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Fighting for health equity: Aboriginal Community Controlled Health Services in a challenging policy context(2019) Coombs, DavidThesisThis thesis explores the critically important work of Aboriginal Community Controlled Health Services (ACCHS) in New South Wales, Australia. It works from the premise that ACCHS enable Aboriginal self-determination in health. It evaluates the policies and practices of government agencies and non-Indigenous health actors, assessing the degree to which they facilitate or constrain ACCHS in this task. A critical evaluation of the policy context in which ACCHS operate is provided, analysing the political intent and community impact of recent reforms. Making use of political economic theories of settler-colonial domination and neoliberal governance, and policy theories that explain how and why governments deploy symbols and moral language for political purposes, an original explanation of the neo-paternalist market-fundamentalist turn in Indigenous affairs policymaking is presented. Drawing on new evidence gathered through interviews with ACCHS CEOs and managers, the thesis presents an account of ACCHS’ unique role in the health system. It offers a nuanced explanation of First Nations peoples’ health inequities, constructed from interviewees’ theoretical insights and relevant scholarly literature. A key research output is the detailed description and modelling of the ACCHS holistic approach to Aboriginal healthcare. This expands our understanding of what ACCHS do, how they do it, and why it is effective. This examination of the ACCHS model of care is of relevance to all healthcare providers in Australia, as it provides practical examples of how to operationalise the social elements of primary healthcare, such as community participation in service design, and the development and delivery of culturally safe health promotion and education activities. This body of work also identifies and critically analyses the key policy challenges that impede the effective and efficient delivery of services by ACCHS in New South Wales. Key challenges identified include funding shortfalls and restrictions, and severe power imbalances between government actors and “mainstream” health actors, on one side, and ACCHS on the other. An extensive list of practicable policy solutions has been developed, making this thesis a valuable and viable source of guidance for policymakers and professionals working in Indigenous health service delivery.
(2023) Wu, YuThesisThe aim of this thesis is to review and statistically synthesize the state of research on the relationship between customer mistreatment and service employees’ affective and behavioral outcomes and to examine the spillover and spiraling mechanisms of resource losses. In study 1, I included 93 effect sizes of 80 independent samples from 70 primary studies (N = 24,708). I used a meta-analytic approach to conduct a quantitative review of the relationship between customer mistreatment and service employees’ affective and behavioral outcomes. Meta-regression was applied to explore the impact of contextual- level moderators (i.e., service provider type, mean sample age, percentage of female employees) on these relationships. Furthermore, I compared the effects of customer mistreatment with the effects of other work-related stressors (i.e., challenge-related stressors and hindrance-related stressors). The results show that customer mistreatment has a significant negative impact on service employees’ affective outcomes (i.e., reduced job satisfaction, reduced organizational commitment, and increased stress) and behavioral outcomes (i.e., increased emotional labor, increased surface acting, increased turnover intention, and increased work withdrawal). Additionally, the relationship between customer mistreatment and service employees’ organizational commitment is influenced by a contextual-level moderator (i.e., service provider type). Furthermore, the meta-analysis results show that the effect sizes between customer mistreatment and employee outcomes ranged from moderately small to moderately large. In study 2, adopting a dynamic perspective of resource loss, I examined the spillover mechanism between employees’ emotional exhaustion in the evening and their negative emotions the next morning. Moreover, I tested the spiraling mechanism from service employees’ emotional exhaustion the previous evening to their emotional exhaustion the next evening. The results show that the impact of customer mistreatment on employees’ evening emotional exhaustion spills over to the next day, which leads them to feel negative emotions in the morning. Furthermore, the impact of customer mistreatment on employees’ evening emotional exhaustion triggers their emotional exhaustion spirals, and their evening emotional exhaustion leads to more emotional exhaustion the next evening. The theoretical and practical implications of these findings are discussed.
(2022) Okuba, TolesaThesisChild growth failure (CGF) is associated with high morbidity which can predispose children to impaired cognitive development. Despite decades of interventions, a high level of CGF has persisted in Ethiopia. A likely key reason for this situation is the undetermined role of water, sanitation, and hygiene (WASH) on child growth. The overarching aim of this thesis was to examine the effects of WASH on child growth in Ethiopia. Data were extensively analysed from the Ethiopia Demographic and Health Survey (EDHS) from 2000 to 2016, and a systematic review was conducted for the thesis. Logistic regression models were fitted to assess the association of access to household WASH facilities with child growth outcomes. We conducted a systematic review and meta-analysis of WASH interventions, separately, and when combined with nutrition. To estimate trends of CGF, we used adjusted margins of predicted probabilities. Socioeconomic inequalities in CGF were estimated using a concentration curve and indices. Children with access to improved household WASH facilities were 33% less likely to have stunting. Non-randomized controlled trial studies (non-RCTs) showed an effect of WASH interventions alone on height-for-age (HAZ) (Mean difference (MD)= 0.14; 95% CI: 0.08 to 0.21) while RCTs did not. WASH alone of non-RCTs and RCTs that were delivered over 18 to 60 months indicated an effect on HAZ (MD = 0.04; 95% CI: 0.01 to 0.08). RCTs showed an effect on children < 2 years (MD = 0.07; 95% CI: 0.01 to 0.13). WASH combined with nutrition showed an effect on HAZ compared with no intervention (MD = 0.13; 95% CI: 0.08 to 0.17) and on weight-for-age (WAZ) (MD = 0.09; 95% CI: 0.05 to 0.13). There was evidence of a decline in levels of CGF between 2000 and 2016 in Ethiopia. In particular, there was a greater steady decline between 2005 and 2011 compared with other periods. Access to improved household WASH facilities mainly contributed to the reduction of CGF. Between 2000 and 2016, the concentration index increased from -0.072 to -0.139 for stunting, -0.088 to -0.131 for underweight and -0.015 to -0.050 for wasting. Key socioeconomic predictors of these inequalities were identified through decomposition analyses. Socioeconomic status of the household, geographic region, antenatal care (ANC), parental education and access to household WASH facilities largely contributed to the inequalities. Access to improved household WASH facilities was strongly associated with reduced odds of stunting. WASH interventions alone improved HAZ when delivered over 18 to 60 months and in the first 1000 days of a child’s life. The effect was stronger when WASH was combined with nutrition interventions. Integrated WASH with nutrition interventions may be an effective way of improving child growth outcomes. Improving identified predictors of socioeconomic status would most likely reduce inequalities in CGF.
