Trachoma is known to be a significant cause of blindness in Australia. It was brought into the public spotlight 30 years ago by Fred Hollows. Unfortunately public interest has waned and so have efforts to combat this terrible and painful blinding disease. The World Health Organization has set the goal of eliminating the disease by 2020. Unless momentum is soon gained in Australia, there is a very real risk that Australia will be the last country on earth where blinding trachoma remains. The importance of trachoma in the overall context of Indigenous health is constantly debated. We set out to evaluate the SAFE strategy, including the impact of a swimming pool. However the project soon changed course. This thesis shows that trachoma is still a major public health concern and a cause of significant visual morbidity. This thesis demonstrates that the A and F components of the SAFE strategy can be an effective intervention. This thesis reports on some of the barriers that are impeding the widespread implementation of SAFE within the Northern Territory of Australia. (For complete abstract open document)

Doctor of Philosophy (PhD) / The alarming rates of ill-health and social disadvantage amongst Australian Indigenous peoples has continued despite improved understanding of the determinants behind these conditions. There appears to be an urgent need to review and re-orientate health and social programs, from a deficit-focused to a strengths-based model, whereby a community’s capacity and resilience is enhanced utilising, and building on, existing strengths and resources. The current study set out to investigate the meaning and role of resilience in the wellbeing of Indigenous Australians. The aim of the study was to examine resilience within an Indigenous context, its potential role in strengthening the Indigenous response to adversity, and the prospective ways in which this may be used in initiatives aimed at boosting health and wellbeing in Indigenous communities. The study involved qualitative in-depth interviews and focus groups within the Indigenous Yaegl community of north-eastern New South Wales. This was achieved through extensive consultation with the community, and a strong commitment to upholding cultural sensitivities and ethical considerations. The data was analysed using a phenomenological framework, involving objective and in-depth thematic analysis, with specific focus on the relationships within the data and their associations with the research questions posed. The study indicates the resilience of the Yaegl community, involving individual, family and community level resilience, involves interdependent protective factors and support structures. The experience of hardship itself, and the ability to employ positive adaptational/coping skills and recruit a variety of protective resources are key to the development of resilience throughout the life continuum. The study demonstrates the importance of these mechanisms not only at the individual level, but also in the resilience of family units and the community. This appears particularly important within the Indigenous context where these levels of functioning are interdependently connected. The study has implications for health and social practitioners looking to broaden their understanding of the Indigenous experience, to one that acknowledges the many existing strengths and protective factors present in Indigenous communities. Practitioners and program developers would benefit from utilising this holistic model of resilience, in which individual, family and community based protective factors play important roles in the prevention of risk and the development of resilience. Programs incorporating this understanding are expected to be more effective in both service delivery and outcomes, because all levels of functioning would be viewed and addressed as interdependent elements in the development of resilience and response to adversity.

Doctor of Philosophy (PhD) / The alarming rates of ill-health and social disadvantage amongst Australian Indigenous peoples has continued despite improved understanding of the determinants behind these conditions. There appears to be an urgent need to review and re-orientate health and social programs, from a deficit-focused to a strengths-based model, whereby a community’s capacity and resilience is enhanced utilising, and building on, existing strengths and resources. The current study set out to investigate the meaning and role of resilience in the wellbeing of Indigenous Australians. The aim of the study was to examine resilience within an Indigenous context, its potential role in strengthening the Indigenous response to adversity, and the prospective ways in which this may be used in initiatives aimed at boosting health and wellbeing in Indigenous communities. The study involved qualitative in-depth interviews and focus groups within the Indigenous Yaegl community of north-eastern New South Wales. This was achieved through extensive consultation with the community, and a strong commitment to upholding cultural sensitivities and ethical considerations. The data was analysed using a phenomenological framework, involving objective and in-depth thematic analysis, with specific focus on the relationships within the data and their associations with the research questions posed. The study indicates the resilience of the Yaegl community, involving individual, family and community level resilience, involves interdependent protective factors and support structures. The experience of hardship itself, and the ability to employ positive adaptational/coping skills and recruit a variety of protective resources are key to the development of resilience throughout the life continuum. The study demonstrates the importance of these mechanisms not only at the individual level, but also in the resilience of family units and the community. This appears particularly important within the Indigenous context where these levels of functioning are interdependently connected. The study has implications for health and social practitioners looking to broaden their understanding of the Indigenous experience, to one that acknowledges the many existing strengths and protective factors present in Indigenous communities. Practitioners and program developers would benefit from utilising this holistic model of resilience, in which individual, family and community based protective factors play important roles in the prevention of risk and the development of resilience. Programs incorporating this understanding are expected to be more effective in both service delivery and outcomes, because all levels of functioning would be viewed and addressed as interdependent elements in the development of resilience and response to adversity.

