Background Better understanding of the demographic distribution of epilepsy and the prevalence of 'more specific forms of epilepsy' in community-based settings would improve our understanding of this disorder at the population level . Although we now have good estimates of epilepsy prevalence for most countries, we still lack knowledge on its demographic distribution by age, ethnicity, region, and socioeconomic status. In addition, no studies to date have reported the prevalence of epilepsy syndromes using patient interview outside a hospital setting. This thesis provides the first community-based estimates of the prevalence of the most common clinical group of epilepsies presumed to have a genetic basis - The Idiopathic Generalised Epilepsies (IGE) - by patient and witness interview. Methods This thesis has involved conducting five pieces of new research: (i) a series of reviews and analyses of descriptive data on epilepsy prevalence, particularly focusing on the critical methodological issues of ascertainment, diagnosis and classification of epilepsy for epidemiological purposes; (ii) the validation of a modified diagnostic epilepsy questionnaire adapted for administration in population studies; (iii) recruitment of a community-based cohort - The Tasmanian Epilepsy Register (TER) - through the Australian national prescription database; (iv) estimation of the overall prevalence and distribution of self-reported treated epilepsy in Tasmania by imputation methods; (v) estimation of the prevalence and distribution of IGE in Tasmania by telephone interviewing. Results My modified diagnostic questionnaire, administered by telephone interviewing and interpreted with standardized guidelines, demonstrated excellent agreement with an epilepsy specialist's clinical assessment in diagnosing the presence of epilepsy (K = 0.94), seizure-onset types (K = 0.84), simple or complex partial seizures (K=0. 87), any generalized non-convulsive seizure (K=0.82), and IGE (K = 0.82). A lthough stil l substantial, agreement was not as close for secondarily general ized seizures (K = 0.74), and generalized tonic-clonic seizures (K = 0.79). 7541 patients treated with antiepileptic drugs (AEDs) in the preceding year in Tasman ia were eligible for recruitment through the Australian national prescription database. After three mail contacts, 54.0% responded, with 43.6% who indicated treatment for epilepsy representing 86.0% of total possible epilepsy cases by imputation (n=2063) in Tasmania. 1180 agreed to participate in the TER, 90.0% of participants received their AEDs either exclusively from their general practitioner (70.9%) or in combination with a medical specialist (19.1%) in the preceding twelve months. The adjusted treated epilepsy prevalence was 4.36 per 1000 (95% CI 4.34, 4.39); this was: lower in women (prevalence ratio 0.92 (95% CI 0.84, 1.00); greater with increasing age (p< 0.001 ); similar in the three main geographical regions; and similar by categories of socioeconomic status based on postcode of residence. Following enrolment, 959/1083 (88.6%) eligible TER participants completed the diagnostic telephone interviewing, with partial epilepsy classified in two thirds, and generalised epilepsy in slightly more than one-fifth. IGE was observed in 20.3%, with tonic-clonic seizures (17.03%) and the absence epilepsies combined (11.01 %) being the most common IGE seizure types and syndromes respectively. The estimated prevalence of IGE was 0.89 per 1000; is highest between the ages of 20-39 years and in females, but was similar between Tasmanian regions and socio-economic groups. IGE prevalence beyond childhood related to refractory childhood or adolescent disease rather than olderonset cases, and was characterised by the presence of myoclonic and tonic-clonic seizures. Generalised seizures, but not IGE, were less prevalent in southern Tasmania. Conclusions Utilising the design approach described in this thesis may provide an alternative to neurological assessment, and when coupled with case ascertainment through prescription data, can provide a valid estimate of the prevalence of 'more specific forms of epilepsy' in countries with high access to health services. The observed pattern of high elderly epilepsy prevalence, is similar to patterns in recent studies in other developed countries, and has important implications for future planning of health services in these countries. IGE represents a considerable proportion of community-treated disease with important aetiological and prognostic determinants occurring at the seizure rather than syndrome level of classification.