The Aboriginal and Torres Strait Islander cross-curriculum priority in Australia’s school curriculum: Learning from First Nations educators(2022) Nyholm, MelissaThesisThe Uluru Statement from the Heart was unanimously endorsed by 250 First Nations delegates in May 2017, culminating a year’s consultation with First Nations people around Australia (Referendum Council 2017a). The Statement calls for a First Nations Voice to Parliament, a Makarrata Commission to supervise agreement-making between governments and First Nations people and truth-telling about First Nations history. These calls for Voice, Treaty and Truth were not only made to the Australian government; the statement also seeks a response from the Australian people (Referendum Council 2017b). Aboriginal and Torres Strait Islander content was mandated in Australia’s inaugural national curriculum, announced in 2008. The national curriculum resulted from increasing global economic pressures and growing federal education influence. This thesis assesses Aboriginal and Torres Strait Islander curriculum content in the context of more recent developments in Indigenous-settler relations through the Uluru Statement: how can school curriculum contribute to self-determination, sovereignty and truth-telling? The research involved two complementary parts: analysis of selected Australian curriculum policies and conversations with First Nations educators. Poststructural analysis of the Australian goals of schooling and the Aboriginal and Torres Strait Islander cross-curriculum framework considered how curriculum policies reflect and construct Indigenous-settler relations. The second component privileged the voices of six senior First Nations educators at the forefront of integrating Indigenous knowledge and culture in school and/or tertiary curriculum and research in Indigenous Studies and other disciplines. Thematic analysis synthesises the experience and advice of these First Nations educators to provide guidance for truth-telling, self-determination and sovereignty within Aboriginal and Torres Strait Islander curriculum. The research clearly points to a need for change in Aboriginal and Torres Strait Islander curriculum development. Recommendations to support truth-telling and contribute to First Nations self-determination and sovereignty through curriculum are provided for curriculum writers and policy makers. Curriculum that tells truths about Australia’s colonised history and supports First Nations self-determination and sovereignty assists all Australian students to understand the complexities of history as well as understand and appreciate the diversity, resilience and knowledges of First Nations Peoples.
Using machine learning to understand and improve care and outcomes for patients with head and neck cancer(2023) Kotevski, DamianThesisHead and neck cancer (HNC) is a complex disease with diversity in treatment modality and survival by anatomical site of origin. There is limited knowledge of the utility of oncology information systems (OIS) for the collection and reporting of HNC data during routine clinical practice to investigate prognostic factors and predict head and neck cancer-specific survival (HNCSS). Routinely collected structured data was extracted from an OIS from seven major hospitals in Australia for patients diagnosed with HNC between 2000 and 2017 and treated with definitive radiotherapy. Deaths were obtained from the National Death Index via record linkage, and HNCSS was measured from the date of diagnosis until death from HNC. Open-source machine learning and nomogram models were used to predict HNCSS and perform multivariable analysis to identify prognostic factors. Descriptive and survival analysis was used to identify inter-hospital variation in data collection, primary radiotherapy treatment, and survival. A random sample of clinical radiation oncology documents from an OIS were anonymised using a customised open-source tool (Microsoft Presidio) to evaluate the use of unstructured information for medical research. Not all user-defined fields were routinely completed and not all hospitals relied solely on the OIS, with one hospital collecting disease information in a parallel database. However, structured information collected in a standardised way with minimal missing data during routine clinical practice in an OIS can be used to predict two-year HNCSS with high performance. Evidence of inter-hospital variation in data completeness, primary radiotherapy dose, and five-year HNCSS was detected. The presence of missing data in the OIS reduced the number of predictors for prognostic analysis and prevented exploratory analysis to explain differences in survival by hospital. Lastly, the application of the anonymisation tool on unstructured clinical information sourced from an OIS demonstrated safe and secure use for some fields and a need to improve the detection and removal of person names. Data mining techniques for unstructured data or strategies to improve structured data collection should be explored to enable the development of prediction models using more complete data, patients, and variables, followed by external validation to confirm model performance.