence in the scientific establishments in health services, and in the community. It is hoped that this study puts the voices of the men forward to help to break down this silence.

During 1987 my essential beliefs about the nature of the world were challenged by a chance event which led to my arrival in Arnhemland. Working with Aboriginal people allowed me to see first hand the failings of Western ideas in Aboriginal education and health. This is how a 12 year collaboration with Aboriginal people began. The aim was to search for answers to the question, 'Why so many ideas that had been successfully used in the Western world, fail to meet the needs of aboriginal people? My experiences prior to 1995 had led me to believe that Both Ways, an education pedagogy developed in teacher education, was the best approach for empowering Aboriginal Health Workers. I believed Both Ways gave Aboriginal Health Workers a means to develop solutions to aboriginal health issues which valued and respected their aboriginal knowledge. I needed to describe and evaluate the practice of both ways with Aboriginal Health workers for the purpose of proving the benefit of this pedagogy for other educators in this field. This thesis describes how I came to think Both Ways was a good idea; how I defined Both ways; and how I put it into practice. It also provides a description of the issues raised in my critique of Both Ways and in my attempts to provide answers to these issues. Several years of collecting data, including records from action research group discussions, participant observation, interviews with peers and students, and formal evaluations left me with many concerns about Both Ways. As educators follow my journey of discovery I hope that they will recognise experiences and insights that they themselves have shared. The descriptions and discussions in this thesis will add significantly to the overall discourse about health worker education. Similarly, the exploration of ideas beyond Both Ways will add significantly to the overall body knowledge about the power relationships involved in teaching in a cross cultural setting
Doctor of Philosophy (PhD)

The pervasive health and social disadvantage faced by Aboriginal and Torres Strait Islander peoples is an acknowledged part of Australian society. The contemporary data reveal striking inequalities between Indigenous and non-Indigenous Australians in most measurable aspects of wellbeing across the life cycle. This reflects a postcolonial history of marginalisation and exclusion from mainstream society, dispossession of traditional lands, forced separation from family and kinship networks, and racism. Despite an increased awareness and disapproval of these inequalities in health, the inequalities persist.The lack of progress in the face of public disapproval and progressive government support underscores the fact that we still do not adequately understand the fundamental causes of Indigenous ill health and disease. A small body of research in Australia has highlighted that socioeconomic status (SES) accounts for a portion of the gap in health but this does not imply that they account for health differences within Indigenous population groups. A robust international literature has consistently shown that socioeconomic factors influence population health. These factors reflect the way in which society is ordered according to wealth, prestige, power, social standing or one’s control over economic resources, and their pattern of association with health has almost always depicted better health for those who are better off— that is, the health of population groups normally follows a gradient pattern. Despite the ubiquity of this observation in the empirical literature, there is uncertainty as to whether it applies to Aboriginal and Torres Strait Islander populations in Australia.Accordingly, this thesis has aimed to assess the pattern of socioeconomic disparities in the health and development of Indigenous populations in Australia, with a specific focus on children. The three key objectives were to: • Describe the developmental status of Indigenous children and the mechanisms that influence this status; • Determine the pattern of association between socioeconomic factors and physical and mental health outcomes; and • Reveal the significant differences (and similarities) in the socioeconomic pattern of child health between Indigenous and non-Indigenous populations, and articulate these in terms of their direction, shape and magnitude.The objectives of the study were primarily assessed using a quantitative analytic framework applied to four existing population-representative datasets: the 2008 National Aboriginal and Torres Strait Islander Social Survey, the 2000–2002 Western Australian Aboriginal Child Health Survey, the 2004–05 National Aboriginal and Torres Strait Islander Health Survey and 2004–05 National Health Survey. Simple univariate and cross-tabulation data were used to describe population characteristics, while the relationships between socioeconomic indicators and health outcomes were assessed using a range of regression techniques. Multilevel models are an important feature of this study, and have enabled a more accurate estimation of the effects of individual and area-level measures of SES on health. Generalised Additive Models were used to account for the possible non-linear nature of associations between continuous SES variables and physical health outcomes, with results presented as non-parametric spline curves. The mechanisms linking SES and mental health were explored using a stepwise approach to the regression analysis. All data in all chapters were weighted to reflect population benchmarks.The findings highlighted that there were significant socioeconomic disparities in the health of Indigenous children in Australia, although the direction, shape and magnitude varied, by both socioeconomic measure and health outcome. While the socioeconomic patterns of Indigenous child health are not universal, they are more consistent for mental than physical health. In addition, the thesis has shown that both conventional and alternative notions of SES can influence health patterns. The largest disparities in child physical health were observed for area-level SES indicators, while housing characteristics and area-level SES both had a strong direct effect on child mental health.The thesis has demonstrated that the patterns of socioeconomic disparities in child health differ markedly in Indigenous and non-Indigenous populations—at least in non-remote settings. It was not uncommon for the magnitude of disparity to be larger in the Indigenous population. These findings lend support to the notion that socioeconomic factors have a differential impact on the health of Indigenous and non-Indigenous populations. The implication of this for policy is that a single approach to stimulating socioeconomic conditions will not have equal benefits to child health outcomes in Indigenous and non-Indigenous populations. While the evidence here underscores the validity of the well-worn edict that “one size does not fit all” in Indigenous health policy, it also reinforces the need to examine health disparities within and across Indigenous and other population groups in order to better inform policy and practiceCollectively, the results have provided clear evidence that socioeconomic factors matter to both the physical and mental health of Aboriginal and Torres Strait Islander children. The diversity of findings implies that SES factors are one facet of the unique and complex set of factors that influence Aboriginal child health and wellbeing.This thesis has made several original contributions to the literature on social inequalities in Indigenous health in Australia and the broader field of social determinants of health. It is one of the few studies internationally to explicitly look at the socioeconomic patterning of health in an Indigenous population, and the first to examine these patterns among Indigenous children using population-representative data. In doing so, the study has begun to bridge the knowledge gap on social inequalities in Aboriginal health in Australia, and will facilitate a better grasp of the complex underlying mechanisms that determine Aboriginal health.For policy, this knowledge can lead to more effective government decision-making in terms of targeting social determinants of health that are of particular significance for Aboriginal populations. It is hoped that the findings of the thesis can provide directions for future research and insights to policy that will, ultimately, increase the pace of change toward health equity in Australia.

This dissertation seeks to investigate the nature and extent of community participation in health education decision making for Torres Strait Islander girls at one Queensland high school. As such, the study is concerned with identifying stakeholders in health education for girls, describing the ways in which stakeholders participate in health education decision-making, and identifying the factors that promote or inhibit community participation in health education decision-making. The question presupposes several standpoints: firstly, that Indigenous communities want to participate in education decision-making and, secondly, that community participation would be desirable in producing good outcomes for Indigenous students. Thus, the literature review is concerned with critiquing discourses of community participation in Indigenous education, the effects on educational outcomes of Indigenous students when community participation is enabled, and reviewing previous research on educational decision-making in health education in Australia. Given the necessity for emancipatory research methodology in Indigenous research contexts, a critical ethnographic case study approach was chosen to investigate the research questions at a high school in the Torres Strait; building a critical case record from field notes, interview data, and documents. Using Carspecken's (1996) stages of data analysis, primary records were reconstructed and dialogically negotiated with participants, to describe system relations. Such an approach allows for power and control relations between researchers and research participants to be explicated, giving voice to usually marginalised groups, such as Indigenous students. This approach was also congruent with specific Torres Strait Islander research protocols, informed by Ailan Kastom, which were necessary to sensitively and successfully undertake the research. Data analysis was informed by a framework of Indigenous community participation theory, derived from Soliman (1995), Heslop (1998 ), Ministerial Advisory Council for Aboriginal and Torres Strait Islander Education (1999) and Stewart (1999), together with curriculum theory, from Bernstein (1976; 1990; 2000). This approach constituted a unique adaptation of Bernstein's pedagogic discourse theory to a Torres Strait Islander educational setting. The findings indicated that there was strong desire by community members, including students, to participate in health education decision-making at Bluewater High. However, the ability of different stakeholder groups to participate in health education varied, with teachers exercising the most power, and students the least. An in-depth, contextual analysis, in which pedagogic decision-making occurred, enabled a number of immediate and long-term recommendations to be developed. It is envisaged that these recommendations will enable greater community participation in health education decision-making for girls at Bluewater High, and more generally in other Indigenous educational settings.

This dissertation seeks to investigate the nature and extent of community participation in health education decision making for Torres Strait Islander girls at one Queensland high school. As such, the study is concerned with identifying stakeholders in health education for girls, describing the ways in which stakeholders participate in health education decision-making, and identifying the factors that promote or inhibit community participation in health education decision-making. The question presupposes several standpoints: firstly, that Indigenous communities want to participate in education decision-making and, secondly, that community participation would be desirable in producing good outcomes for Indigenous students. Thus, the literature review is concerned with critiquing discourses of community participation in Indigenous education, the effects on educational outcomes of Indigenous students when community participation is enabled, and reviewing previous research on educational decision-making in health education in Australia. Given the necessity for emancipatory research methodology in Indigenous research contexts, a critical ethnographic case study approach was chosen to investigate the research questions at a high school in the Torres Strait; building a critical case record from field notes, interview data, and documents. Using Carspecken's (1996) stages of data analysis, primary records were reconstructed and dialogically negotiated with participants, to describe system relations. Such an approach allows for power and control relations between researchers and research participants to be explicated, giving voice to usually marginalised groups, such as Indigenous students. This approach was also congruent with specific Torres Strait Islander research protocols, informed by Ailan Kastom, which were necessary to sensitively and successfully undertake the research. Data analysis was informed by a framework of Indigenous community participation theory, derived from Soliman (1995), Heslop (1998 ), Ministerial Advisory Council for Aboriginal and Torres Strait Islander Education (1999) and Stewart (1999), together with curriculum theory, from Bernstein (1976; 1990; 2000). This approach constituted a unique adaptation of Bernstein's pedagogic discourse theory to a Torres Strait Islander educational setting. The findings indicated that there was strong desire by community members, including students, to participate in health education decision-making at Bluewater High. However, the ability of different stakeholder groups to participate in health education varied, with teachers exercising the most power, and students the least. An in-depth, contextual analysis, in which pedagogic decision-making occurred, enabled a number of immediate and long-term recommendations to be developed. It is envisaged that these recommendations will enable greater community participation in health education decision-making for girls at Bluewater High, and more generally in other Indigenous educational settings.

