Health in Orphanages Project (HOPe)

A few years ago while studying the oral health of school children in Kerala, India, one of the schools I visited was a boarding school for orphaned children. It was obvious from just observing these children and through dental examinations that the health of these orphaned children was a lot worse than children from the non-orphanage schools in my study. While at the time I was doing my masters degree and did not have the liberty to pursue this issue further, I made a mental note that when I had settled down in my career I would re-visit this issue. Fast forward to 2013 (five years since I visited the orphanage in Kerala) and we (my wife and I) have set up the Health in Orphanages Project (HOPe), with support from University researchers and community partners, to explore the health of children residing in orphanages in India.

So what is an orphan – United Nations Children’s Fund (UNICEF) defines an orphan as not only a child who has lost one or both parents but also those who have lost a father but have a surviving mother or have lost their mother but have a surviving father (1, 2). It is estimated that, as of 2010, there were 132 million orphaned children across the globe (about 2% of the world’s population), a shocking number. Of these children, 69 million were located in Asia, 53 million in Sub-Saharan Africa, and 10 million in Latin America and the Caribbean. India alone is home to 32 million orphaned children (~ 2.6% of India’s population or 7.5% of India’s child population). Yet it is quite rare for the local populace in India to encounter these children in their normal lives. The social structure in India has ensured that these children are a hidden and socially stigmatised community.

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Photo of an orphanage from my last trip to India

In spite of such large numbers the available information on the health of children residing in orphanages, particularly in India, is very limited. The available information gave us some insight into the health of these children but again highlighted the need to work with this hidden section of the community that we call the ‘disadvantaged among the disadvantaged’. A parent-child relationship is important for the mental and physical development of the child and the absence of this relationship can be detrimental to their health. Such a separation can negatively impact on various aspects of their development, particularly in relation to their psychosocial, emotional and cognitive skills. The social disadvantage is due to the lack of social and cultural identity that growing up in a family would provide. A joint report by UNICEF, UNAIDS & USAID on orphaned children state that institutional care such as orphanages can be detrimental to the child’s development as they socially isolate the children, discourage autonomy, put the children at risk of losing their family and community identities, and fail to provide any mechanism to support a child’s emotional or mental needs (1). As a result of these issues, orphaned children generally have poor oral health; poor mental health; are malnourished; have low immunity; are prone to medical conditions such as HIV, cardiomyopathy, fetal alcohol syndrome, hepatitis C, otitis media & congenital adrenal hyperplasia; and recurrent episodes of diarrhoea, fever & cough (3, 5-10). These children, particularly girls, are at a high sexual risk which includes having sex at an earlier age, pregnancy and the risk of contracting HIV/AIDS (11-15). Also common among orphaned children are behavioural and cognitive issues such as thought problems, rebellious nature, aggression and being withdrawn (6, 7, 17). A study of children in Romanian orphanages found that due to ‘global neglect’ (when deprivation occurs in more than one domain of child development, such as language, touch and family support) the brain size of orphaned 3-year-olds was significantly smaller when compared to that of a normal child of the same age (16).

So it is quite evident that these children face additional challenges that impact on their health and wellbeing. However, without sufficient country/location specific evidence local program planners and policy makers will not be able to make a case for targeted interventions. We aim to provide this evidence and use the information from this research to determine the future direction of the project. Our first stage will be to explore the health issues affecting children residing in orphanages in the State of Kerala, which is located on the south-west coast of India. At present there are approximately 400 registered orphanages in the State of Kerala alone, with on average 100 children per orphanage (18). We envisage that through HOPe we will be able to provide the evidence needed to progress towards healthier and more socially inclusive environments for these children.

About the author: Bradley Christian is a Research Fellow at the Jack Brockhoff Child Health and Wellbeing Program, working on Teeth Tales – a community based oral health promotion intervention for pre-school children from a refugee and migrant background. Brad is a dentist with specialist training in Dental Public Health whose research interests are around social disadvantage, children and oral health.

 