Background Better understanding of the demographic distribution of epilepsy and the prevalence of 'more specific forms of epilepsy' in community-based settings would improve our understanding of this disorder at the population level . Although we now have good estimates of epilepsy prevalence for most countries, we still lack knowledge on its demographic distribution by age, ethnicity, region, and socioeconomic status. In addition, no studies to date have reported the prevalence of epilepsy syndromes using patient interview outside a hospital setting. This thesis provides the first community-based estimates of the prevalence of the most common clinical group of epilepsies presumed to have a genetic basis - The Idiopathic Generalised Epilepsies (IGE) - by patient and witness interview. Methods This thesis has involved conducting five pieces of new research: (i) a series of reviews and analyses of descriptive data on epilepsy prevalence, particularly focusing on the critical methodological issues of ascertainment, diagnosis and classification of epilepsy for epidemiological purposes; (ii) the validation of a modified diagnostic epilepsy questionnaire adapted for administration in population studies; (iii) recruitment of a community-based cohort - The Tasmanian Epilepsy Register (TER) - through the Australian national prescription database; (iv) estimation of the overall prevalence and distribution of self-reported treated epilepsy in Tasmania by imputation methods; (v) estimation of the prevalence and distribution of IGE in Tasmania by telephone interviewing. Results My modified diagnostic questionnaire, administered by telephone interviewing and interpreted with standardized guidelines, demonstrated excellent agreement with an epilepsy specialist's clinical assessment in diagnosing the presence of epilepsy (K = 0.94), seizure-onset types (K = 0.84), simple or complex partial seizures (K=0. 87), any generalized non-convulsive seizure (K=0.82), and IGE (K = 0.82). A lthough stil l substantial, agreement was not as close for secondarily general ized seizures (K = 0.74), and generalized tonic-clonic seizures (K = 0.79). 7541 patients treated with antiepileptic drugs (AEDs) in the preceding year in Tasman ia were eligible for recruitment through the Australian national prescription database. After three mail contacts, 54.0% responded, with 43.6% who indicated treatment for epilepsy representing 86.0% of total possible epilepsy cases by imputation (n=2063) in Tasmania. 1180 agreed to participate in the TER, 90.0% of participants received their AEDs either exclusively from their general practitioner (70.9%) or in combination with a medical specialist (19.1%) in the preceding twelve months. The adjusted treated epilepsy prevalence was 4.36 per 1000 (95% CI 4.34, 4.39); this was: lower in women (prevalence ratio 0.92 (95% CI 0.84, 1.00); greater with increasing age (p< 0.001 ); similar in the three main geographical regions; and similar by categories of socioeconomic status based on postcode of residence. Following enrolment, 959/1083 (88.6%) eligible TER participants completed the diagnostic telephone interviewing, with partial epilepsy classified in two thirds, and generalised epilepsy in slightly more than one-fifth. IGE was observed in 20.3%, with tonic-clonic seizures (17.03%) and the absence epilepsies combined (11.01 %) being the most common IGE seizure types and syndromes respectively. The estimated prevalence of IGE was 0.89 per 1000; is highest between the ages of 20-39 years and in females, but was similar between Tasmanian regions and socio-economic groups. IGE prevalence beyond childhood related to refractory childhood or adolescent disease rather than olderonset cases, and was characterised by the presence of myoclonic and tonic-clonic seizures. Generalised seizures, but not IGE, were less prevalent in southern Tasmania. Conclusions Utilising the design approach described in this thesis may provide an alternative to neurological assessment, and when coupled with case ascertainment through prescription data, can provide a valid estimate of the prevalence of 'more specific forms of epilepsy' in countries with high access to health services. The observed pattern of high elderly epilepsy prevalence, is similar to patterns in recent studies in other developed countries, and has important implications for future planning of health services in these countries. IGE represents a considerable proportion of community-treated disease with important aetiological and prognostic determinants occurring at the seizure rather than syndrome level of classification.