This thesis concerns the relationship between ideology, values, beliefs, politics, language, discourses, public policy and health outcomes. By examining the origins of federal health policy concerning Aboriginal and Torres Strait Islander Peoples 1972-2001 I have explored the idea that the way a problem is constructed through language determines solutions enacted to solve that problem, and subsequent outcomes. Despite three decades of federal policy activity Aboriginal and Torres Strait Islander children born at the start of the 21st Century could expect to live almost 20 years less than non-Indigenous Australians. Explanations for the gap include that the colonial legacy of dispossession and disease continues to wreak social havoc and that both health policy and structures for health services have been fundamentally flawed. The research described in this thesis focuses on the role of senior Federal politicians in the health policy process. The research is grounded in theory which suggests that the values and beliefs of decision makers are perpetuated through language. Using critical discourse analysis the following hypotheses were tested: 1. That an examination of the language of Federal politicians responsible for the health of Aboriginal and Torres Strait Islander Peoples over three decades would reveal their beliefs, values and discourses concerning Aboriginal and Torres Strait Islander Peoples and their health 2. That the discourses of the Federal politicians contributed to policy discourses and frames in the Aboriginal and Torres Strait Islander health policy environment, and 3. That there is a relationship between the policy discourses of the Aboriginal and Torres Strait Islander health policy environment and health outcomes for Aboriginal and Torres Strait Islander Peoples. The hypotheses were proven. I concluded that there was a relationship between the publicly-expressed values and beliefs of politicians responsible for health, subsequent health policy and resulting health outcomes. However, a model in which theories of discourse, social constructions of people and problems, policy development and organisational decision-making were integrated did not adequately explain the findings. I developed the concept of "policy imagination" to explain the discrete mechanism by which ideology, politics, policy and health were related. My research suggests that the ideology and values which drove decision-making by Federal politicians responsible for the health of all Australians contributed to the lack of population-wide improvement in health outcomes for Aboriginal and Torres Strait Islander Peoples in the late 20th Century.

This study is a critical reflection on two music projects that I conducted in my home area of Ipswich, Australia, prior to undertaking this research. The music projects involved participatory action research to investigate the music heritage and culture of the rural Ipswich region. The purpose of this study is to review and analyse the creative processes that I used in the rural Ipswich music projects in order to develop suitable practice frameworks for similar projects in future. The first music project was a collaborative investigation of the music history of Purga in rural Ipswich (2003-2005). Local people and those who used to live in the area were invited to come back to share memories of the music from the area with one another. People collaborated creatively: This allowed me to write The Purga Music Story and Harold Blair (2005), an inter-generational community education package. In 2003, we established the Purga Music Museum as a meeting place where the music heritage and culture of our neighbourhood is performed and displayed. The second music project (2006) was a study of contemporary music in rural Ipswich that resulted in community consultation and the development of a Music Action Plan for the area. I continued facilitating community music in rural Ipswich, as the curator of the Purga Music Museum, until 2008. Both music projects presented different challenges in the establishment of processes that would be effective for the needs and interests of people from various cultural groups. The work was fraught with complex decisions and ethical dilemmas about representation and music cultural heritage management because our neighbourhood previously contained the Purga Aboriginal Mission (1915-1948). The findings therefore relate to the struggles of the ‘Stolen Generation’-- Aboriginal and Torres Strait Islander people who were taken away from their families and forced to live in government-controlled residential situations. New, respectful approaches had to be found, conducive to the health and well-being of all concerned. For this reason, participatory action research methods were developed and a ‘Community of Discovery’ approach was used. Throughout this study, I investigate issues that arose as people told their music stories, and passed on music heritage and culture from one generation to the next. The key question is “What are appropriate frameworks of culturally engaged community music practice for rural Ipswich?” This study also draws on findings from the music projects to address the sub-questions, “How did community music practice function in the past in rural Ipswich?” “What is the current situation regarding contemporary community music practice in rural Ipswich?” and “What can be done to enhance future community music practice for rural Ipswich?” Aspects of music and health practice complement each other in this study. As a dual qualified music and health professional, I draw on expertise from both of these areas. Ethnographic methods were used to record and review the findings from each music project. The analysis is grounded in review of literature and other sources, creative display and performance, analysis of music history, community consultation, and critical reflection on my own community music practice. Finally, this evidence-based process of professional reasoning leads to the development of appropriate practice frameworks that transform the way that I intend to deliver services in future, and will hopefully inspire others. The thesis has five parts. The context and rationale for the research are outlined in Part 1. This is followed by description of the two music projects in Part 2. Part 3 is an exploration of how my music practice is situated in relation to scholarly literature (and other sources) and outlines the chosen theoretical constructs or models. This prepares for critical analysis and discussion of specific issues that arose from reflection on practice in Part 4. The conclusions of the research, presented in chapter 9, outline the creative processes, underlying principles, and the philosophy of my practice. The study concludes with an epilogue, which is a consideration of the present situation and suggested future directions for service provision and research.

Improving the patient journey for Indigenous people has become an important focus to reduce the rates of cardiovascular disease and address underlying factors contributing to the disparities of care between Indigenous and non-Indigenous people. This study has demonstrated that a culturally safe cardiac outreach service staffed by Indigenous and non-Indigenous people is capable of providing timely evidence based care to the standards of best practice. The findings of this study indicate that racism at an interpersonal, individual, organisational and societal level contribute, interact and conspire to influence the Indigenous patient journey within mainstream health services. Identifying as Indigenous is not good for your health because, significantly, the patient journey commences with the collection of Indigenous status, an act of defining race that reinforces the disparity between Indigenous and non-Indigenous people.

Within Australia, data on the oral health and health-related quality of life experiences of Aboriginal and Torres Strait Islander children living in urban areas are lacking. This project utilised a mixed-methods approach to contribute new epidemiological and life experience data to the field of oral health and create a culturally specific, parent-proxy tool to measure the health-related quality of life of Aboriginal and Torres Strait Islander children. These findings provide contemporary oral health data to inform policy and a foundation for the development of other culturally specific health-related quality of life measures for Aboriginal and Torres Strait Islander peoples.

As required by the Master of Philosophy (Applied Epidemiology) program I completed a field placement in the Strategic Investment, Data and Evaluation Section in the Indigenous Health Division, Australian Government Department of Health. Following the introduction chapter (chapter 1), this thesis contains three projects, which aimed to: 1) explore the performance of health organisations providing social and emotional wellbeing (SEWB) services for Aboriginal and Torres Strait Islander peoples (chapter 2); 2) analyse the relationships between health organisations’ cultural safety policies and the uptake of Medicare Benefits Scheme (MBS) health assessments among Aboriginal and Torres Strait Islander clients (chapter 3); and 3) describe and the characteristics of inpatients who acquired vanA vancomycin-resistant enterococci and compare the characteristics of inpatients with vanA versus vanB sterile site infections at the John Hunter and Calvary Mater Newcastle hospitals in Newcastle, New South Wales (chapter 4). My first project was a national survey of SEWB service delivery in 2014-15 using a quantitative questionnaire, administrative data and qualitative case studies. Service delivery strengths included accessibility, capability, continuity, appropriateness, responsiveness and sustainability. Fifteen opportunities to strengthen SEWB service delivery were identified, including in the areas of: client access, perceptions and experiences of service delivery; strengthening the SEWB workforce; and facilities required to support service delivery. These opportunities represent potential approaches that could improve the SEWB of Aboriginal and Torres Strait Islander peoples. For my second project, I used logistic regression to model univariate relationships between seven cultural safety policies and low or high uptake of MBS health assessments in 2014-16 using existing administrative and service performance data. Data from 174 health organisations showed no associations between cultural safety policies and health assessment uptake, however this is likely due to study and data limitations. In my third project, I conducted two case series analyses. The first described numbers and proportions of 168 vanA and vanAB acquisitions in 2013-2015. It also examined potential contributing environmental exposures and other risk factors that might lead to infection or colonisation. The second case series used Wilcoxon rank-sum, Chi-squared or Fisher’s exact tests to compare morbidity and mortality outcomes between vanA and vanB for 42 inpatients with laboratory-confirmed sterile site infections in 2015. No specific environmental exposures or risk factors that likely contributed to acquisition, and no difference in morbidity and mortality outcomes between genotypes, were identified. This may suggest that vanA is endemic to the hospital environment, highlighting the importance of standard, enhanced and tailored infection prevention and control precautions. To meet the teaching requirements, I presented to my peers on logic models and confounding. Additional to the program requirements, I completed an internship in the Ebola Community Engagement Team at the World Health Organization, Geneva, Switzerland. Chapters 5 and 6, respectively, reflect on these experiences. I highly value the opportunities and the skills, experience and knowledge in epidemiology, public health research and practice I developed in the program. I applied my knowledge of logic models, skills in data analysis and interpretation, and knowledge of the importance of understanding and accommodating culture and belief systems when addressing public health issues in my paid employment in my field placement.

This thesis evaluates a chronic condition self-management program for Aboriginal and Torres Strait Islander people in urban south-east Queensland who have or are at risk of cardiovascular disease. Outcomes showed short-term improvements for some anthropometry measures which could be a trend for improvement in other anthropometry indicators over the longer term. The program was of particular benefit for participants who had several social and emotional wellbeing conditions. The use of an Aboriginal and Torres Strait Islander conceptual framework was critical in undertaking culturally competent quantitative research in this project.

Chronic disease is the most significant contributor to the mortality gap between Australia’s First Nations people and the overall Australian population. This study explored chronic disease self-management and health literacy in First Nations adults living in remote Queensland. Key findings were poor communication by healthcare providers coupled with limited health literacy abilities of individuals were the major barriers to active engagement with managing chronic disease. Providing a supportive health literacy environment and the provision of appropriate health information delivered in a cultural safe way using clinical yarning, may assist with closing the gap in First Nations people.

This thesis contributes to the decolonisation of health promotion by examining Indigenous-led health promotion practice in an urban setting. Using critical ethnography, the study revealed dialogical, identity-based approaches that centred relationship, community control and choice. Based on the findings, the thesis proposes four interrelated principles for decolonising health promotion and argues that Indigenous-led health promotion presents a way to bridge the rhetoric and practice of empowerment in Australian mainstream health promotion practice.

Thesis (Master of Letters)--Central Queensland University, 1998.
"A dissertation submitted in partial fulfilment of the requirements for the Degree of Letters in History. Central Queensland University." Cover title.