Understanding how proximal, intermediate, and distal determinants of Indigenous peoples’ health in Canada, relate to the physical and mental health of First Nations, Métis, and Inuit, can shed light on how to allocate health-related resources to address well documented health disparities in these groups. This dissertation contributes to the literature by addressing two population-level quantitative research questions pertaining to Indigenous peoples’ physical and mental health, and a qualitative case study examining what factors maintain and improve Indigenous community health workers’ mental wellness and access to mental health supports. First, this thesis establishes a link between being Indigenous and health-related quality of life using multivariate regressions, as well as decomposition techniques. Second, the relationship between having an ancestor who survived the Residential School System, and five physical and mental health outcomes, controlling for determinants of health are estimated using multivariate ordered logistic and logistic regressions. Third, given that Indigenous self-government is an important determinant of health and wellbeing, an explanatory single-case study design is used to explore what factors maintain and improve, or create barriers to mental wellness and access to mental health supports for Indigenous community health workers in an Indigenous-governed health system. These chapters build on each other, and use a variety of methodological approaches, to identify if and to what degree observable determinants of health account for the physical and mental health of Indigenous peoples living in Canada. Substantively, this thesis evaluates empirically, the relationship between determinants of health and health outcomes for Indigenous peoples. Findings could be used to advocate for adequate and sustained investment in programs and services responsive to the contexts and needs of Indigenous men and women living in Canada. Methodologically, novel applications of statistical/econometric methodologies, furthers understanding of quantitative relationships examined with respect to Indigenous peoples’ physical and mental health at the population-level. In terms of a theoretical contribution, this dissertation contributes by lending further insight into the empirical relationships between determinants of Indigenous peoples’ health and health outcomes, and by introducing a framework for conceptualizing factors that strengthen mental wellness of Indigenous community health workers in remote Northern contexts in Canada. / Thesis / Doctor of Philosophy (PhD) / First Nations, Métis, and Inuit make up 4.3% of the Canadian population and together represent the three distinct identities of Indigenous peoples living in Canada. Indigenous peoples’ experiences of colonization have had impacts on their physical and mental health. Additionally, experiences of colonization have also affected many determinants of Indigenous peoples’ health ranging from access to food and clean drinking water, to the availability of appropriate education, social, and healthcare services. The following chapters explore how certain experiences of being Indigenous in Canada are associated with physical and mental health outcomes, taking into consideration determinants of health. Even after controlling for all of the things known to be related to Indigenous peoples’ physical and mental health, and that are typically used to explain any differences in health between groups, there is still a difference in health outcomes between Indigenous and non-Indigenous peoples in Canada. There is also still a difference in physical and mental health outcomes between Indigenous adults with and without an ancestor who attended the Residential School System. The effects of colonization also influence Indigenous community health workers’ mental wellness, and access to mental health supports while living and working in a remote, Northern community.

The challenge of ameliorating or preventing the health problems of Indigenous Australians living in remote areas is compounded by the profound professional, cultural, social and personal isolation of the health professionals who work there. This isolation has direct effects on the recruitment and retention of health professionals to remote communities, and their ability to work effectively in this unfamiliar environment. The overarching goal of this research was to strengthen the capacity of these professionals to improve the quality of remote area maternity services in Australia and the experiences and outcomes for birthing women and their families. This was achieved by investigating a process of engagement with a wide range of stakeholders and utilising contemporary communication technology through the Internet. A case study approach was undertaken using participatory action research (PAR) with the elements off rapid assessment, response and evaluation methods (RARE). The research explored, described and analysed the development of resources aimed at decreasing isolation and increasing communication in the remote setting. Identifying the barriers, facilitators and utility of an information technology intervention was an integral part of the investigation process. The first case study saw the development and evaluation of the Maternity Care in the Bush Web Based Resource Library, designed to decrease the isolation of practitioners from the educational resources and professional expertise available in current literature, guidelines and reports. The second case study targeted isolation from peers, with the development and evaluation of the Remote Links Online Community. This was designed to build partnerships between isolated practitioners, for the purpose of interactive peer support, information exchange and mentoring. The third and fourth case studies were guided by Aboriginal researchers and resulted in the development of the Birthing Business in the Bush Website, designed to decrease practitioners' isolation from cultural knowledge. An integrated component of this Website is the Primary Health Care Guide to Planning Local Maternity Services, designed to decrease the isolation of the health care practitioner from the community in which they are working. Issues related to conducting research in the Australian Indigenous setting have been explored, analysed and detailed. Each case study contributed new knowledge and learning about the challenges and contemporary contexts of remote area maternity service provision in Australia. The use of PAR, and, most particularly, how this can be used in Indigenous research to produce goals that extended beyond the individual researcher's goals, has been described. The current difficulties associated with computer mediated communication, as experienced by remote practitioners, have been highlighted. The research has identified areas of need within the workforce that, if addressed, could contribute to improved health services. Importantly, the research has documented, acknowledged, honoured and disseminated the voices of Aboriginal women, through the far reaching communication technology that is the Internet. Furthermore, the voices, concerns and conditions of remote maternity services providers were also documented and acknowledged. This workforce, often invisible and poorly valued, was assisted and supported to provide evidenced based, culturally appropriate maternity care, through the resources that were developed. To further progress the lessons taken from the research, recommendations have been developed and are listed in the Conclusion.

