Understanding and valuing Aboriginal and Torres Strait Islander ways of working: Opportunities for change in health service provision to Aboriginal and Torres Strait Islander peoples

This thesis draws on an analysis of the experiences of Aboriginal and/or Torres health professionals to argue that the Australian health system is missing opportunities to create something better for Aboriginal and Torres Strait Islander health clients and health professionals. In 2018 Closing the Gap1 will be 10 years old and despite 10 years of national policy designed to close the gap on Aboriginal and Torres Strait Islander disadvantage in Australia, only one of the seven key measures remains on track to meet the goals set for 2020 (Department of the Prime Minister and Cabinet, 2017). There is an immediate need to make change in Aboriginal and Torres Strait Islander health through changes in national policy, systems and practices. This thesis investigates the workplace experiences of Aboriginal and Torres Strait Islander health professionals working in mainstream and in community controlled health services in the Australian Aboriginal and Torres Strait Islander health sector. I have explored this from an Australian Aboriginal (Koori) perspective that was informed by Indigenous2 theories including decolonisation, Cultural Interface and Indigenous Standpoint Theories. As a Koori scholar undertaking doctoral research in a Western academy I respected and upheld both my cultural and my Western academic ethics and requirements: Yarns, including my own, are central to this thesis. I have used Indigenous research methods, Yarning and PhotoYarning, the latter having been developed as a new Indigenous research method by me within this doctoral study. Fifteen Aboriginal and Torres Strait Islander health workers from diverse health services across Australia contributed data. The empirical chapters highlight Aboriginal and Torres Strait Islander ways of working in Australian health services. For the Australian health sector to provide culturally safe services that meet the needs of Aboriginal and Torres Strait Islander peoples of Australia it needs to better engage with Aboriginal and Torres Strait Islander ways of being, knowing, doing and seeing

Food Insecurity in Kalamazoo

Introduction: Food insecurity is both an inconvenience and problem. As of 2013, over 16 million children in the USA were food insecure. The consequences of food insecurity include health issues from nutritional deficits, developmental difficulties, and behavioral problems that manifest in educational, personal and professional challenges. Overall, food insecurity and its impact on individuals and families is under-recognized. Additionally, the extent to which physicians play a role in helping patients secure access to food assistance programs remains unclear. Objective: The objective of this study was to assess the efficacy and methodologies of current healthcare practices based in Kalamazoo County, MI, in identifying pediatric patients who are food insecure. Results will help local assistance resources, such as Kalamazoo Loaves and Fishes, improve outreach efforts and re-focus their programs. Furthermore, results could impact physician practices regarding identifying those who are food insecure. Methods: The American Academy of Pediatrics (AAP) developed a 2-question survey with 97% sensitivity for identifying food insecurity. The questions are: Within the past 12 months, we worried whether our food would run out before we got money to buy more and Within the past 12 months, the food we bought just didn\u27t last and we didn\u27t have money to buy more. Using these questions as a foundation, we developed an electronically distributed 20-question survey that assessed awareness of food insecurity among Kalamazoo pediatric and family medicine physicians. Survey questions covered years of practice, usage of the AAP questions, level of formal training on food insecurity, mid-level and support staff, and resources recommended to patients. Results and Discussion: The 25 responses were analyzed for differences between groups. Although no significant relationships were found, 76% of respondents believed food insecurity directly related to their patient\u27s illness, though only 52% ask direct questions about food insecurity. Women, Infants and Children (WIC) program referrals were common and almost all respondents were willing to include the two AAP-validated food insecurity screening questions in their practice. A consensus emerged that a list of local resources would be helpful in addressing food insecurity. Conclusion: Kalamazoo pediatricians and family medicine physicians believe food insecurity directly relates to the problems affecting their patients. However, only half of physicians ask patients about food insecurity. Future work should focus on expanding physician-patient conversations about food insecurity, addition of validated food insecurity questions to patient questionnaires, and compiling a list of local resources for distribution to local providers