This paper discusses women’s involvement in their children’s mathematics education. It does, where possible, focus Torres Strait Islander women who share the aspirations of Aborginal communities around Australia. That is, they are keen for their children to receive an education that provides them with opportunities for their present and future lives. They are also keen to have their cultures’ child learning practices recognised and respected within mainstream education. This recognition has some way to go with the language of instruction in schools written to English conventions, decontextualised and disconnected to the students’ culture, Community and home language.

This thesis is the first to comprehensively evaluate Acute Respiratory Illness with Cough (ARIwC) in urban, predominantly Aboriginal and Torres Strait Islander, children. It identified a community experiencing significant disadvantage and a concerning burden of ARIwC. Positive findings include the frequent presentation to primary health care, continuity of primary health care provider, and knowledge of when cough is abnormal; factors that are all critical to the success of interventions and further research to reduce the burden of disease.

Thesis (B. Mus.(Hons.))--University of Adelaide, Dept. of Music Studies, 1996.
A loose leaved appendix of Transcriptions in back pocket (31 leaves). Includes bibliographical references (leaves 69-71).

[The Mariner's Chart]I've chosen to use the metaphor of the mariners chart to highlight the characteristics that are the essential elements of this study. This metaphor also sits comfortably with the Torres Strait Islander people, both historically and contemporaneously. The document '(IN) THE BEGINNING: The mariner’s chart to the folio’, represents the chart which enables readers ofthis study to 'navigate' their individual progress through the study in ways that reflect the reader's motivation/s. As with most maritime voyages, destinations can be reached via a number of different routes. These routes will be partially determined by motivations including tides, winds, directness, the skill of the navigator and the whim of the skipper. These motivations also apply to any reading of this study. The essential starting point will bedetermined initially by reference to the chart. Being made aware of the elements of the folio (logs of the various voyages) will influence where the reader goes from there; in other words, what folio elements (logs of the voyages) the reader will go to first and the order they chooseto follow, subsequent to that. There is no necessary order in which the logs of the various voyages should be read, following the initial reference to the 'chart'.The mariner's chart identifies low water marks, channel markers, reefs, sandbanks, and unseen obstacles. These represent only a handful of the dangers the reader (mariner) will face on the voyage. Likewise the study has its share of 'dangers', both seen and unseen. Thewhole nature of the study is in a sense, dangerous. I anticipate that any reading of the study will necessarily reflect the idiosyncrasies of the reader, so that the conclusions that I have reached, represent only one view of the data. The identification of the data itself reflects a level of interpretation that is also very personal, highlighting the reality that others(readers/mariners) may see greater significance in aspects of the recorded data that the author has not. The log of the voyage, My Journey An Autobiographical Narrative, clearly identifies a very personal journey or series of journeys, all of which reflect a range of reefs and sandbars that the author has sometimes been stranded on, between tides, giving time for reflection on actions that have either proven unsuccessful or are cause for quietcontemplation. Each of the folio elements reflects this metaphoric mix of danger and clear passage, in many different ways and at many different levels, inviting the individual and equally legitimate reactions of each reader.Whilst Torres Strait Islanders historically navigated by the stars and the seasons today, electronic navigation charts have tended to replace these important and culturally significant practices. Torres Strait people have metaphorically experienced being stranded on reefs andshoals and being wrecked, especially in terms of the education processes they have been exposed to, by virtue of this cultural shift. The process, educationally, of replacing the reliable historic (navigation) practices of Torres Strait Islanders with contemporary, western(navigation charts) practices has frequently resulted in confusion, frustration and a failure to produce successful educational outcomes for Torres Strait Islanders - clear passage to the future. The reasons for this situation are explored in greater depth in this study.With these explanations in mind then, the reader is invited to engage on their own voyage through this study.

This study involves the analysis of one of the most recent Indigenous Education policies, the Aboriginal and Torres Strait Islander Education Action Plan 2010-2014 (MCEECDYA, 2011). It examines how the language used within policy positions Aboriginal and Torres Strait Islander peoples. Articulating Rigney's (1999) Indigenist Research Principles with Fairclough's (2001) Critical Discourse Analysis provides a platform for critical dialogues about policy decision-making. In doing so, this articulation enables and emphasises the need for potential policy revision to contribute to the Aboriginal and Torres Strait Islander struggle for self-determination.

This thesis explored how six teachers of mathematics embedded Aboriginal and Torres Strait Islander Peoples’ Histories and Cultures into the core mathematics curriculum. Semi-structured interviews were conducted, then written transcripts were analysed through the use of Bernstein’s Theory of Pedagogic Discourse. Teachers shared their perspectives on how they have developed their cultural capabilities, and how this has informed culturally responsive teaching of mathematics. Recommendations are made for how to support in-service teachers with their personal cultural capabilities to authentically embed Aboriginal and Torres Strait Islander Peoples’ Histories and Cultures in mathematics curriculum.

This thesis focuses on non-Indigenous educators’ work around embedding Indigenous perspectives in early childhood education curricula. In place of reporting examples of ‘good’ educational practice, the study questions how whiteness and racism continue to operate in diversity work that is seen to be productive and inclusive. The thesis argues for a more comprehensive framework for embedding Indigenous perspectives in before-school contexts to support educators’ efforts. New strategies for professional development are also suggested to support changes in disciplinary knowledge and pedagogy.

This research project was undertaken to ascertain what Torres Strait Islander students, who have relocated from various locations around Australia to Brisbane in order to attend university, report as having assisted them in their transition to a metropolitan area to undertake their university studies or suggest would have assisted them. The findings of this research contribute to knowledge about how current and future Torres Strait Islander students can be better supported to transition to university and improve their chances of success whilst at university.

This exegesis examines the context of my studio work submitted for the degree of Doctor of Visual Art at Griffith University in 2004. My art practice reflects my identity, which is complex and many-stranded, but at its core is my identity as a 21st century woman of Torres Strait Islander descent. I also acknowledge multiple heritages and, like many of my contemporaries, I am a descendant of those two thirds of the Torres Strait population who now live on the Australian mainland. Having been born and brought up on the mainland also means that I am connected to, and have been affected by, wider Australian Indigenous issues, particularly those resulting from the alienation and dislocation which stem from colonialism. Therefore, as I draw from both traditional and contemporary modes and theory to explore the appropriateness of my art practice, this exegesis centres on the question: What constitutes culturally appropriate practice for me as a contemporary Torres Strait Island woman?

In this thesis I propose to address what are, in my view, significant educational problems: how to tease out and analyse those principles, concerning equity and social justice, which underlie a particular program of teacher education. I want to discuss the kinds of principles, issues and considerations which have to be faced when designing such a program as the Diploma of Teaching (Early Childhood Education) for Aboriginal and Torres Strait Islander students at James Cook University. The issues I will address are these: (a) The extent to which the notion of equality of educational opportunity is being addressed in the provision of teacher-education programs in Queensland in general, and James Cook University in particular; (chapter 1). (b) Ways in which the Diploma of Teaching (Early Childhood Education) p r o g r am aims to produce teachers able to act as agents of bi-cultural transmission; (chapters 2 and 3). (c) The value, usefulness and desirability of James Cook University setting up a teacher-education program specifically for Aboriginal and Torres Strait Islander students from geographically remote communities, thus increasing the participation rates of Aborigines and Islanders in teacher-education programs; (chapters 4 and 5). This process of analysis has led me to structure the thesis around three dimensions: (i) The historical context of the program; (ii) The program as one response to the problems faced by educational institutions in meeting the educational needs of Aboriginal people; (iii) A basis for the next phase in the development of new programs of teacher - education for indigenous students living in remote communities. This is a qualitative research project, based on my interpretation of available documentation, my use of relevant literature, and my own involvement as planner of, and teacher in the program. It is not a quantitative research project. The structure of the thesis has, as its introduction, an analysis of the extremely complex situation which exists at James Cook University. This analysis leads to a search for a set of principles to provide the theoretical underpinning of the program, which in turn leads through a combination of theory and practice to the "praxis" of the program as a model of equity and educational practice in teacher-education. The thesis is concluded by the presentation of the current stage in the development of a program for teacher-education students in remote communi ties. The conceptual framework for my thesis has been developed through my determination to increase my understanding of the complexities of developing teacher-education programs for indigenous students at James Cook University. The thesis is developed through case study techniques including: personal observation and recording of my work as Program Planner; a situational analysis of the historical background, leading up to the development of the Diploma of Teaching (Early Childhood Education) ; a discussion of the stages through which the development team proceeded with intentionality and empathy towards its task of constructing a specific program of teacher-education; and my use of existing literature to comprehend the educational and social problems which the program attemted to alleviate. Throughout my thesis the specificity of the "case", and the eclectic position I have adopted, have acted as boundaries of my conceptual framework. My thesis attempts to show that the "case" of the development of teacher-education programs for Aboriginal and Torres Strait Islander students at James Cook University, although an idiosyncratic instance , is valuable as illumination , if not for generalisation, and thus has a credibility and usefulness. The characteristics of the case-study method are frequently more appropriate to expansion is than reductionist activities, and I have tried to show how the different perspectives of Aboriginal and non-Aboriginal people, together with the beliefs, attitudes and values of such different interest-groups as university academics, Commonwealth and State Education Department bureaucrats, and teachers and parents in schools, have emphasised both the importance of questioning assumptions and the importance of critical, experiential understanding.

This thesis examined the educational outcomes for Indigenous children enrolled in Queensland state (public) primary schools from the perspective of the collective and social impact of programs and services. The study used quantifiable data to show that the gap is not closing, regardless of an improvement in attendance, along with literacy and numeracy achievement levels, in certain regions of Queensland.

The Countried experience of Aboriginal and Torres Strait Islander Peoples of (Australia), ground a resilience and strength in sovereign thinking through the Stories we share laterally with family and inter-ancestrally through our connections to the Dreaming. The stories we share develop a sense of inalienability we have that is connected to the Countries of origin we share and identify with across the continental scape of Land, Water and Sky Country. As a formative philosophical assumption, the Countried existence that this dissertation develops, illuminates the significance of this research thinking to contribute to the continued development of Indigenous education for Aboriginal and Torres Strait Islander students attending secondary high schools across (Australia). By attending to the ways Elders as significant Indigenous leaders describe and develop their storied lives through lived experience, this Countried philosophy emerges through the Storied knowing of Country. By examining the approaches to learning Aboriginal and Torres Strait Islander students adopt, further evidence can be contributed to the research surrounding Indigenous thinking and cognitive approaches to thinking through education learning tasks. By examining the perceptions and beliefs of non-indigenous teachers, this dissertation aims to contribute evidence to Indigenous pedagogies that teachers can deploy in the delivery of meaningful Indigenous Knowledge curricula content. Summatively, this thesis found that when deep engagements are made into the notion of inalienability of Countried experience, salient avenues of thinking and learning and teaching emerge surrounding the ways education can continue to elaborate and relate meaningfully to the First Peoples of Australia.