New Zealand’s population, like the global population, is ageing. An important element of successful ageing is the maintenance of optimal nutritional status, which is linked to general health and quality of life. The purpose of this mixed methods study, guided by qualitative descriptive methods, was to identify barriers to healthy eating in a group of older single-living New Zealand men. Understanding the men’s perspectives on meal procurement and preparation, in essence walking in their shoes, was a key part of identifying barriers to healthy eating. A cohort of 12 men participated, each completing a semi-structured interview as well as a nutrition knowledge and nutritional risk assessment questionnaire. Data from the semi-structured interviews was analysed using a general inductive approach. The results of the questionnaire were used to enrich description in this mixed methods study. Three core themes emerged from the data which were ‘Individual Circumstances’; ‘Nutrition Knowledge and Skills’; and ‘Food-Related Values’. Potential barriers to healthy eating, in terms of individual circumstances, were limited finances, limited mobility and a lack of personal transport. These barriers were partially ameliorated by effective, reliable social and support networks. A diverse range of shopping, cooking and gardening skills, as well as nutrition knowledge, existed amongst the men. Poor nutrition knowledge and limited cooking skills were possible barriers to healthy eating. Strong beliefs the men held about how food procurement and preparation should occur, termed food-related values, were also potential barriers to healthy eating. Values identified were ‘the importance of healthy eating’; ‘structure in food-related activities’; ‘convenience’; and ‘like it or not, it has to be done – shopping and cooking’. Depending on the prioritisation of values by the individual, they could develop into barriers. For example, prioritising ‘convenience’ over ‘the importance of healthy eating’ led to decisions that negatively impacted dietary intake. This study highlighted the diversity of experiences, circumstances, skills and priorities of older single-living men. Interventions aimed at improving the dietary behaviours of older single-living New Zealand men must recognise the heterogeneity of this population and support the values they hold in regards to food-related activities.

This study was conducted in a rubber farming community in Southern Thailand with rubber farmers and their first-line public healthcare providers as the study informants. The study aims were to first, explore perceived effects of work exposures in rubber farming on rubber farmers’ health, second, identify decisions made in response to the effects of work exposures on health, and third, determine influencing factors on the construction of the perception and the process of decision making. Data were obtained using ethnographic research methods, underpinned by an interpretative paradigm. Unstructured interviews and participant observation were employed as the principal means of data collection. Together with the primary methods of data collection, note taking (fieldnotes, fieldwork personal journal, and photographs) and reviewing/analysing existing documents were employed. While data were being collected, initial data analysis was carried out to make sense of information gained and direct further steps of the data collection. After terminating the data collection, ethnographic data analysis suggested by Spradley (1979, 1980) was used to determine themes to meet the aims of the study. The study findings reveal that individual rubber farmers and healthcare providers construct perceptions of effects of rubber farming on rubber farmers’ health and decisions on the actions taken to manage the rubber farmers’ work-related health problems based on their own accounts of compounding factors. Among factors identified, discrepancies between health policy and its practice, coupled with the existence of a hierarchy of power-superior-inferior relationships among individual levels of health authority-emerge as the most powerful factors, inducing the emergence of other factors. Recommendations made as a result of this study draw attention mainly to the minimisation of the discrepancies between health policies and their implications, and the establishment of partnership status among authorised health agencies and between health agencies and rubber farmers in order to improve the quality of occupational safety and health services provided to the rubber farmers.

Osteoporosis is a serious public health issue, which is growing in significance because of our aging population. It is estimated that one in three New Zealand women over the age of 50 years will suffer from an osteoporotic-related fracture. The risk of osteoporosis among South Asian women living in New Zealand is unknown. However, this is an important and growing population group. The purpose of this study was to determine osteoporosis knowledge, health beliefs and dietary calcium intake in a sample of South Asian women living in Auckland, New Zealand. Relationships between these variables and the predictors of dietary calcium intake were examined. A sample of 102 South Asian women (mean age of 41.6 years) completed an online questionnaire to assess osteoporosis knowledge and health beliefs using the validated Osteoporosis Knowledge Test (OKT) and Osteoporosis Health Belief Scale (OHBS), respectively. A four day food diary was used to assess dietary calcium and energy intake. In general, these South Asian women were lacking in osteoporosis knowledge, they did not perceive themselves to be susceptible to osteoporosis and did not consider osteoporosis to be a serious disease. They perceived many benefits of consuming a high calcium diet for the prevention of osteoporosis and did not identify many barriers to dietary calcium intake. In addition, these South Asian women were highly health motivated. Perceived barriers to dietary calcium intake (R=-0.32; P<0.01) and health motivation (R=0.30; P<0.01) were significantly correlated to dietary calcium intake. Health motivation, perceived barriers to dietary calcium intake and the use of a dietary supplement were significant predictors of dietary calcium intake and together explained 27% of the variance. These findings suggest that osteoporosis prevention interventions may need to increase awareness, overcome perceived barriers to dietary calcium intake as well as maintain health motivation among these South Asian women to achieve sufficient dietary calcium intake.