References

  1. UNAIDS, UNICEF, USAID. Children on the Brink 2004: A joint report of new orphan estimates and a framework for action2004.
  2. UNICEF. Orphans. UNICEF Press Centre; 2012 [cited 2012]; Available from: http://www.unicef.org/media/media_45279.html.
  3. Thielman N, Ostermann J, Whetten K, Whetten R, O’Donnell K, the Positive Outcomes for Orphans (POFO) Research Team. Correlates of Poor Health among Orphans and Abandoned Children in Less Wealthy Countries: The Importance of Caregiver Health. PLoS ONE 7(6) 2012;7(6):e38109.
  4. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-2006 India. Mumbai IIPS2007.
  5. Watts H, Gregson S, Saito S, Lopman B, Beasley M, Monasch R. Poorer health and nutritional outcomes in orphans and vulnerable young children not explained by greater exposure to extreme poverty in Zimbabwe. Tropical Medicine and International Health. 2007;12(5):584-93.
  6. Erol N, Simsek Z, Munir K. Mental health of adolescents reared in institutional care in Turkey: challenges and hope in the twenty-first century. Eur Child Adolesc Psychiatry. [Research Support, N.I.H., Extramural]. 2010 Feb;19(2):113-24.
  7. Hermenau K, Hecker T, Ruf M, Schauer E, Elbert T, Schauer aM, et al. Childhood adversity, mental ill-health and aggressive behavior in an African orphanage: Changes in response to trauma-focused therapy and the implementation of a new instructional system. Child and Adolescent Psychiatry and Mental Health 2011, 5:29. 2011;5(29).
  8. Khare V, Koshy A, Rani P, Srilata S, Kapse SC, Agarwal A. Prevelance of Dental caries and Treatment needs among the orphan children and adolescents of Udaipur district, Rajasthan, India. The Journal of Contemporary Dental Practice. 2012;13(2):182-7.
  9. Lassi ZS, Mahmud S, Syed EU, Janjua NZ. Behavioral problems among children living in orphanage facilities of Karachi, Pakistan: comparison of children in an SOS Village with those in conventional orphanages. Soc Psychiatry Psychiatr Epidemiol 2011;46:787-96.
  10. Johnson DE, Traister M, Iverson S, Dole K, Hostetter MK, Miller LC. HEALTH STATUS OF US ADOPTED CHINESE ORPHANS. .  1996 Abstracts The American Pediatric Society and The Society for Pediatric Research (1996) 39, 135–135; doi:101203/00006450-199604001-008151996.
  11. Birdthistle I, Floyd S, Machingura A, Mudziwapasi N, Gregson S. From affected to infected? Orphanhood and HIV risk among female adolescents in urban Zimbabwe. AIDS 2008;2008:759-66.
  12. Dunbar M, Maternowska M, Kang K, Laver S, Mudekunye-Mahaka I. Findings from SHAZ!: a feasibility study of a microcredit and life-skills HIV prevention intervention to reduce risk among adolescent female orphans in Zimbabwe. J Prev Interv Community 2010;38:147-61.
  13. Gregson S, Nyamukapa C, GP GG, M MW, JJ JL, et al. HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe. AIDS Care. 2005;17.
  14. S SK, Dunbar M, Minnis A, Medlin C, Gerdts C, NS Padian NS (2008) Poverty gi, and women’s risk of human immunodeficiency virus/AIDS. Ann N Y Acad Sci 1136: 101–110. Poverty, gender inequities, and women’s risk of human immunodeficiency virus/AIDS. Ann N Y Acad Sci. 2008;1136:101-10.
  15. Mmari K. Exploring the relationship between caregiving and health: Perceptions among orphaned and non-orphaned adolescents in Tanzania. Journal of Adolescence. 2011;34:301-9.
  16. Perry BD. Childhood experience and the expression of genetic potential: What childhood neglect tells us about nature and nurture. Brain and Mind. 2002;3(1):79-100.
  17. Baguma P.  Assessment of psychosocial support programmes for orphans/vulnerable children in Uganda. International Journal of Psychology. 2012;47(1):467-77.
  18. List of charitable institutions.  Thiruvananthapuram: Department of Social Welfare;  [cited 2011]; Available from: http://www.old.kerala.gov.in/dept_socialwelfare/Grant-in-aid.htm.

Research with culturally and linguistically diverse communities

Encouraging people to participate in research can be a tough gig. We are usually asking people to volunteer their time just for a small piece of information, which is sometimes only relevant and generalisable if large numbers provide this same, small piece of information. As researchers we know the enormous value that gathering this information can have to inform change at the policy, practice and the community level. But the general population sometimes does not place the same value on research or understand how important the research and outcomes can be. So, how do we encourage people to participate in research? And in particular, how do we encourage those from culturally and linguistically diverse backgrounds, where research may not be a common concept or practice.

I am currently working on a large scale child oral health research project entitled ‘Teeth Tales’, being conducted in partnership with government and community agencies  and Australian families from refugee and migrant backgrounds. Oral health is included in the Victorian Health and Wellbeing Plan 2011 – 2015 as a priority area for preventative health, as it is one of the most preventable diseases, particularly for children. Tooth decay is Victoria’s most prevalent health problem, with more than half of all children and almost all adults affected (1). Initial qualitative research was conducted with mothers from Lebanese, Iraqi and Pakistani backgrounds exploring oral health practices, beliefs and service needs. We learnt about many cultural differences and the real interest these communities have to learn more about keeping their children’s teeth healthy. From this earlier research, a community-based trial was developed to include an oral health education program for parents delivered by a trained educator from the same cultural background. This peer educator is able to talk about traditional beliefs and practices and introduce parents to the key Dental Health Services Victoria oral health messages of ‘Eat Well, Drink Well, Clean Well and Stay Well’. The program also included a site visit to local dental and family services. In addition to this education program, local services underwent a review of their practices to improve their competence in dealing with culturally diverse communities.