While transformative learning has been investigated in a range of contexts, there remains little known about the extent to which higher education is transformative for Aboriginal and Torres Strait Islander students. Therefore, this study explores the experiences of Indigenous students undertaking university studies in order to understand the nuances and complexities of their journeys into and throughout the cultural interface within the context of higher education. This qualitative interpretive study applied narrative inquiry to investigate the experiences of 19 undergraduate Indigenous university students. Written narratives, focus groups and in-depth interviews were used to collate 19 individual student stories for analysis and interpretation. The key themes emergent from these narratives related to the students’ development of self-efficacy, the negotiation of their families’ perceptions and expectations and the affirming of their cultural identities as Aboriginal and Torres Strait Islander people. The two key theoretical concepts used to guide the discussion of the themes were Nakata’s (2007) cultural interface theory and Mezirow’s (1991) transformative learning theory. The findings of this study revealed that university learning had fostered, for most of the student participants, a sense of transformation and change. New relationships with peers were found to be a critical part of the students’ support network while at university. As the students progressed throughout their studies, they gained confidence and a sense of belonging within the university community. Such enablers fostered an increased sense of self-worth and wellbeing that further developed the students’ sense of self-efficacy and ability to succeed at the cultural interface of higher education. Family was seen as vitally important in relation to support for the students but also at times a challenge to be negotiated carefully. Finally, it was also found that university had strengthened the students’ relationship to their Indigeneity. These findings have key implications for the way institutions support and teach Aboriginal and Torres Strait Islander students and provides a nuanced insight into their university journeys at the cultural interface.

The Thesis explores the life situations of the three Mackay-based groups: Aboriginal, Torres Strait and South Sea Islander through oral history research and the lived experience of an Elder from each of these groups. Using a combination of oral and written approaches, the project seeks to document ongoing interactions between the three groups from the 1930s and assess their implications for culture, identity and mobility.

The overarching research problem for this study was the need to improve upon rational models of policy analysis and delivery, to suit complex postmodern implementation environments. A theoretical model suited to implementing and evaluating major education reform initiatives was devised. Called the 'Multiple Discourse Model', it was grounded in systems theory, containing elements reminiscent of social systems, organisational and structural functionalist research, especially that of Hoy and Miskel (1982)1. However the model was also designed to incorporate a parallel naturalistic analysis reminiscent of postmodern critical pragmatic approaches, such as those explored by Cherryholmes (1994)2. Over a period of five years, this model was developed through an evaluation of the implementation of the National Aboriginal and Torres Strait Islander Education Policy (AEP) in the Australian Capital Territory government secondary schools sector. The distinguishing feature of the study's methodology was its multiperspective analysis, an approach suggested by Mclaughlin (1987)3 to take account of the differing communities of discourse which exist in a reformist policy implementation environment. To operationalise the research problem, dimensions of policy effectiveness were articulated. These were addressed through a comprehensive set of research indicators, extracted from the AEP's national policy goals and the local strategic and operational plans. Data aimed at judging the effectiveness of implementation were collected from multiple sources using multiple research instruments. These data were analysed in three stages using a purpose-designed computer program which could cross-reference between the four interacting dimensions of research indicators, research instruments, data sources, and potential variables modifying policy/program outcomes. It was found that this model produced clear conclusions about the effectiveness of AEP implementation in the delimited sector, within the framework of the AEP's own policy assumptions. The model also provided insights into critical issues which are generalisable to the national context, such as the power of cultural hegemony and the socio-political predicament of Aboriginal and Torres Strait Islander dispossession. As a methodology, the model was found to have a number of technical advantages, including its capacity for focussing on selected areas of the implementation environment, its provision of access to multiple levels of detail amongst data and its possession of mechanisms for monitoring its own internal validity. The evaluation case study, used as the vehicle for the Multiple Discourse Model's development, demonstrated that best-practice administration was in place which enhanced short and medium-term policy/program outcomes. However, the study's findings also suggested that a fundamental disjuncture existed between the AEP's policy/administration paradigm and the conflicting assumptions of the primary target communities, reinforcing the findings of Sykes (1986)4. The research results suggested that despite measurable successful inputs, the planned long-term outcomes of the AEP will not necessarily be achieved. No significant administrative structures or actions were apparent which could resolve this lack of synchrony at the interface between government delivery systems and 'grass roots' Aboriginal and Torres Strait Islander community values. This raised doubts about whether any systems approach, however well refined, could be socially useful not only for evaluation, but also as a basis for reform policy and public administration in a postmodern pluralist democratic setting. The evaluation was therefore used as a locus for theoretical reflection as well. A new policy paradigm is suggested, based on a power-sharing 'theory of community', more in keeping with Aboriginal and Torres Strait Islander peoples' aspirations for self determination and more likely to alleviate the so far unresolved destructive effects of cultural and political dispossession.

My placement for the Master of Philosophy in Applied Epidemiology (MAE) degree was with the Evidence and Evaluation section, within the Indigenous Health Division, Australian Government Department of Health. In this thesis, I present projects undertaken which fulfil the requirements of the MAE program. Data analysis project: The Northern Territory Aboriginal Health Key Performance Indicators (NT AHKPIs) are a collection of key performance indicators that measure primary health care (PHC) performance. I conducted a descriptive analytical study of the NT AHKPIs. The data that inform the NT AHKPIs are not currently in the public domain, this chapter is therefore a closed chapter. Evaluation project: I evaluated the NT AHKPIs to assess the extent to which the NT AHKPIs are addressing their intended goals and to determine whether they were being used for other purposes; my approach to the evaluation was utilisation focused. Preliminary findings show that the KPIs are useful to inform service planning and continuous quality improvement, but there is room for improvement. Findings were reported back to the NT AHKPI steering committee to inform ongoing strengthening of the NT AHKPI system. Epidemiological study: Anaemia in Aboriginal and Torres Strait Islander children in the NT is a public health problem. I undertook a study to describe the application of best practice guidelines for screening and management of children aged 6 months to 3 years with anaemia in the NT. Findings show that of 5,543 children, 63% were screened for anaemia. The prevalence of anaemia was 40% - a ‘severe’ public health problem as defined by the World Health Organisation (WHO). A very low proportion of anaemic children were recorded as treated according to best practice guidelines, however, our findings are subject to multiple potential biases and these findings need to be validated. Outbreak investigation: I was a member of the Communicable Disease Network Australia team that investigated an unusual cluster of Ralstonia bacteraemia from 1 April to 26 June 2014 in three states in Australia. The objectives of this investigation were to assess the possibility of a causal association between the administration of propofol and Ralstonia bacteraemia, and to identify sources of the infections. The propofol solution passed all sterility and contamination tests, but 18% of the flip-off caps and external surfaces of the rubber stoppers were contaminated with a variety of bacterial species including R. mannitolylitica. These isolates were genetically indistinguishable from three out of eight isolates from patients with R. mannitolylitica bacteraemia. Findings from this study highlighted the need for proper aseptic techniques when administering intravenous injections. I spent ten weeks in Sierra Leone supporting the WHO’s response to the Ebola virus disease outbreak (EVD). I summarise my role and responsibilities in the outbreak, including a description of our investigation of a cluster of cases with EVD.

This thesis comprises a collection of applied epidemiological studies including an evaluation and epidemiological study, an outbreak investigation, and a data analysis. All studies are focused on Aboriginal and Torres Strait Islander One Health (which recognises that the health of people is related to the health of animals and their interaction with the environment), sexual health, and child health. All studies highlight the importance of partnerships and community involvement. The first study is an evaluation of a community driven animal health and management program in the remote Aboriginal community of Wadeye in the Northern Territory. Wadeye has approximately 2300 residents and 650 dogs and cats. However, there is very limited access to veterinary care and animal medicines. To address community concerns regarding animal health, an animal health and management program was co-developed and implemented by Animal Management in Rural and Remote Indigenous Communities (AMRRIC) and the Thamarrurr Development Corporation (TDC) Rangers, with support from the West Daly Regional Council. This study is a quantitative epidemiological study that evaluated the impact of this animal health and management program in Wadeye. This included analysing animal and human health outcomes before and after program implementation to assess the impact of the animal program on the health of animals and people within the community. This study involved engagement and partnerships with AMRRIC and TDC, as well as the community of Wadeye. The second study is an outbreak investigation analysing Human Immunodeficiency Virus (HIV) notifications among the Aboriginal and Torres Strait Islander population in Far North Queensland to determine if an outbreak has occurred. The Tropical Public Health Unit - Cairns observed an increase in HIV notifications since 2014 affecting the Aboriginal and Torres Strait Islander population. HIV has been notifiable in Queensland since 1984. This study is a quantitative descriptive analysis, using the Queensland Notifiable Conditions database, to analyse data on HIV notifications from 1 January 1984 - 30 June 2019, to quantify the history of HIV notifications and assess whether an outbreak has occurred. This study involved engagement and partnerships with local health organisations, Queensland Health, and the South Australia Health and Medical Research Institute (SAHMRI). The third study is a data analysis focusing on chronic disease risk in Aboriginal children involved in the Study of Environment on Aboriginal Resilience and Child Health (SEARCH). SEARCH is a cohort study of Aboriginal children and adolescents and is conducted with four Aboriginal Community Controlled Health Services (ACCHS) in New South Wales. Chronic disease affects Aboriginal and Torres Strait Islander adults at higher rates than non-Indigenous Australian adults. However, it is not clear if this risk emerges during childhood and/or adolescence. This study is a cross-sectional analysis that quantifies the distribution of chronic disease markers in the cohort overall, and in relation to age group, gender, and Body Mass Index (BMI). This study involved engagement and partnerships with two ACCHS including the Tharawal Aboriginal Medical Service (based in Western Sydney), and the Riverina Medical and Dental Aboriginal Corporation (based in Wagga Wagga), and also the SEARCH project team based at the Sax Institute. The teaching requirements of the MAE are also detailed in this thesis including a lessons from the field session about the use of logic models in evaluations and a teaching session about One Health in field epidemiology.