Despite nurses having legitimate ethical rights and responsibilities, they are often constrained in practice from acting in ways they believe to be morally correct. This thesis presents a qualitative exploration of factors that influenced eight newly graduated nurses as they endeavoured to practice ethical mental health nursing in New Zealand. Data was gathered from in depth interviews with the participants and analysed using a thematic analysis method. A critical lens was employed to view the data so as to make visible aspects of the social and political context within which the participants were situated. The participants? moral practice was profoundly influenced by a number of relational experiences they had. These relationships were then determinants in their moral development, professional socialization and their ability to practice in accordance to their moral beliefs. Key aspects of these relationships were their experiences with nursing education and the influence of the organisations where they worked. Recommendations are made to both areas to enable and support moral nursing practice for new graduate mental health nurses. New graduate nurses inherently desire to practice in a way that honours the client and is therefore inherently ethical. Moral nursing practice is an everyday occurrence that must be situated in a culture of respect and regard for both clients and nurses. New graduate nurses have much to offer the profession and the tangata whaiora of the mental health services. They must be valued and supported to act in accordance to their moral ideals.

Immersed in a context of constrained health resources, nurse managers are at great risk of the experience and negative consequences of values clashes and ethical conflict, such as burnout and attrition. Replicating a qualitative descriptive study previously conducted in Canada (Gaudine & Beaton, 2002) this research is aimed at increasing knowledge of the experience of nurse managers’ ethical conflict with their health care organizations in New Zealand. Semi-structured interviews were used to gather data from eight nurse managers in New Zealand, which was analyzed using a general inductive approach to qualitative research. The experience of advocating for values that may be shared by both nursing and the health care organization, such as safety, teamwork and quality patient care, were revealed in the conceptual category of Nursing Management Advocacy. As with their Canadian study counterparts, Isolation was revealed as a key factor that made the experience of ethical conflict worse and involves the social experiences of silencing, employment barriers and invisibility. Support describes the factors that mitigated the experience of ethical conflict and involves personal, professional and organizational support, and are likewise similar to the experiences of Canadian nurse managers. The Bottom Line describes a focal point of the experience of ethical conflict where the health care organizations predominantly fiscal bottom line was confronted and challenged by nurse managers, and where the nurse manager might reach their own bottom line and choose to leave the organization. Being and Becoming Nursing Leaders describes the outcomes of ethical conflict for nurse managers who were not only transformed into nursing leaders, through learning, reflection, and growth but also counted the costs of nursing leadership. This study concludes that supportive colleagues, organizational structures and culture are essential to mitigating the experience of ethical conflict and isolation which nurse managers encounter. The study also concludes that reducing isolation and supporting nurse managers will ensure that nursing values are appropriately represented and articulated in the health care organization’s decision making systems and processes.

High levels of diet related chronic disease in New Zealand has lead to the development of health promotion programmes. The work place is an important venue to implement health promotion programmes to encourage staff to make healthy lifestyle choices. The aim of this research is to examine if a physical activity programme may be a ‘gateway’ to other positive behavioral changes such as healthy eating and/or cutting down smoking. This research introduces a health promotion programme to employees at a call centre. The intervention involved 3 groups: the health promotion group (HPG), which received both the physical activity programme (10,000 steps @ work ‘lite’ programme) plus nutritional information; the nutritional group (NG), which received only the nutritional information and the control group (CG), which did not take part in the intervention. The impact of the nutritional seminars with or without the exercise programme was measured by the participants’ reported fruit, vegetable, snack consumption and transtheoretical stages of change for exercise, fruit and vegetable intake, healthy snacking and smoking. A questionnaire was used to collect data retrospectively. The health promotion group (HPG) made positive changes in all behaviours unlike the nutritional group (NG) and the control group (CG). This provides some support for the hypothesis that physical exercise may act as a ‘gateway’ to other positive behavioural changes.

