Reproducing injustice? : the roles of social institutions and policy actors in the persistence of inequalities in Aboriginal and Torres Strait Islander life expectancy

Using critical realism as a philosophy and methodology, this thesis seeks to identify underlying social structures, powers and mechanisms that could contribute to the persistence of inequality in the average life expectancy at birth between Aboriginal and Torres Strait Islander peoples and the non-Indigenous population of Australia in the 21st century. In 2018 Australians were among the world’s longest-lived populations. However, the gap in life expectancy at birth between Indigenous and non-Indigenous Australians is ten years (Australian Institute of Health and Welfare, 2018b, p. 29). Social determinants are estimated to be responsible for more than one third (34%) of the gap, health behavioural risk factors are estimated to account for about one-fifth of the health gap, but almost half the gap (47%) is due to unexplained factors (Australian Institute of Health and Welfare, 2018b, p. 32). This is from the ‘in brief Australia’s Health). I begin this thesis with a discussion of ontology and epistemology in order to set the scene for the methods of investigation I adopt. I outline the critical realist method that I adopted in the thesis, based on a six-step framework developed by Bendik Bygstad and Bjørn Erik Munkvold (Bygstad & Munkvold, 2011, p. 5). I then draw on epidemiological and routine administrative data to describe a social phenomenon in the empirical domain – inequalities in the average life expectancy at birth, in health, and in access to social determinants of health between the Indigenous and non-Indigenous Australian populations. Analysis reveals a pattern of statistical regularity – the inequalities are systematic across all the indicators. They have persisted despite the Indigenous and non-Indigenous populations living in the same country, under the same constitution and under the same governments. Contemporary theoretical explanations of determinants of inequalities in the health of populations do not wholly explain reasons for their persistence. They do not identify mechanisms available to people and institutions with political and social power and privilege that are being activated to perpetuate inequalities across generations. I select all public policies (taken together) through which Australia has been governed as events in the actual domain that have contributed to the persistence of the systematic patterns of inequalities reported in the empirical domain. I identify key components of the events that are generalisable across them all. I conduct a critical realist review of transdisciplinary literature. Through the process of abstraction, I develop a theoretical framework of generative mechanisms and structures that could plausibly explain how the events contribute to the persistence of the systematic patterns of inequality described in the empirical domain. From theoretical perspectives on institutionalism, social justice, racism, colonialism, and power I identify candidate mechanisms in the real domain. I assess (and confirm) through an interview study that the mechanisms could be practically adequate indicators of underlying powers being activated by contemporary policy actors to influence public policy decisions (events); and that the contribution of the mechanisms to explanations of the events (and outcomes) could be validated in future research. Social institutions both enable and constrain the formulation of public policies. The worldviews of policy actors shape policy decisions and reproduce or transform the institutions. All policy ideas are filtered through the institutions and actors that have power to govern. The subordinate value ascribed by the colonisers to Indigenous Australian peoples and cultures was used to exclude them from access to power and authority to govern, and from participation as peers in society. The injustices became institutionalised in law, policies and professional practice and normalised in the worldview of the citizenry. Despite some positive progress over time, the hard fact of the inequality in life expectancy that has persisted into the 21st century cannot be ignored. Indigenous peoples have used all possible avenues available to them to resist and reverse injustices and to create positive change – sources of injustice or barriers to change are already clear to them. This research instead seeks to expose underlying mechanisms through which social institutions and policy actors with power and authority to govern perpetuate injustices of the past. The exposed mechanisms are avenues through which to reverse the injustices - working authentically with Indigenous peoples and nations, by sharing power and authority to govern, by achieving representative and cultural justice in all policy spaces. Meeting Indigenous Australians’ demands for power to co-create the policy table, to determine socially just public policies, and to co-create Australia’s future is not only a moral obligation – it is necessary to life itself

National appraisal of continuous quality improvement initiatives in Aboriginal and Torres Strait Islander primary health care: final report

There has been a substantial increase in interest in continuous quality improvement (CQI) efforts in the Australian primary health care arena over the past several years, including in the Indigenous primary health care sector. This interest has promoted increased financial incentives (e.g. to achieve accreditation and/or complete specific services such as health checks), attention to developing performance indicators, and moves to rationalise reporting requirements using web-based information technology.This project: reviewed current efforts and directions in light of recent and emerging national, regional and local CQI initiatives and major strategic directions relevant to Indigenous primary health care, and identified potential actions to progress further development of CQI initiatives over the next decade, taking into account strengths, weaknesses, opportunities and priorities. Authored by Associate Professor Marilyn Wise, Ms Sandra Angus, Dr Elizabeth Harris and Ms Sharon Parker