The challenge of ameliorating or preventing the health problems of Indigenous Australians living in remote areas is compounded by the profound professional, cultural, social and personal isolation of the health professionals who work there. This isolation has direct effects on the recruitment and retention of health professionals to remote communities, and their ability to work effectively in this unfamiliar environment. The overarching goal of this research was to strengthen the capacity of these professionals to improve the quality of remote area maternity services in Australia and the experiences and outcomes for birthing women and their families. This was achieved by investigating a process of engagement with a wide range of stakeholders and utilising contemporary communication technology through the Internet. A case study approach was undertaken using participatory action research (PAR) with the elements off rapid assessment, response and evaluation methods (RARE). The research explored, described and analysed the development of resources aimed at decreasing isolation and increasing communication in the remote setting. Identifying the barriers, facilitators and utility of an information technology intervention was an integral part of the investigation process. The first case study saw the development and evaluation of the Maternity Care in the Bush Web Based Resource Library, designed to decrease the isolation of practitioners from the educational resources and professional expertise available in current literature, guidelines and reports. The second case study targeted isolation from peers, with the development and evaluation of the Remote Links Online Community. This was designed to build partnerships between isolated practitioners, for the purpose of interactive peer support, information exchange and mentoring. The third and fourth case studies were guided by Aboriginal researchers and resulted in the development of the Birthing Business in the Bush Website, designed to decrease practitioners' isolation from cultural knowledge. An integrated component of this Website is the Primary Health Care Guide to Planning Local Maternity Services, designed to decrease the isolation of the health care practitioner from the community in which they are working. Issues related to conducting research in the Australian Indigenous setting have been explored, analysed and detailed. Each case study contributed new knowledge and learning about the challenges and contemporary contexts of remote area maternity service provision in Australia. The use of PAR, and, most particularly, how this can be used in Indigenous research to produce goals that extended beyond the individual researcher's goals, has been described. The current difficulties associated with computer mediated communication, as experienced by remote practitioners, have been highlighted. The research has identified areas of need within the workforce that, if addressed, could contribute to improved health services. Importantly, the research has documented, acknowledged, honoured and disseminated the voices of Aboriginal women, through the far reaching communication technology that is the Internet. Furthermore, the voices, concerns and conditions of remote maternity services providers were also documented and acknowledged. This workforce, often invisible and poorly valued, was assisted and supported to provide evidenced based, culturally appropriate maternity care, through the resources that were developed. To further progress the lessons taken from the research, recommendations have been developed and are listed in the Conclusion.