This thesis is a compilation of applied epidemiological studies undertaken throughout the course of the Master of Philosophy in Applied Epidemiology (MAE) program. The focus of this thesis is on Aboriginal and Torres Strait Islander health and wellbeing and uses a strengths based, mixed methods approach. Community based participatory research methodologies were utilized in these studies. An outbreak investigation was also undertaken as part of the MAE competencies. This thesis includes the following studies: - The data analysis and major epidemiological studies explore the association between caring for country, through participation in a Ranger program, and wellbeing. A cross sectional analysis of data collected in Central Australia in 2017, comparing health and wellbeing (life satisfaction, general health, psychological wellbeing and family wellbeing) among Aboriginal and Torres Strait Islander people employed as Rangers (n=43) versus not employed as Rangers (n=160). - The Stronger Communities for Children (SCfC) program was evaluated through collection of cultural participation data (a key program outcome). Community based participatory research was utilised and community researchers were trained in delivering the survey through partnership with the Palngun Wurnangat Aboriginal Corporation, the Kardu Lurruth Ngala Purrungime Committee and the National Centre of Epidemiology and Population Health. - An outbreak investigation was undertaken of a cluster of Salmonella Typhimurium with a unique MLVA pattern in Canberra, ACT. Descriptive epidemiology and an environmental investigation was undertaken to identify the source of the pathogen, and implement public health measures to mitigate risk to the public of further infection. This thesis outlines additional activities undertaken during the MAE. Peer-reviewed articles, conference presentations, lesson plans and study proposals are included throughout.

Research Doctorate - Doctor of Philosophy (Phd)
The limited available data shows Aboriginal and Torres Strait Islander Peoples have disproportionately high rates of diabetes-related foot disease, and experience amputation up to 38 times more frequently than non-Indigenous Australians. The high rate of diabetes-related foot disease in this population results in reduced quality of life, elevated hospitalisation rates and associated expenditure, and significantly contributes to preventable deaths. The reasons for higher rates of diabetes-related foot disease in Aboriginal and Torres Strait Islander Peoples are complex, with a lack of available culturally safe care, low socioeconomic status and poor engagement with Western health services significantly contributing to the current catastrophic outcomes. To effectively address diabetes-related foot disease in Aboriginal and Torres Strait Islander Peoples, a better understanding of the extent of the problem is required, and, there needs to be improved access to culturally safe foot care through better service provision and a more culturally capable health workforce. This thesis had the overarching aims of establishing the foot health of Aboriginal and Torres Strait Islander Peoples in the local Central Coast community, and developing methods to improve access to, and delivery of, culturally safe foot care. This thesis investigated, via systematic review, the current state of diabetes-related foot disease in Aboriginal and Torres Strait Islander Peoples and the availability and effectiveness of foot care services to reduce diabetes-related foot complications in this population. The reviews demonstrated there is a lack of nationwide data relating to diabetes-related foot disease in Aboriginal and Torres Strait Islander Peoples, and, that most data focuses on amputation rates, with little information available regarding specific types of diabetes-related foot complications. Nevertheless we found Aboriginal and Torres Strait Islander Peoples had between a 3 to 6 fold increased likelihood of both foot ulcer and minor or major amputation, and, that these occurred at a younger age. Furthermore, we found no evidence of state- or nation-wide foot health programs for prevention of diabetes-related foot disease in Aboriginal and Torres Strait Islander Peoples. Existing services were localised and there was little evaluation of the acceptability of these programs, levels of community engagement or impact on foot disease. Subsequently through an extensive community consultation process we used an effective co-design approach to develop a foot care service embedded in an undergraduate podiatry program. Key design elements included; integrating ongoing community consultation; involvement of Aboriginal health workers and practitioners connected to their local community; recognising the role of community in cultural capability training of health students; and, creating a flexible and accessible care model that is aligned with the community foot care priorities. To conduct a comprehensive evaluation of the foot care service model, we used culturally appropriate methods to determine the Aboriginal and Torres Strait Islander perspective of program success through research yarns and customised surveys, as well as service utilisation data. These data demonstrated that service elements including yarning circles and group appointments, as well as student placements, increased participant engagement with, and ownership of the clinic. Increasing accessibility to the clinic was flagged as a mechanism to further increase engagement. In addition, student placement in a culturally safe clinic significantly improved students’ understanding of multiple aspects of cultural capability (e.g. understanding of culture, history, and their interrelationship with health and health care delivery), and level of confidence with providing culturally appropriate and safe foot care. In summary this research highlights the devastating impact of diabetes-related foot disease for Aboriginal and Torres Strait Islander people and the importance of a co-designed approach to delivery of culturally safe foot health care, as well as the central role of immersive experiences for developing a culturally safe future podiatry workforce.

I completed my Masters of Applied Epidemiology during 2017-18 with the NHMRC funded Centre for Research Excellence in Improving Health Services for Aboriginal and Torres Strait Islander Children (CRE ISAC) located at the University of Western Australia. My projects focussed mostly on social epidemiology, with the exception of my outbreak. Chapter two provides a case-control study of a point source outbreak of Salmonella Typhimurium, which occurred at a university residential college in April 2018. Epidemiological and environmental investigation identified the most likely source of the outbreak to be raw eggs used in coleslaw. Public health action was the provision of information on the safe handling of eggs to prevent further outbreaks. Chapter three, public health data analysis, was a population-based birth cohort study using linked datasets with information on a cohort of Aboriginal and Torres Strait Islander children, and their mothers and siblings. The 2009 and 2012 Australian Early Development Census was used to assess developmental vulnerability across five domains of development in Aboriginal children born in Western Australia. Latent class analysis was used identify and describe profiles of risk for developmental vulnerability. Six distinct classes were identified. My surveillance project, provided in chapter four, was the evaluation of the Western Australian population based data linkage Intellectual Disability Exploring Answers (IDEA) surveillance system. I evaluated the usefulness, simplicity, flexibility, data quality, acceptability, representativeness, timeliness, and stability of the IDEA system. This was completed by process observation, semi-structured interviews and data analysis. The IDEA system has successfully been used to understand prevalence rates and inform resource allocation. Advocacy organisations could play an important role in the sustainability of the system. Additional variables or enhanced surveillance for functional capacity could strengthen the system and provide information for people living with intellectual disability and their families. Chapter five is my epidemiology project which was a cross-sectional study of 1554 clinical child health audits and associated systems assessments from 74 primary care services from 2012-2014. Composite process of care indicators (PoCIs) were developed for social and emotional wellbeing, child neurodevelopment and anaemia. Crude and adjusted logistic regression models were fitted clustering for health services. 32.0% (449) of records had a social and emotional wellbeing PoCI, 56.6% (791) had an anaemia PoCI and 49.3% (430) had a child neurodevelopment PoCI. The study found that the need for young Indigenous children aged 24-59 months to receive quality care for important social and health indicators should be a priority. Processes of care and organisational systems within primary care services are important for the optimal management of anaemia in Indigenous children. The final chapter concludes with my lessons from the field. This provided me with an opportunity to deliver a count regression teaching opportunity to my peers.

Research Doctorate - Doctor of Philosophy (PhD)
This doctoral thesis by publication provides new knowledge in two important and related areas in Aboriginal and Torres Strait Islander health. Firstly, the thesis investigates opportunities in primary health care for reducing some of the major contributors to the health disparity between Aboriginal and Torres Strait Islander people and non-Indigenous Australians. It suggests that strategies are needed to better support patients and GPs in accurately identifying patients at risk and also support the need for a continued policy commitment towards these activities. Secondly, where evidence is lacking of effective primary health care interventions, the research aims to inform health and medical research policy to support research that will maximise health improvements for Aboriginal and Torres Strait Islander people. It aims to inform policy-makers, health practitioners, researchers and Aboriginal and Torres Strait Islander communities on opportunities for health gains that are evident in primary health care and through more targeted health and medical research. One of the key findings of this doctoral research is the lack of intervention research being conducted specifically in Aboriginal and Torres Strait Islander health. It identifies the lack of research outputs that can be used to inform clinical practice as well as health policy and programs. The findings offer strategies that may be able to be implemented into policy to address barriers to increasing the amount of high quality intervention research being conducted in Australia. Another key finding is that research funding disproportionally funds descriptive research rather than measurement and intervention research. The findings aim to inform future health and medical research funding allocation in a way that targets specific health topics, types of research, as well as disciplines that may result in health gains more quickly due to their ability to more rapidly translate findings into policy and practice. The implications of the research aim to be practical and achievable. In primary health care, improving screening according to evidence-based guidelines will greatly improve the health of Aboriginal and Torres Strait Islander people. Where the evidence is lacking on effective health care strategies specifically targeting Aboriginal and Torres Strait Islander people, strategic research is needed that will create evidence to address the major causes of the health gap between Aboriginal and Torres Strait Islander people and non-Indigenous Australians.

It has been acknowledged that the mental health of Aboriginal and Torres Strait Islander people has been 'bedevilled' by the inappropriate application of non- Indigenous models of mental health. Given the poor health outcomes of Indigenous people, another approach to mental health practice is perhaps required. In order to enhance Indigenous health and wellbeing, it is necessary for non-Indigenous practitioners to find a culturally safe way in which to enter the negotiated space of cross-cultural mental health. Such practice can be facilitated through understanding both the points of similarity and divergence in perspectives of mental health across cultures. While the majority of Indigenous people live in urban areas, understandings of Indigenous mental health have primarily been derived from research in rural and remote communities. It is unclear whether findings from rural and remote research are applicable in urban Indigenous communities. The aim of the current research is to address this gap and to explore understandings of mental health in an urban Indigenous sample. This study provided a voice for urban Aboriginal and Torres Strait Islander people to convey their understandings of mental health so that an accurate representation may be available for those who are engaged in health promotion and mental health treatment. Using a positive psychology framework, a strengths-based approach was taken in this study in order to explore understandings of mental health. A qualitative research investigation was conducted with a sample of 19 Australian Aboriginal and Torres Strait Islander participants. Data was collected via individual semi-structured interviews and focus groups. Qualitative analysis was conducted using thematic analysis. A model of Indigenous mental health was developed taking an holistic perspective. Four themes emerged as reflecting health and wellbeing and are presented in a model of Indigenous mental health:- • Coping Skills: emotional, behavioural and cognitive; • Knowledge: regarding physical health and access to mental health care; • Social Support: personal resources and help-seeking behaviours; and • Connectedness: cultural, social and family and kinship. The theme of connectedness emerged as reflecting a unique contribution to Indigenous health and wellbeing. The role of connectedness to country, family and kinship, knowledge and social networks was highlighted. Further, the theme of connectedness also emerged as central to supporting cultural identity. Not only did connectedness promote and protect mental health and cultural identity, factors that diminished cultural identity also negatively impacted upon mental health. The striking similarity between mental health and cultural identity, as seen in the common theme of connectedness, highlights the necessity of attending to cultural factors to facilitate positive health outcomes. This model of Indigenous mental health begins to fill in the boundaries of the negotiated space that is cross-cultural psychology - the space where both Indigenous and non-Indigenous knowledge offers a path or guidelines to enhance health and wellbeing. It is essential to address those factors that are similar across cultures – coping skills, social support and knowledge, but also to engage at the cultural interface of connectedness to culture, kinship and social networks. This information has implications for cross-cultural clinical practice, through providing a map for non-Indigenous practitioners to engage in culturally safe practice. Further, this information will support the development of culturally safe health and wellbeing programs that sustain and nurture the cultural identity and mental health of Indigenous people. In this way, meaningful contributions may be made by health professionals to 'close the gap' in health and mental health outcomes for Indigenous people.