‘Joining the Dots: Linking Prenatal Drug Exposure to Childhood and Adolescence’ – Research Protocol of a Population Cohort Study

INTRODUCTION: Prenatal drug exposure (PDE) is one of the most important causes of child harm, but comprehensive information about the long-term outcomes of the families is difficult to ascertain. The METHODS AND ANALYSIS: Information from routinely collected administrative databases was linked for all births registered in New South Wales (NSW), Australia between 1 July 2001 and 31 December 2020 (n=1 834 550). Outcomes for seven mutually exclusive groups of children with varying prenatal exposure to maternal substances of addiction, including smoking, alcohol, prescription/illicit drugs and neonatal abstinence syndrome will be assessed. Key exposure measures include maternal drug use type, maternal social demographics or social determinants of health, and maternal physical and mental health comorbidities. Key outcome measures will include child mortality, academic standardised testing results, rehospitalisation and maternal survival. Data analysis will be conducted using Stata V.18.0. ETHICS AND DISSEMINATION: Approvals were obtained from the NSW Population and Health Services Research Ethics Committee (29 June 2020; 2019/ETH12716) and the Australian Capital Territory Health Human Research Ethics Committee (11 October 2021; 2021-1231, 2021-1232, 2021-1233); and the Aboriginal Health and Medical Research Council (5 July 2022; 1824/21), and all Australian educational sectors: Board of Studies (government schools), Australian Independent Schools and Catholic Education Commission (D2014/120797). Data were released to researchers in September 2022. Results will be presented in peer-reviewed academic journals and at international conferences. Collaborative efforts from similar datasets in other countries are welcome

‘Joining the Dots: Linking Prenatal Drug Exposure to Childhood and Adolescence’ – Research Protocol of a Population Cohort Study

INTRODUCTION: Prenatal drug exposure (PDE) is one of the most important causes of child harm, but comprehensive information about the long-term outcomes of the families is difficult to ascertain. The METHODS AND ANALYSIS: Information from routinely collected administrative databases was linked for all births registered in New South Wales (NSW), Australia between 1 July 2001 and 31 December 2020 (n=1 834 550). Outcomes for seven mutually exclusive groups of children with varying prenatal exposure to maternal substances of addiction, including smoking, alcohol, prescription/illicit drugs and neonatal abstinence syndrome will be assessed. Key exposure measures include maternal drug use type, maternal social demographics or social determinants of health, and maternal physical and mental health comorbidities. Key outcome measures will include child mortality, academic standardised testing results, rehospitalisation and maternal survival. Data analysis will be conducted using Stata V.18.0. ETHICS AND DISSEMINATION: Approvals were obtained from the NSW Population and Health Services Research Ethics Committee (29 June 2020; 2019/ETH12716) and the Australian Capital Territory Health Human Research Ethics Committee (11 October 2021; 2021-1231, 2021-1232, 2021-1233); and the Aboriginal Health and Medical Research Council (5 July 2022; 1824/21), and all Australian educational sectors: Board of Studies (government schools), Australian Independent Schools and Catholic Education Commission (D2014/120797). Data were released to researchers in September 2022. Results will be presented in peer-reviewed academic journals and at international conferences. Collaborative efforts from similar datasets in other countries are welcome

Self-care management of bothersome symptoms as recommended by clinicians for patients with a chronic condition: A Delphi study