The purpose of this study was to (1) explore the experiences and perceptions of clinicians who participated in a pilot cultural safety intervention in the Northwest Territories and (2) to make recommendations to pilot intervention in terms of design, content, and delivery. Indigenous and process evaluation research principles underlined this qualitative research project. Data was collected through semi-structured interviews with eight clinicians who participated in the pilot intervention. Findings, identified through thematic analysis, reveal that participants were satisfied with many aspects of the pilot intervention, including key learnings, but also experienced challenges. Among these challenges were dominant discourses that suppress conversations about power and privilege. These research results will inform the sponsors of this project to further refine the pilot training model to enhance clinician learning and engagement. This study may be insightful to researchers and program developers in other jurisdictions. / Graduate

Introdução: A pesquisa analisa em uma perspectiva etnográfica o cotidiano de cuidado de enfermeiras à população indígena Mura do município de Autazes-Amazonas. Objetivo: Analisar a perspectiva das enfermeiras sobre o cuidado à saúde da população indígena Mura do município de Autazes-Amazonas. Metodologia: Trata-se de um estudo etnográfico, realizado com dez enfermeiras que atuavam no cuidado à população indígena Mura no Município de Autazes, nos cenários do Hospital de Autazes e dos Polos- Base das aldeias de Pantaleão e Murutinga. O trabalho de campo foi realizado no período de agosto de 2015 a janeiro de 2016, sendo coletados os dados por meio da observação participante, com anotação sistemática em diário de campo, e de entrevistas semi- estruturadas, seguindo um roteiro com aspectos relacionados ao perfil das participantes e perguntas voltadas ao conhecimento sobre saúde indígena, experiência do cuidar do indígena e formação do enfermeiro para atuação em contexto indígena. A coleta e a análise de dados foram realizadas concomitantemente durante toda a realização do trabalho de campo, que foram agregados em temas, elaborados com base nas observações de campo e nos dados das entrevistas, sendo discutidos segundo o referencial da antropologia da saúde, das Políticas de Saúde Indígena, dos conceitos de cuidar/cuidado em um sentido mais amplo no campo da Enfermagem e, em particular, na perspectiva do cuidado transcultural. A pesquisa foi aprovada pelo Comitê de Ética em Pesquisa da Escola de Enfermagem de São Paulo. Resultados: Foram elencados seis temas que discorrem sobre os cuidados de enfermagem à saúde indígena, envolvendo os desafios e as dificuldades vivenciadas pelas participantes do estudo. Os temas que emergiram foram: Práticas de cuidado de enfermeiras à população indígena Mura de Autazes; O contexto hospitalar e o cuidar do indígena Mura; Cuidados diferenciados e atenção diferenciada: entre modos de olhar e de cuidar da população indígena Mura; Aspectos culturais que envolvem o cuidado ao indígena Mura: dificuldades e desafios para enfermeiras; Fragilidades estruturais dos serviços: dificuldades e desafios para as ações de saúde junto à população indígena e Fragilidades na formação do enfermeiro para atuação em contexto intercultural. Conclusão: Os resultados revelam a necessidade premente de mudanças estruturais no processo de trabalho e melhores condições para realização das ações de cuidados da enfermeira à população indígena; de formação continuada que contemple as especificidades culturais da população indígena; de ação interdisciplinar que promova o diálogo entre saúde, antropologia e cuidado transcultural para minimizar atitudes etnocêntricas dos profissionais de saúde à população assistida no contexto investigado. Recomenda-se fortemente que as Instituições de Ensino Superior em regiões geográficas com população indígena reorientem seus currículos para a formação do enfermeiro para atuar em contexto intercultural e com competências para prestar atenção diferenciada à população indígena. Novas pesquisas precisam ser desenvolvidas para preencher lacunas nessa área de conhecimento. / Introduction: The research analyzes, from an ethnographic perspective, the daily care of nurses to the indigenous Mura population of the municipality of Autazes-Amazonas. Objective: To analyze the nurses\' perspective on the health care of the indigenous Mura population of the municipality of Autazes-Amazonas. Method: This is an ethnographic study carried out with ten nurses who worked in the care of the indigenous Mura population in the municipality of Autazes, in the settings of the Hospital of Autazes and the Base Poles of the villages of Pantaleão and Murutinga. Field work was carried out from August 2015 to January 2016, and data were collected through participant observation, with systematic annotation in field diaries, and semi-structured interviews, following a script with aspects related to the profile of the participants and questions related to knowledge about indigenous health, indigenous care experience, and nurse training to work in an indigenous context. Data collection and analysis were performed concomitantly throughout the field work. Data were aggregated into themes, elaborated based on field observations and interview data, discussed according to the anthropology of health, the Indigenous Health Policies, the concepts of care/caring in a broader sense in the field of Nursing and, in particular, from the perspective of cross-cultural care. The research was approved by the Research Ethics Committee of the School of Nursing of São Paulo. Results: Six themes were named that discuss nursing care for indigenous health, involving the challenges and difficulties experienced by the study participants. Themes that emerged were: Practices of care of nurses to the indigenous population Mura de Autazes; The hospital context and the care of the indigenous Mura; Differentiated care and differentiated attention: between ways of looking and caring for the indigenous Mura population; Cultural aspects that involve care for the indigenous Mura: difficulties and challenges for nurses; Structural weaknesses of services: difficulties and challenges for health actions with the indigenous population and Fragilities in the training of nurses to work in an intercultural context. Conclusion: The results reveal the urgent need for structural changes in the work process and better conditions for carrying out nursing care actions to the indigenous population; Continuing education that contemplates the cultural specificities of the indigenous population; Interdisciplinary action that promotes the dialogue between health, anthropology and transcultural care to minimize ethnocentric attitudes of health professionals to the population assisted in the investigated context. It is strongly recommended that Higher Education Institutions in geographic regions with indigenous populations reorient their curricula to the training of nurses to act in an intercultural context and with competencies to give differentiated attention to the indigenous population. New researches need to be developed to fill gaps in this area of knowledge.