This thesis presents an illustration of the access barriers to health care as experienced by Aboriginal and Torres Strait Islander peoples in Mount Isa, Queensland, Australia. This examination is conducted via fieldwork observations and the narratives of Aboriginal and Torres Strait Islander peoples in Mount Isa, as well as the stories of the health professionals that care for them. In particular, this thesis attempts to unpack the term 'cultural barriers' as used in health and medical literature in discussions of access. Stories are placed within the context of Australian rural health issues and considerations of global issues affecting rural, minority and Indigenous populations. The research represents a distinct blend of anthropology and health services research principles and practices. This perspective is developed utilising principles from the 'Mindful Bodies' approach within Critical Medical Anthropology, which seeks an understanding of human health issues via examination at three levels (or bodies): the individual body, the social body and the body politic (Scheper-Hughes and Lock 1987). Critical issues of concern with regards to health service provision in Mount Isa are examined using Penchansky and Thomas's (1981) taxonomy, the 5As of Access. This taxonomy allows for a nuanced discussion of access by unpacking the term and identifying the various aspects that create access: Availability, Accessibility, Affordability, Accommodation and Acceptance. Dedicated ethnographic fieldwork was undertaken in Mount Isa from October 2007 to August 2009. An examination of the ways that Aboriginal and Torres Strait Islander peoples in Mount Isa express their understandings of the barriers to health care has two advantages. First, such discussions at a local level align with and illuminate the barriers that affect Aboriginal and Torres Strait Islander populations nationally. Second, the significance assigned to such barriers, and examination of what may constitute a cultural barrier (as discussed in health literature) highlights the ways in which cultural difference becomes constructed as problematic in health system encounters. Culture should not be seen as a barrier to health care, but should be seen as an opportunity for increased awareness, understanding and improved personal care for patients in the health system.

Research Doctorate - Doctor of Philosophy (PhD)
This thesis by publication is a body of work containing an introduction, six papers and a closing chapter with conclusions and recommendations for future practice, policy and research. All papers explore the area of concern being smoking during pregnancy among Aboriginal and Torres Strait Islander women, with a focus on how expectant mothers can be empowered to quit smoking. At the time of submission of this thesis, three of the six papers have been published or accepted for publication in peer-reviewed journals and the other three are under review.

"When compared to other women Australia Aboriginal women are considered the most socially and economically disadvantaged and have the poorest health status. Aboriginal women in Rockhampton, Central Queensland are not excluded from this lived reality. This research has explored Aboriginal women's perceptions and experiences of health and health services in Rockhampton. Drawing on these experiences, and centring the voices of these women, the study reports on findings concerning cross-cultural issues, communication, policy, practice and service delivery. Importantly, the study has built new knowledge identifying the complex relationship between identity, body and well-being." -- abstract.

My MAE was undertaken at the South Australian Health and Medical Research Institute (SAHMRI), during 2018-2019. My studies focussed on the health and wellbeing of adolescent and young Aboriginal and Torres Strait Islander peoples, with the exception of my outbreak project. My studies included: Analysis of public health dataset - A retrospective study of South Australian adolescents aged 10-24 years utilising data from the Integrated South Australian Activity Collection dataset. The aim of the study was to assess leading causes and trends in hospital separations among adolescents in South Australia (SA) between 2006 and 2015, by sex, age groups and Aboriginal status. Counts and proportions of leading causes of separation were calculated as age-standardised rates and negative binominal regression was used to assess trend over time. Epidemiological study - Let's Talk About It 2019, an online survey of sexual health, knowledge, behaviours and access to health services for sexually transmitted infections (STI) and bloodborne viruses (BBV), amongst young South Australians aged 16-29 years, both Aboriginal and Torres Strait Islander and non-Indigenous. Descriptive analysis, univariate and adjusted logistic regression models were used to determine whether socio-demographic characteristics and sexual risk behaviours were associated with specific behaviours. Evaluation of a public health surveillance system - The preliminary evaluation of the ATLAS Aboriginal and Torres Strait Islander Sexual Health Surveillance Network - a national sentinel surveillance system within Aboriginal community-controlled health services (ACCHS). The evaluation of ATLAS involved a document review, stakeholder interviews and analysis of ATLAS data using the Centers for Disease Control and Prevention (United States of America) Updated Guidelines for Evaluating Public Health Surveillance Systems. I assessed the following attributes: acceptability, simplicity, flexibility, data quality, representativeness, timeliness, stability, and usefulness. Outbreak investigation - An epidemiological investigation and a retrospective case-control study of an outbreak of Salmonella Havana in alfalfa sprouts, in Adelaide. The outbreak was conducted during June and July 2018 with colleagues from SA Health. Investigations identified the most likely source to be alfalfa sprouts. Public health action lead to a consumer level recall of all alfalfa sprout products and public health alert. Teaching - This chapter outlines two teaching sessions, (i) a teaching session to first year MAE scholars, on a Single Overarching Communication Outcome (SOCO) in relation to the communication of a public health message; and (ii) a Lessons From the Field to my fellow scholars, on 'Conducting research with Aboriginal and Torres Strait Islander communities'.

This thesis presents a collection of applied epidemiological studies and is primarily focused on health risk behaviours and preventive health programs. The studies included: - a cross-sectional analysis of data from two national Aboriginal and Torres Strait Islanders surveys. The study examined estimates of smoking prevalence by Indigenous Regions, 2012/13 and 2014/15; - a pre- and post- study of a local Aboriginal-developed tobacco control campaign in Central Australia. The study examined change in smokers and ex-smokers knowledge, attitude and behaviours to tobacco use, 2016-17; - a retrospective cohort study of Aboriginal Community Controlled Health Services which examined if outcomes in smoking were associated with targeted Indigenous tobacco control funding, 2014-2017; - a clinical audit to identify and provide recommendations to improve the pathways available to help identified smokers quit, in six Aboriginal Community Controlled Health Services in Queensland 2017; - an evaluation of the Royal Flying Doctors Service Monitoring System for an obesity-prevention program, the Healthy Living program, delivered in remote communities in South Australia 2007-2016; and, - an outbreak investigation of gastroenteritis following Melbourne Cup luncheons in the Canberra, November 2016. In all but one study, I examined data availability, collection and analysis to support program evaluations. Although, Australian national survey data for the Aboriginal and Torres Strait Islander population are the most comprehensive source on health risk behaviours, the data’s utility for evaluating regional program level activities and campaigns is challenged by small sizes and data restrictions. In my study of regional smoking prevalence, I noted that wide confidence intervals meant that changes over time at a regional level could not be detected. Further, cross sectional analysis is restricted to comparing changes in sub-populations, jurisdictions or regions over time rather than an analysis of changes in individuals over time. As such, these analyses do not allow the attribution of exposures, including exploring what program specific activities and campaigns lead to changes. In response to the national data limitations, managers and implementers of individual programs are opting to develop their own studies, monitoring and evaluation systems. In my pre- and post- study of smokers in Central Australia, I observed improvements in participants’ knowledge of smoking health risks and increased numbers of ex-smokers. I have recommended that next phase of Australian Government’s Tackling Indigenous Smoking evaluation needs to better examine which program specific exposures in tobacco control led to: the de-normalisation of tobacco use in communities; increased quit attempts; reduced uptake of smoking; and, the overall declines in smoking prevalence. I also examined the RFDS Monitoring System, a program monitoring system established to track changes in participants due to community-based health promotion activities. Local surveys/sentinel surveillance and program monitoring can help to improve program reporting and evaluations, is responsive to local data requests and builds health service capabilities. However, the system for ongoing data collection at an individual program level can also be compromised because of lack of comparability across sites/activities, limited budget, inadequate definitions of sampling frames, lack of standard operating procedures for data collection and the onus on nontechnical staff to analyse data. Australia needs an enhanced data collection system for preventive health that supports both local and regional data needs, while remaining comparable at a national level.

Research Doctorate - Doctor of Philosophy (PhD)
Aboriginal and Torres Strait Islander people, hereinafter respectfully referred to as Aboriginal people, a have a rich heritage and diverse cultures. They have a strong connection to their community and country. However, Aboriginal people have suffered long-lasting effects from colonisation, dispossession of land and racism with devasting impacts, particularly for health outcomes. In Australia, Aboriginal people have up to three-fold higher rates of chronic disease compared to non-Aboriginal people. Given the high risk of frequent avoidable admissions and unplanned hospital readmissions for people with chronic diseases, it is not surprising that Aboriginal people also have higher rates of these types of hospitalisations compared to non-Aboriginal people. High rates of avoidable admissions and unplanned readmissions reflect sub-optimal community healthcare and poor hospital care. However, little research has explored these types of potentially unnecessary hospitalisations for Aboriginal people with chronic disease in Australia’s most populous state of New South Wales (NSW). This thesis explores frequent avoidable admissions and unplanned readmissions among Aboriginal people by focusing on three key aims. The first was to examine the prevalence and trends of frequent avoidable admissions and unplanned readmissions of Aboriginal and non-Aboriginal people residing in NSW, utilising linked hospital administrative data. International research examining the factors associated with unplanned readmissions in general populations indicate the importance of factors such as chronic disease management, a regular general practitioner, good health literacy and medication adherence. Therefore, the second aim of this thesis was to identify perceptions of Aboriginal people regarding potential contributors to chronic-disease-related unplanned readmissions. In-depth interviews were conducted with a sample of Aboriginal people who had been readmitted to hospital. Telephone follow-up has been used alongside other intervention components, such as tailored discharge planning and patient education, with the aim of reducing unplanned readmissions in surgical and general medicine patients. The final aim of this thesis was to examine the potential impact of telephone follow-up in reducing unplanned readmissions rates for patients with chronic disease. This involved a systematic review of the research literature on the impact of telephone follow-up, and an evaluation of a program utilising telephone follow-up for Aboriginal people. The implications of the findings of this work are discussed in relation to hospital and community health service practices and state-wide data monitoring. Further explorative research and a community-led multicomponent telephone follow-up enhancement intervention are proposed.