Citizenship, as effective social, cultural and economic participation for refugee groups, depends on appropriate institutional structures and processes in resettlement societies. This thesis using critical social theoretical perspectives addresses the paradox of being legally a citizen, but substantively excluded from the very rights that constitute such citizenship. The thesis draws on theoretical models of newcomer integration in order to promote the development of a more inclusive society for refugees in New Zealand. The issues to be considered include responses from central government and from public institutions—particularly health, education, employment and welfare—in addressing social exclusion and promoting integration. The questions of refugee integration to be addressed conceptually must take into consideration cultural and religious diversity, on the one hand, and socio-economic inequality on the other. In New Zealand, the 1987 review of refugee resettlement policy, which established an annual quota of 750 places, has given priority to those with the highest health and social needs and removed preferences for specific national, ethnic and religious groups. Significantly, in the 1990s radical neo-liberal economic reforms were introduced and publicly provided health, education and welfare systems were restructured. This posed serious challenges to the core idea of social citizenship in general in New Zealand society. Noticeable ethnic diversification has been just one element of the resettlement policy changes; the other has been long-term social and economic exclusion in the refugee groups settled since this time. This study indicates that New Zealand’s notably humanitarian refugee resettlement policy is not matched by adequate central government and public institutional responses and resources with which to integrate refugee groups. This qualitative study examines the role of one institution in particular, health care. The study takes a multi-method approach, using historical and social policy analysis to set the structural context for the interpretation of data from participant interviews. During fieldwork, twenty-eight semi-structured interviews were conducted with health care providers in community, primary and secondary care sectors in the Auckland region, in both governmental and non-governmental agencies. This research demonstrates at a service level, the consequences of overlooking refugee peoples in New Zealand social policy, data collection systems, research and health strategies. Importantly though, the research discovers a number of ‘activation points’—or approaches that have been developed by health care practitioners—that highlight future opportunities for the inclusion of refugee groups. One finding is that the New Zealand health system must address the question of how to effect a shift from universalist conceptions of generalised eligibility for health services to targeted interventions for refugees. The conclusions drawn from the study are: firstly, that an overarching integration policy for refugees, led by central government, is required. Secondly, institutional responses that accommodate the special psychosocial, socio-economic and cultural/religious requirements of refugee groups are needed. This would include the development of a locally relevant multiculturalism to guide social policy in New Zealand. In the long-term, for peoples from refugee backgrounds to become full political, social, economic and cultural members of New Zealand society, there needs to be a rethinking of the contemporary models of citizenship offered.

Recent Māori, sexual, and primary health developments have been influenced by the principle of participation. For example, the use of a whānau-centred approach, of community development, and of Primary Health Organisations allows participation in decision-making. However, none of the abovenamed strategies adequately explain how young Māori women can participate in decision-making in one common area: Māori, sexual, primary health policy. This thesis explores how Primary Health Organisations can work with young Māori women to promote sexual health to whānau by focusing on policymaking processes and effective participation mechanisms. Māori health development from colonial Contact to 2005 is reviewed before the broad health framework (the New Zealand Health Strategy and the New Zealand Public Health and Disability Act 2000) is defined. A critique of relevant policy, in particular He Korowai Oranga (2002), the Sexual and Reproductive Health Strategy (2001), and The Primary Health Care Strategy (2001), reveals scope for participation and whānau-centredness. Primary Health Organisations pose challenges to whānau sexual health promotion. However, with public participation from young Māori women, like the thesis participants, new opportunities can be realised. The research was conducted in accordance with a Mana Wāhine-based methodology called Tāniko The four parts (Mana Wāhine, Te Ao Tawhito, Te Ao Hou, and Te Ao Mārama) defined the research aim and objectives. A qualitative strategy employing semi-structured interviews with three young Māori women was followed by a confirmatory stage of content analysis utilising a deductive public participation evaluation tool: the Tāniko instrument. The instrument analysed four policymaking decisions and two mechanisms: organised peer groups and the wāhine-centred approach. The research concluded that when defining how, by whom, and to whom information is presented, organised peer groups can be utilised at the coordination and evaluation policymaking stages. The wāhine-centred approach can share or manage participation through problem definition, consultation, decision, and implementation.