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ABSTRACT Introduction Oral diseases have a severe impact on rural and remote Indigenous communities of Australia with widespread, severe dental caries leading to a significant number of Indigenous children requiring multiple dental extractions under general anaesthesia each year; a scenario rarely seen elsewhere in Australia. This burden of oral disease occurs in these communities in the context of very limited availability of dental personnel and access to oral health care. The rural and remote Indigenous communities of Australia rely on Indigenous Health Workers as key primary health care personnel. Experience in Western Australia and the Northern Territory suggests that the oral health role of these personnel can be developed to improve community oral health and reduce the burden of oral disease in Indigenous communities. The development of the Indigenous Health Worker oral health role is supported by major stakeholders including: the peak Indigenous health organisation, the National Aboriginal Community Controlled Health Organisation; the peak dental health organisation, the Australian Dental Association; and by Australia’s National Oral Health Plan. Yet limited progress has been made in the development of this role. Why? This case study seeks to answer this question through the exploration of the complex, multiple factors influencing the development of the oral health role of Indigenous Health Workers in the Cape York region and so support the development of this role among Indigenous Health Workers. Methodology This research was conducted in accordance with the National Health and Medical Research Council’s Statement and Guidelines for ethical conduct of Indigenous health research. Ongoing consultation took place with key Indigenous health organisations of the region. including Apunipima Cape York Health Council, Gurriny Yealamucka Health Service and the Queensland Aboriginal and Torres Strait Islander Health Worker Training Aboriginal Corporation, to confirm that the research focus was a priority of the communities of the region and to gain input into the design and implementation of the project. With the support of these Indigenous health organisations the study focused on the three communities in which an initial introduction to oral health promotion was provided to Indigenous Health Workers by Queensland Health through its Crocodile Smiles Project. Qualitative methodologies were used with data collection in the region undertaken through semi-structured interviews with 58 health personnel in the remote Indigenous communities of Hopevale, Napranum and Yarrabah; and in the regional centres of Cairns, Cooktown and Weipa. These interviews explored the perceptions of Indigenous Health Workers, dental personnel and their co-workers regarding the priority, characteristics and support needs of the development of the Indigenous Health Worker oral health role in the region. Results Interviews with rural and remote health personnel highlighted the severe impact of oral disease in these communities and on their health services and the high priority given to the development of the Indigenous Health Worker oral health role. These health personnel are seen as key to Indigenous health promotion in the region. Contrasting perspectives were found among rural and remote health personnel regarding the characteristics of an appropriate Indigenous Health Worker oral health role with consistent support being given to the development of the oral health promotion role and varied perspectives found concerning the development of a clinical oral health role. Rural and remote health personnel also highlighted the significant barriers to the development of the Indigenous Health Worker oral health role existing at the clinic and regional levels. Conclusion This study identifies drivers of role development as including oral health needs and oral health skills shortages in rural and remote Indigenous communities of Cape York. Facilitators to role development were found to include: the legislative and policy environment; the support of Indigenous Health Workers and their co-workers; and the policies and plans of Queensland Health and the Indigenous Community Controlled Health Organisations of the region. Significant barriers include: the existing work burden of Health Workers; the lack of clarity of Health Worker role definition; and the difficulties inherent in the development of appropriate inter-professional and cross-cultural training and management support strategies which are able to be implemented in remote settings. The research highlights the complexity of factors to be considered in achieving the system¬wide changes needed to support the development of this role and makes recommendations in the areas of policy, training, management and research to best support the development of this role. In focusing on the development of the oral health role of Indigenous Health Workers the study has examined an area of significance to the Indigenous community using culturally sensitive research methods in remote settings and has addressed a significant though little explored area of dental research – the development of the oral health role of non-dental personnel.