Exploring Clinical Risk Factors for Breast Cancer among American Indian Women

Objective: Very little is known about the breast cancer risk profile among American Indian women. Previous research shows that the proportion of American Indian/Alaska Native women with baseline characteristics (commonly known breast cancer risk factors) differs from other ethnicities. This retrospective case control study was designed to the explore the association of these factors among American Indian women with and without breast cancer. Methods: Cases and controls were retrospectively selected from the medical records of American Indian women who obtained their health care from Quentin N. Burdick Memorial Health Care Facility (IHS) in Belcourt, ND. For each woman with breast cancer (n=141), two controls were selected when possible (n=278). Risk factors examined included woman’s age, age at first live birth, age of menarche, the number of previous benign breast biopsies, the total number of first-degree relatives with breast cancer, body mass index and parity. Odds ratios and 95% confidence intervals were calculated using logistic regression. Results: Many of the associations found among American Indian women who obtained their health care from Quentin N. Burdick Memorial Health Care Facility (IHS) in Belcourt, ND, between risk factors commonly identified in other populations and breast cancer were weakly positive. Nulliparity was the only risk factor to consistently show a positive significant association (OR = 2.87, 95% CI 1.16-.7.12). Conclusion: Disparities in breast cancer incidence, mortality and screening among Northern Plains American Indian emphasize the need to better understand the risk factors associated with breast cancer in this population. Based on the results of this study, the value of current risk prediction models in American Indian communities is uncertain and clinicians should be cautious in using these models to inform American Indian patients of their risk for breast cancer

Enhanced Auditory Neuron Survival Following Cell-Based BDNF Treatment in the Deaf Guinea Pig

Exogenous neurotrophin delivery to the deaf cochlea can prevent deafness-induced auditory neuron degeneration, however, we have previously reported that these survival effects are rapidly lost if the treatment stops. In addition, there are concerns that current experimental techniques are not safe enough to be used clinically. Therefore, for such treatments to be clinically transferable, methods of neurotrophin treatment that are safe, biocompatible and can support long-term auditory neuron survival are necessary. Cell transplantation and gene transfer, combined with encapsulation technologies, have the potential to address these issues. This study investigated the survival-promoting effects of encapsulated BDNF over-expressing Schwann cells on auditory neurons in the deaf guinea pig. In comparison to control (empty) capsules, there was significantly greater auditory neuron survival following the cell-based BDNF treatment. Concurrent use of a cochlear implant is expected to result in even greater auditory neuron survival, and provide a clinically relevant method to support auditory neuron survival that may lead to improved speech perception and language outcomes for cochlear implant patients

Working in disadvantaged communities: What additional competencies do we need?

Background: Residents of socioeconomically disadvantaged locations are more likely to have poor health than residents of socioeconomically advantaged locations and this has been comprehensively mapped in Australian cities. These inequalities present a challenge for the public health workers based in or responsible for improving the health of people living in disadvantaged localities. The purpose of this study was to develop a generic workforce needs assessment tool and to use it to identify the competencies needed by the public health workforce to work effectively in disadvantaged communities. Methods: A two-step mixed method process was used to identify the workforce needs. In step 1 a generic workforce needs assessment tool was developed and applied in three NSW Area Health Services using focus groups, key stakeholder interviews and a staff survey. In step 2 the findings of this needs assessment process were mapped against the existing National Health Training Package (HLT07) competencies, gaps were identified, additional competencies described and modules of training developed to fill identified gaps. Results: There was a high level of agreement among the AHS staff on the nature of the problems to be addressed but less confidence indentifying the work to be done. Processes for needs assessments, community consultations and adapting mainstream programs to local needs were frequently mentioned as points of intervention. Recruiting and retaining experienced staff to work in these communities and ensuring their safety were major concerns. Workforce skill development needs were seen in two ways: higher order planning/epidemiological skills and more effective working relationships with communities and other sectors. Organisational barriers to effective practice were high levels of annual compulsory training, balancing state and national priorities with local needs and giving equal attention to the population groups that are easy to reach and to those that are difficult to engage. A number of additional competency areas were identified and three training modules developed. Conclusion: The generic workforce needs assessment tool was easy to use and interpret. It appears that the public health workforce involved in this study has a high level of understanding of the relationship between the social determinants and health. However there is a skill gap in identifying and undertaking effective intervention

Highly Pathogenic Avian Influenza Virus A (H7N3) in Domestic Poultry, Saskatchewan, Canada, 2007