BACKGROUND: Chronically medically ill patients often need clinical assistance with symptom management, as well as self-care interventions that can help to reduce the impact of bothersome symptoms. Experienced clinicians can help to guide the development of more effective self-care interventions. OBJECTIVE: To create a consensus-based list of common bothersome symptoms of chronic conditions and of self-care management behaviors recommended to patients by clinicians to reduce the impact of these symptoms. METHODS: A two-round Delphi study was performed among an international panel of 47 clinicians using online surveys to identify common and bothersome symptoms and related self-care management behaviors recommended to patients with heart failure, chronic obstructive pulmonary disease, asthma, type 2 diabetes, or arthritis. RESULTS: A total of 30 common bothersome symptoms and 158 self-care management behaviors across the five conditions were listed. Each chronic condition has its own bothersome symptoms and self-care management behaviors. Consensus was reached on the vast majority of recommended behaviors. CONCLUSIONS: The list of common bothersome symptoms and self-care management behaviors reflect consensus across four countries on many points but also disagreement on others, and a few recommendations are inconsistent with current guidelines. Efforts to encourage clinicians to recommend effective self-care management behaviors may reduce symptom impact in chronically ill patient populations

Patterns of self-care decision-making and associated factors: A cross-sectional observational study

OBJECTIVE: The aim of this study was to identify for the first time patterns of self-care decision-making (i.e. the extent to which participants viewed contextual factors influencing decisions about symptoms) and associated factors among community-dwelling adults with chronic illness. METHODS: This was a secondary analysis of data collected during the development and psychometric evaluation of the 27-item Self-Care Decisions Inventory that is based on Naturalistic Decision-Making (n = 430, average age = 54.9 ± 16.2 years, 70.2 % female, 87.0 % Caucasian, average number of chronic conditions = 3.6 ± 2.8). Latent class mixture modeling was used to identify patterns among contextual factors that influence self-care decision-making under the domains of external, urgency, uncertainty, cognitive/affective, waiting/cue competition, and concealment. Multivariate multinomial regression was used to identify additional socio-demographic, clinical, and self-care behavior factors that were different across the patterns of self-care decision-making. RESULTS: Three patterns of self-care decision-making were identified in a cohort of 430 adults. A \u27maintainers\u27 pattern (48.1 %) consisted of adults with limited contextual influences on self-care decision-making except for urgency. A \u27highly uncertain\u27 pattern (23.0 %) consisted of adults whose self-care decision-making was largely driven by uncertainty about the cause or meaning of the symptom. A \u27distressed concealers\u27 pattern (28.8 %) consisted of adults whose self-care decision-making was highly influenced by external factors, cognitive/affective factors and concealment. Age, education, financial security and specific symptoms were significantly different across the three patterns in multivariate models. CONCLUSION: Adults living with chronic illness vary in the extent to which contextual factors influence decisions they make about symptoms, and would therefore benefit from different interventions

Symptom characteristics, perceived causal attributions, and contextual factors influencing self-care behaviors: An ecological daily assessment study of adults with chronic illness

Objective: insights into how symptoms influence self-care can guide patient education and improve symptom control. This study examined symptom characteristics, causal attributions, and contextual factors influencing self-care of adults with arthritis, asthma, chronic obstructive pulmonary disease, diabetes, or heart failure. Methods: adults (n = 81) with a symptomatic chronic illness participated in a longitudinal observational study. Using Ecological Daily Assessment, participants described one symptom twice daily for two weeks, rating its frequency, severity, bothersomeness, duration, causes, and self-care. Results: the most frequent symptoms were fatigue and shortness of breath. Pain, fatigue, and joint stiffness were the most severe and bothersome. Most participants engaged in active self-care, but those with fatigue and pain engaged in passive self-care (i.e., rest or do nothing), especially when symptoms were infrequent, mild, somewhat bothersome, and fleeting. In people using passive self-care, thoughts, feelings, and the desire to conceal symptoms from others interfered with self-care. Conclusion: most adults with a chronic illness take an active role in managing their symptoms but some conceal or ignore symptoms until the frequency, severity, bothersomeness, or duration increases. Practice implications: When patients report symptoms, asking about self-care behaviors may reveal inaction or ineffective approaches. A discussion of active self-care options may improve symptom control

Lessons learned from the MOMENT study on how to recruit and retain a target population online, across borders, and with automated remote data collection