This thesis presents a collection of applied epidemiological studies within an Aboriginal and Torres Strait Islander social, health and well-being context. I have applied mixed method approaches to epidemiological knowledge and methods to meet the required Masters of Philosophy in Applied Epidemiology (MAE) competencies. A social and cultural determinants of health framing was applied to the evaluation of a social health program, epidemiological study and data analysis study. Field work was undertaken with Aboriginal communities in the evaluation, epidemiological study and outbreak investigation and were underpinned by community engagement and community based participatory research models. The studies include: 1. Cross-sectional analysis of data from the Footprints in Time: Longitudinal Study of Indigenous Children (LSIC). The study explores the prevalence of community leadership aspirations and other future aspirations for children aged 9 to 12 years participating in Wave 8 of the LSIC study. Descriptive and analytical analyses were included to examine the association between leadership aspirations and key demographic factors: age, sex and remoteness. Additionally, I explored other self-reported aspirations for children with community leadership aspirations to further unpack leadership from a holistic perspective. I applied qualitative inquiry with LSIC key informants to contextualise the findings. An important feature of the study includes comparisons being made within an Aboriginal and Torres Strait Islander cohort, as opposed to comparisons between Indigenous and non-Indigenous people; 2. Outbreak investigation of mumps in an Aboriginal community in Queensland (Qld). The outbreak investigation took place in Yarrabah, March 2018 and was in partnership with Gurriny Yealamucka Health Service Aboriginal Corporation. The study included field epidemiology, advocacy and community engagement models of practice. Building relationships with the Aboriginal Health Workers (AHWs) was key to the study. The AHWs contributed to adaptation of a public health questionnaire and facilitated cultural brokerage between myself and the community to administer the follow-up questionnaire. I identified gaps between public health and primary health care practice and recommended practical strategies to help strength the relationship; and 3. Process evaluation of a Commonwealth funded program, Stronger Communities for Children (SCfC) was undertaken with a remote community in the Northern Territory, January to June 2018. A partnership between the ANU, Palngun Wurnangat Aboriginal Corporation, Kardu Lurruth Ngala Purrungime committee and community members guided the study. An epidemiological study was a component of the evaluation and included administering an adjusted survey instrument to collect data from the SCfC participants on cultural participation. Building community relationships was key and required a number of field visits to the community where I facilitated workshops with the main stakeholders to ensure community voice remained at the center of the study. Community input directed the study design, adaptation of the survey instrument, and development of the logic model and community researcher manual.

Aboriginal and Torres Strait Islander people are the first people of Australia. Consequences of colonisation and ongoing societal marginalisation and racism has led to significant health and wellbeing impacts on this population. Aboriginal and Torres Strait Islander people view health through a Social and Emotional Wellbeing (SEWB) framework. There are currently no measures of SEWB, with proxy measures used instead. The Kessler Psychological Distress Scale is a measure of psychological distress often used as a proxy for measuring SEWB. This thesis uses mixed-methods and best-practice approach to assess the reliability and validity of the culturally-modified, 5-item Kessler Psychological Distress Scale (K5) in the Aboriginal and Torres Strait Islander population. The results of this study found good internal consistency, construct validity, convergent validity, and divergent validity. The K5 was also found to have good clinical utility in indicating depressive and anxiety disorders at a cut-off of 10. Assessment of K5 face validity indicates that the measure achieved face validity for psychological distress but fails to accurately measure SEWB. Thus, the K5 is a valid measure of psychological distress for Aboriginal and Torres Strait Islander people, but the measure fails as a measure of SEWB.

Background: A randomised control trial (RCT) was conducted in the Torres Strait and Northern Peninsula Area (NPA) Health Service District (HSD) during the period 1998-2000. The main intervention strategy for this trial was the introduction of a simple recall/patient reminder system in Primary Health Care Centres (PHCCs) in an attempt to improve the organisation and management of diabetes care. After a twelve-month period, there was a significant reduction (40 per cent) in the number of patients admitted in the intervention sites between baseline and followup. However, as hospitalisation data was derived from the PHC clinic records, it has been suggested that this methodology may have underestimated both the number of patients and hospital episodes captured in the RCT study population.

Aim: To conduct a retrospective re-evaluation study of the hospitalisation component of the original RCT in an attempt to better assess the impact of the clinic recall system for patients with diabetes in the Torres Strait and NPA, 1998-2000. All patients from the RCT were to be tracked manually through three local public hospitals for hospitalisation episodes in a bid to validate the total number of admissions for these Torres Strait Islanders (TSIs) with diabetes.

Methods and Subjects: Subjects included all those patients suffering with diabetes living in the Tones Strait and NPA whose PHC records had been audited during the original RCT. Instead of using PHC clinic patient files, hospital -based patient information systems were used (as a different data source) in order to validate the number of admissions for each individual from the trial. Analysis of the data used the same methodology as the RCT (that is, communities were clustered into intervention and control sites) in order to interpret results in terms of whether or not the implementation of a recall system in the intervention sites had any impact on the hospitalisation rates of patients with diabetes in the Torres Strait.

Results: In comparison with the RCT, the new hospitalisation study found some degree of underestimation in the number of patients identified as having hospitalisations and secondly, considerable underestimation in terms of the number of hospital episodes found. At baseline, the hospital -checking methodologyidentified one extra person and 102 additional episodes of care. At followup, this new methodology found an extra 30 persons and an additional 119 episodes of care. In comparison to the RCT, the new study showed an overall 6.7 per cent increase in the number of individual patients detected having had an admission in the study period. However, there was a large 47.1 per cent increase in extra hospital episodes detected across both audit timeframes.

Discussion: This study supports the main findings of the original RCT. That is, the new study also found a reduction in the proportion of patients hospitalised for any kind of `diabetes -related condition' in the intervention sites between baseline and followup. This reduction was slightly less at 29 per cent in the intervention sites (compared to 40 per cent in RCT across intervention sites) for 'total diabetes -related conditions,' however this new study finding was not statistically significant. The re-evaluation study also found that at followup, those in the intervention sites were 19 per cent significantly less likely to be hospitalised for a diabetes -related condition than those in the control sites (compared with a significant 40 per cent in the RCT). Therefore, admissions for diabetes -related conditions can be reduced or avoided through better organisation and a systematic approach to the management of PHCCs. Although hospital -based information systems may have been more sensitive in detecting patients with hospitalisation episodes and additional episodes for known patients, the tracking of individuals through the public hospital system (without a unique identifier) was problematic and time consuming.

Conclusion: The main aim of the RCT was to improve the organisation and management of PHC in the Tones Strait, in terms of clinical management for the large number of diabetic clients that are served. The original RCT findings suggested that improvements in diabetes care in the intervention sites such as the introduction of a patient recall system was successful in reducing the numbers of patients subsequently admitted to hospital. The re-evaluation study of hospitalisations using a different methodology has also been successful in recording a reduction in the number of people with diabetes being hospitalised from the intervention sites despite a 47 per cent increase in the number of hospital episodes being detected overall.