Epidemiologic, serologic, and molecular phylogenetic methods were used to investigate an outbreak of highly pathogenic avian influenza on a broiler breeding farm in Saskatchewan, Canada. Results, coupled with data from influenza A virus surveillance of migratory waterfowl in Canada, implicated wild birds as the most probable source of the low pathogenicity precursor virus

Analysing NSW state policy for child obesity prevention: strategic policy versus practical action

There is increasing worldwide recognition of the need for government policies to address the recent increases in the incidence and prevalence of childhood obesity. The complexity and inter-relatedness of the determinants of obesity pose a genuine policy challenge, both scientifically and politically. This study examines the characteristics of one of the early policy responses, the NSW Government\u27s Prevention of Obesity in Children and Young People: NSW Government Action Plan 2003-2007 (GAP), as a case study, assessing it in terms of its content and capacity for implementation. This policy was designed as an initial set of practical actions spanning five government sectors. Most of the policy actions fitted with existing implementation systems within NSW government, and reflected an incremental approach to policy formulation and implementation. As a case study, the NSW Government Action Plan illustrates that childhood obesity policy development and implementation are at an early stage. This policy, while limited, may have built sufficient commitment and support to create momentum for more strategic policy in the future. A more sophisticated, comprehensive and strategic policy which can also be widely implemented and evaluated should now be built on this base

A Simplified Score to Quantify Comorbidity in COPD

Importance Comorbidities are common in COPD, but quantifying their burden is difficult. Currently there is a COPD-specific comorbidity index to predict mortality and another to predict general quality of life. We sought to develop and validate a COPD-specific comorbidity score that reflects comorbidity burden on patient-centered outcomes. Materials and Methods Using the COPDGene study (GOLD II-IV COPD), we developed comorbidity scores to describe patient-centered outcomes employing three techniques: 1) simple count, 2) weighted score, and 3) weighted score based upon statistical selection procedure. We tested associations, area under the Curve (AUC) and calibration statistics to validate scores internally with outcomes of respiratory disease-specific quality of life (St. George's Respiratory Questionnaire, SGRQ), six minute walk distance (6MWD), modified Medical Research Council (mMRC) dyspnea score and exacerbation risk, ultimately choosing one score for external validation in SPIROMICS. Results Associations between comorbidities and all outcomes were comparable across the three scores. All scores added predictive ability to models including age, gender, race, current smoking status, pack-years smoked and FEV1 (p<0.001 for all comparisons). Area under the curve (AUC) was similar between all three scores across outcomes: SGRQ (range 0·7624–0·7676), MMRC (0·7590–0·7644), 6MWD (0·7531–0·7560) and exacerbation risk (0·6831–0·6919). Because of similar performance, the comorbidity count was used for external validation. In the SPIROMICS cohort, the comorbidity count performed well to predict SGRQ (AUC 0·7891), MMRC (AUC 0·7611), 6MWD (AUC 0·7086), and exacerbation risk (AUC 0·7341). Conclusions Quantifying comorbidity provides a more thorough understanding of the risk for patient-centered outcomes in COPD. A comorbidity count performs well to quantify comorbidity in a diverse population with COPD

In what ways does the mandatory nature of Victoria's municipal public health planning framework impact on the planning process and outcomes?

BACKGROUND: Systems for planning are a critical component of the infrastructure for public health. Both in Australia and internationally there is growing interest in how planning processes might best be strengthened to improve health outcomes for communities. In Australia the delivery of public health varies across states, and mandated municipal public health planning is being introduced or considered in a number of jurisdictions. In 1988 the Victorian State government enacted legislation that made it mandatory for each local government to produce a Municipal Public Health Plan, offering us a 20-year experience to consider. RESULTS: In-depth interviews were undertaken with those involved in public health planning at the local government level, as part of a larger study on local public health infrastructure and capacity. From these interviews four significant themes emerge. Firstly, there is general agreement that the Victorian framework of mandatory public health planning has led to improvements in systems for planning. However, there is some debate about the degree of that improvement. Secondly, there is considerable variation in the way in which councils approach planning and the priority they attach to the process. Thirdly, there is concern that the focus is on producing a plan rather than on implementing the plan. Finally, some tension over priorities is evident. Those responsible for developing Municipal Public Health Plans express frustration over the difficulty of having issues they believe are important addressed through the MPHP process. CONCLUSION: There are criticisms of Victoria's system for public health planning at the local government level. Some of these issues may be specific to the arrangement in Victoria, others are problems encountered in public health planning generally. In Victoria where the delivery structure for public health is diverse, a system of mandatory planning has created a minimum standard. The implementation of the framework was slow and factors in the broader political environment had a significant impact. Work done in recent years to support the process appears to have led to improvements. There are lessons for other states as they embark upon mandated public health plans