Increasingly, studies use social media to recruit, enroll, and collect data from participants. This introduces a threat to data integrity: efforts to produce fraudulent data to receive participant compensation, e.g., gift cards. MOMENT is an online symptom-monitoring and self-care study that implemented safeguards to protect data integrity. Facebook, Twitter, and patient organizations were used to recruit participants with chronic health conditions in four countries (USA, Italy, The Netherlands, Sweden). Links to the REDCap baseline survey were posted to social media accounts. The initial study launch, where participants completed the baseline survey and were automatically re-directed to the LifeData ecological momentary assessment app, was overwhelmed with fraudulent responses. In response, safeguards (e.g., reCAPTCHA, attention checks) were implemented and baseline data was manually inspected prior to LifeData enrollment. The initial launch resulted in 411 responses in 48 hours, 265 of which (64.5%) successfully registered for the LifeData app and were considered enrolled. Ninety-nine percent of these were determined to be fraudulent. Following implementation of safeguards, the re-launch yielded 147 completed baselines in 3.5 months. Eighteen cases (12.2%) were found fraudulent and not invited to enroll. Most fraudulent cases in the re-launch (15 of 18) were identified by a single attention check question. In total, 96.1% of fraudulent responses were to the USA-based survey. Data integrity safeguards are necessary for research studies that recruit online and should be reported in manuscripts. Three safeguard strategies were effective in preventing and removing most of the fraudulent data in the MOMENT study. Additional strategies were also used and may be necessary in other contexts

Digitising diabetes education for a safer Ramadan:Design, delivery, and evaluation of massive open online courses in Ramadan-focused diabetes education

Aims: Ramadan-focused diabetes education is critical to facilitate safer Ramadan fasting amongst Muslim people living with diabetes. We present the design, delivery, and evaluation of two parallel massive open online courses (MOOCs) in Ramadan-focused diabetes education for people with diabetes and HCPs. Methods: Two Ramadan-focused diabetes education MOOCs were developed and delivered for Ramadan 2023: one for HCPs in English, and another for people with diabetes in English, Arabic and Malay. A user-centred iterative design process was adopted, informed by user feedback from a 2022 pilot MOOC. Evaluation comprised a mixed-methods evaluation of pre- and post-course user surveys. Results: The platform was utilised by people with diabetes and their family, friends and healthcare professionals. Overall, a total of 1531 users registered for the platform from 50 countries, 809 started a course with a 48% subsequent completion rate among course starters. Qualitative analysis showed users found the course a user-friendly and authoritative information source. In the HCP MOOC, users reported improved post-MOOC Ramadan awareness, associated diabetes knowledge and ability to assess and advise patients in relation to their diabetes during Ramadan (p&lt;0.01). Conclusions: We demonstrate the potential of MOOCs to deliver culturally tailored, high-quality, scalable, multilingual Ramadan-focused diabetes education to HCPs and people with diabetes.</p

Neolithic settlement at the woodland's edge: palynological data and timber architecture in Orkney, Scotland

It has often been assumed that the islands of Orkney were essentially treeless throughout much of the Holocene, with any ‘scrub’ woodland having been destroyed by Neolithic farming communities by around 3500 cal. BC. This apparently open, hyper-oceanic environment would presumably have provided quite marginal conditions for human settlement, yet Neolithic communities flourished and the islands contain some of the most spectacular remains of this period in north-west Europe. The study of new Orcadian pollen sequences, in conjunction with the synthesis of existing data, indicates that the timing of woodland decline was not synchronous across the archipelago, beginning in the Mesolithic, and that in some areas woodland persisted into the Bronze Age. There is also evidence to suggest that woodland communities in Orkney were more diverse, and therefore that a wider range of resources was available to Neolithic people, than has previously been assumed. Recent archaeological investigations have revealed evidence for timber buildings at early Neolithic settlement sites, suggesting that the predominance of stone architecture in Neolithic Orkney may not have been due to a lack of timber as has been supposed. Rather than simply reflecting adaptation to resource constraints, the reasons behind the shift from timber to stone construction are more complex and encompass social, cultural and environmental factors