Research Doctorate - Doctor of Philosophy (PhD)
Globally, tobacco use is the leading cause of morbidity and mortality, causing an annual death rate of seven million people. In Australia, tobacco use is responsible for 9% of the total burden of disease. Smoking during pregnancy remains a significant public health problem for specific population groups, causing miscarriage, stillbirth, low birth weight and more. Psychosocial interventions such as behavioural counselling have been shown to be effective. Clinical guidelines in Australia recommend using the 5As approach: Ask about smoking status, Advise briefly to quit, Assess nicotine dependence and motivation to quit, Assist as needed (including behavioural counselling and nicotine replacement therapy [NRT] if required), and Arrange follow-up and referral to smoking cessation support services. NRT is recommended if the woman is unable to quit using only behavioural counselling, with oral NRT considered as first line. Aboriginal and Torres Strait Islander pregnant women have the highest smoking rates in Australia at 43%, facing multiple barriers to quitting smoking, including lack of adequate support from health providers. Health providers also face many barriers to support pregnant women to quit smoking, on an individual and systematic organisational level. To date, very few interventions have tried to improve health providers’ management of smoking with Aboriginal and Torres Strait Islander pregnant women. Those that have either did not use rigorous research methods or suffered from multiple implementation challenges. The aim of this thesis was to explore health providers’ practices regarding smoking cessation care during pregnancy, barriers to the provision of smoking cessation care and methods for improving health providers’ care, and to test an evidence-based behaviour change intervention to improve health providers’ provision of smoking cessation care to pregnant Aboriginal and Torres Strait Islander women. Papers one to five explore health providers’ provision of smoking cessation care during pregnancy in general. Some data for Aboriginal and Torres Strait Islander pregnant women who smoke is also presented. The results of the first five studies were used to refine the development of a multi-component pilot intervention: the Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy intervention for implementation in Aboriginal medical services. Papers six to eight explore the development of the intervention resources, the intervention protocol and the effect of this intervention on health providers’ smoking cessation care. Three related theoretical frameworks were drawn on throughout the research: the Theoretical Domains Framework (TDF), Behaviour Change Wheel (BCW) and the COM-B (Capability, Opportunity, Motivation–Behaviour) model for behaviour change. Paper one, “Opportunities Missed: A Cross-Sectional Survey of the Provision of Smoking Cessation Care to Pregnant Women by Australian General Practitioners and Obstetricians”, presents the results of a national cross-sectional survey of 378 general practitioners (GPs) and obstetricians about their knowledge, attitudes and practices providing smoking cessation care to pregnant women. Data from this survey revealed low levels of provision of several smoking cessation care components (“Assess”, “Assist” and “Arrange”), with only 15.6% of GPs and obstetricians reporting “often and/or always” performing all of the recommended 5As. Specifically, GPs and obstetricians reported that they lacked time, resources and confidence in their ability to prescribe NRT during pregnancy, and lacked optimism that their intervention would be effective. Paper two, “Clinician Factors Associated with Prescribing Nicotine Replacement Therapy in Pregnancy: A Cross-Sectional Survey of Australian Obstetricians and General Practitioners”, reports the results from the same cross-sectional survey mentioned in paper one, exploring GPs’ and obstetricians’ NRT prescribing rates and factors that might influence this. Overall, 25% of GPs and obstetricians reported “never” prescribing NRT, with nearly 50% reporting they would “never” prescribe combination NRT (NRT patch plus an oral NRT). GPs had higher odds of prescribing NRT compared to obstetricians. Other factors that significantly increased the odds of NRT prescription were reading the Royal Australian College of General Practitioners (RACGP) guidelines, confidence in their ability to prescribe NRT and viewing NRT as safe, effective and with good patient adherence. Paper three, “Overcoming Challenges to Treating Smoking during Pregnancy – A Qualitative Analysis of Australian General Practitioners’ Barriers and Facilitators”, reports on semi-structured qualitative interviews that were conducted with 19 GPs, aiming to explore their management of smoking during pregnancy in greater depth and what would enable them to improve their smoking cessation support to pregnant women. GPs were recruited from the cross-sectional survey participants and from those attending a national GP conference. Participants reported they lacked communication skills to provide pregnant patients adequate support for quitting, focusing on providing information on smoking harms and discussing treatment options only with patients who reported an interest in quitting. Lack of time, NRT cost, previous negative experiences with NRT and safety concerns, being unfamiliar with the Quitline process and uncertainty over its suitability (specifically for Aboriginal and Torres Strait Islander peoples) were all perceived as additional challenges. Participants reported needing clear detailed guidelines, with visual resources they could use to discuss treatment options with patients. Paper four, “Nicotine Replacement Therapy for Smoking Cessation in Pregnancy – A Narrative Review”, provides an overview of the current guidelines regarding NRT use in pregnancy, while considering the existing evidence base on NRT safety, efficacy and effectiveness during pregnancy. Animal models show that nicotine is harmful to the foetus, especially for brain and lung development, but human studies have not found any harmful effects on foetal and pregnancy outcomes. Previous studies have used NRT doses that might have been too low and not have adequately accounted for the higher nicotine metabolism during pregnancy, and thus not sufficiently treating withdrawal symptoms. Nonetheless, studies of efficacy and effectiveness in the real world suggest that NRT use during pregnancy increases smoking cessation rates. Current national clinical guidelines from Australia, the United Kingdom, New Zealand and Canada recommend that if women are unable to quit smoking with behavioural interventions alone, they should be offered NRT in addition to behavioural counselling. The guidelines also impose many restrictions on NRT prescription during pregnancy and do not provide practical detailed guidance on when to initiate NRT and how to titrate the dosage. Pragmatic suggestions for clinical practice are made, including an approach for initiating and titrating NRT dosage during pregnancy and for discussing the risks versus benefits of using NRT in pregnancy with the pregnant patient and her partner. Paper five, “Improving Health Providers’ Smoking Cessation Care in Pregnancy: A Systematic Review and Meta-Analysis”, reviews the data from all published interventions aimed to improve health providers’ smoking cessation care during pregnancy. To be included, the intervention studies needed to collect data on the health providers’ performance. Overall, 16 studies describing 14 interventions were included – 10 used a quasi-experimental design (pre–post), with only six studies using a randomised controlled trial (RCT) design. Using the Cochrane Effective Practice of Care (EPOC) taxonomy of intervention components, the review found that the median number of intervention components reported by studies was two (range 1–6). The most common intervention components used were training (93%, n=13), educational resources (64%, n=9) and reminders (57%, n=8). Studies used a variety of outcome measures, with different data collection methods (such as self-report through survey, women’s report on the health providers’ care, audit of medical records or recordings of medical consultations), affecting the ability to synthesise the data. Specifically, the “Assist” or “Provide smoking cessation support” component of care was ill defined with vast variability between studies. Meta-analysis of the different smoking cessation care components (according to the 5As) showed a small significant increase in the provision of all smoking cessation care components. The review suggests that use of a behaviour change theory to guide intervention development, and inclusion of audit and feedback, increases the likelihood of intervention effectiveness in improving health providers’ provision of certain smoking cessation care components. Paper six, “Assessing and Validating an Educational Resource Package for Health Professionals to Improve Smoking Cessation Care in Aboriginal and Torres Strait Islander Pregnant Women”, describes a multi-centre community-based participatory research study. This study aimed to assess a collaboratively developed educational resource package to aid health providers’ smoking cessation care in pregnant Aboriginal and Torres Strait Islander women. A panel of eight experts with complementary expertise provided input and suggestions to aid simplicity and usefulness of the resources. Staff members from three Aboriginal medical services in New South Wales (NSW), Queensland (Qld) and South Australia (SA) scored each of the patients’ resources using the “Suitability of Material” scoring method, finding that all received adequate or superior scoring. Average readability was grade 6.4 for patient resources (range 5.1–7.2; equivalent to ages 10–13 years) and 9.8 for health provider resources (range 8.5–10.6; equivalent to ages 13–16 years). Content analysis from focus groups with health providers from the three Aboriginal medical services revealed four themes including “Getting the message right”, “Engaging with family”, “Needing visual aids” and “Requiring practicality under a tight timeframe”. Results were presented back to a Stakeholder and Consumer Aboriginal Advisory Panel (SCAAP), and resources were adjusted accordingly for inclusion in the ICAN QUIT in Pregnancy multi-component intervention. Paper seven, “The Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy Pilot Study Protocol: A Feasibility Step-Wedge Cluster Randomized Trial to Improve Health Providers’ Management of Smoking during Pregnancy”, describes the protocol of a step-wedge cluster randomised pilot study: the ICAN QUIT in Pregnancy intervention. This protocol described an intervention aiming to improve health providers’ provision of evidence-based, culturally responsive smoking cessation care to pregnant Aboriginal and Torres Strait Islander smokers. Six Aboriginal medical services were randomised into three clusters for implementation. Clusters received the intervention staggered by one month. The intervention included a three-hour training webinar for health providers, educational resource packages for health providers and pregnant women, free oral NRT for pregnant women and audit and feedback on health providers’ performance. Health providers would complete a cross-sectional survey pre training and post training. Health providers’ outcomes would include changes in self-reported knowledge, attitudes and practices after receiving the intervention. Paper eight, “Improving Smoking Cessation Care in Pregnancy at Aboriginal Medical Services: ICAN QUIT in Pregnancy Step-Wedge Cluster Randomized Pilot Study”, presents the pilot study outcomes of changes in health providers’ knowledge, attitudes and practices. Of 93 eligible health providers, 50 consented to the trial (54%), 45 completed the pre-intervention survey (90%) and 20 completed the post-intervention survey (40%). About 42% (n=39) of health providers participated in the webinar training. Health providers’ knowledge was measured using two composite scores – one calculated using all 24 true/false statements and the other derived from 12 NRT-specific statements. Mean knowledge composite scores improved significantly from pre to post (78% vs 84% correct, p=0.011). The mean NRT-specific knowledge composite score also improved significantly (68% vs 79% correct, p=0.004). Self-assessment of 24 attitudes to providing smoking cessation care was measured using a 5-point Likert scale (Strongly Disagree to Strongly Agree). Two composite mean scores were calculated –one for 15 general smoking cessation care attitudes and the other for seven NRT-specific attitudes. The mean attitude composite score improved significantly (3.65 [SD 0.4] to 3.87 [SD 0.4]; p=0.017). The mean NRT-specific attitudes composite score also improved significantly (3.37 [SD 0.6] to 3.64 [SD 0.7]; p=0.005). Self-reported provision of smoking cessation care components was measured on a 5-point Likert scale (Never to Always); none of the practices improved significantly, including the prescribing of NRT. In summary, increasing health providers’ provision of smoking cessation care to pregnant Aboriginal and Torres Strait Islander women is a significant priority in Australia. This body of work highlights that currently, health providers are lacking in their provision of smoking cessation care, specifically in their support for pregnant Aboriginal and Torres Strait Islander women to quit smoking. Particularly, the provision of the “Assist” smoking cessation component was low, including the prescription of NRT. Multiple barriers exist and include lack of knowledge, skills (especially communication skills), time, resources and lack of optimism. Guidelines do not provide clear guidance, including the optimal timing for initiating NRT and titrating the dosage. The pilot intervention tested within this thesis showed promising initial results, with health providers significantly improving their knowledge and attitudes, although this did not translate into improved practices. Several strategies might enhance the effectiveness of the intervention and should be tested in a larger and adequately powered trial. The complex nature of tobacco smoking, and considering its historical and social context in Aboriginal communities, suggests that wider and more intensive interventions are needed.

Research Doctorate - Doctor of Philosophy (PhD)
Aboriginal and Torres Strait Islander Australians have a substantially lower life expectancy and greater burden of chronic disease than their non-Indigenous Australian counterparts. The current health status of Indigenous Australians can be linked to a history of colonization and dispossession, as well as to past and ongoing racism and discrimination. While acknowledging the need to address such broader social determinants of health, there is also significant potential to improve the health of Aboriginal and Torres Strait Islander Australians through reducing the disproportionate prevalence of key health risk behaviours among this population, such as smoking, poor diet, excess alcohol and physical inactivity. Primary care is an important setting for the delivery of preventive health care, and Aboriginal Community Controlled Health Services (ACCHSs) are well placed to provide primary care for Aboriginal communities. A range of preventive care interventions have shown success in modifying health risk behaviours in non-Indigenous healthcare settings. However, such strategies are not well tested in Aboriginal health. Therefore this thesis aimed to explore the acceptability of strategies including point-of-care screening, and the provision of patient feedback, in the ACCHS setting. The need for primary care to address ‘lifestyles’ or patterns of interrelated health risks is also being increasingly recognized. In order to inform the provision of more holistic preventive care, this thesis also explored the clustering patterns of key health risk behaviours among ACCHS clients. Patient preferences for addressing their health risks, including whether health risks should be addressed individually, sequentially or simultaneously, and the types of support that would be most helpful, were examined. Implications of the results of these studies for the delivery of appropriate and effective primary care for Aboriginal and Torres Strait Islander Australians are discussed. Based on these findings and drawing on the existing literature, a multi-component, community-based intervention aimed at reducing multiple health risk behaviours is also proposed.