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Photo from:  http://www.dshs.state.tx.us/dental/promo_oh.shtm

For this trial we recruited Lebanese, Iraqi and Pakistani families in metropolitan Melbourne with children aged 1 – 4 years. We wanted to make sure that the research was as useful and relevant to families as possible so we sought the advice and expertise of relevant cultural organisations. They provided guidance on the cultural practices and beliefs of the target cultural groups, and the cultural appropriateness of our research methodology. They also helped us to recruit families, conduct the trial, interpret the findings and they provided language assistance. If it wasn’t for these partnerships we may have been lucky to recruit 10 families rather than the over 500 families who ended up participating! The advice and support of these cultural partners is invaluable when trying to recruit families with a refugee or migrant background, some of whom may be unfamiliar with research conduct, health promotion and the Australian health system.

In order to evaluate the success of the program we needed to check children’s teeth before and after the trial, as well as ask parents to complete a questionnaire. The free dental screenings for the children proved to be a key incentive for parents to register for the study. Oral health is one of the most contentious current health issues in Australia as access to fast, affordable dental care is often not available. The private dental system is run as a business and many walk out of the service with an expensive bill. The public dental system has huge waiting lists and strict eligibility for access. We found that many parents were not aware that children and refugee and asylum seekers in Victoria are considered a priority group for public dental services access. So when our study offered a free dental screening for children many families jumped at the opportunity!

The strategies outlined above helped us to successfully recruit over 500 families into our study. Engaging culturally and linguistically diverse groups in research can be difficult, but is very important, particularly for health services that need to respond to the evolving health needs of refugee and migrant and groups.

To read more about the ‘Teeth Tales’ study please visit:  http://mccaugheycentre.unimelb.edu.au/research/current/intergenerational_health/teeth_tales

Blog by Dana Young

Research Fellow, Child Public Health

The University of Melbourne

e: dana.young@unimelb.edu.au

References

  1. NACOH. 2004, Healthy mouths healthy lives: Australia’s National Oral Health Plan 2004-2013. Adelaide, National Advisory Committee on Oral Health, Australian Health Ministers’ Advisory Council.

On the conference circuit – from Melbourne to Thailand and back again

In an academic work environment you could say that one of the ‘perks’ is representing your work, or collaborative work, at academic and topic-focused conferences (However in comparison to my days working in the private health industry, business travel in the University signals a more economically responsible mode, namely frequenting the back of the plane rather than the upper deck on long haul flights!). This year has been no exception for me, being fortunate to attend a range of conferences on topics of public health, health promotion, knowledge translation and exchange, and obesity prevention.

So we pack our bags, roll up our posters and prepare our presentation slides at the eleventh hour – but what for? What motivates researchers and practitioners to scramble to find funding so we can run laps of the conference circuit? What benefit does our research and its end-users gain from us attending these forums?

Recently I attended with colleagues what might be considered seminal conferences in public health research/practice/policy: The World conference on Health Promotion by the International Union for Health Promotion and Education (IUHPE) – in Pattaya, Thailand, followed by the Public Health Association of Australia annual conference – in Melbourne. We’ve also attended emerging conferences in our field of interest: The “FUSE 2nd Conference on Knowledge Exchange in Public Health: How to get practice into science” – in Noordwijkerhout, The Netherlands; and the “2nd Annual NHMRC research translation symposium: from Bench to Bourke” – in Sydney. Note the similar style of the long-winded titles on the last two conferences on knowledge translation… For people interested in communicating and doing ‘real world’ research, you’d think we’d have more succinct event titles!

Aside from enjoying a working week near a sandy beach or among fields of tulips, I believe that conference attendances (and active participation obviously) are a necessary perk if we want our research to be useful and utilised, and if we want to link our ideas to a broader national and international dialogue. At these conferences, I took away a few points about the issues being explored and debated, as well as some reflections on what we gain from attending, and thus what we offer as research practitioners. Here’s a wrap-up, fresh from my suitcase.

Salient issues that resonated for me as a conference participant:

  1. Social justice concerns are high on the agenda in public health and health promotion.
    All the policy, practice and research communities represented at theses conferences appear to be very dedicated to chipping away at the systemic barriers to attainment of good health. Good thing.
  2.  Public health and health promotion decision-makers, advocates and researchers need to better articulate what we do, and what good it does.
    What is public health and health promotion anyway? Sure, we all know that the sum of our parts is more than water sanitation and quit-smoking campaigns, but try explaining that to a new acquaintance at a backyard barbeque. And what are the benefits of investing Government dollars in preventive health? Can anyone tell me the economic return on investment of health promotion partnership meetings, or the productivity gains from banning junk-food ads in kids TV viewing hours? Either way, a strong theme that continued to emerge for me was the sheer lack of public outrage when public health research funds are cut, or when a health promotion unit is shut down.
  3. Working across sectors means singing from the same song-sheet.
    I often go to conferences realising that I’m preaching to the converted. It’s not a new concept that public health and health promotion decision-makers need to be working with other sectors like planning, transport and education – this message has continued to come through, but more focused on tweaking our agendas and language, to make it easier to work together. Finding processes to allow cross-sectoral work are getting more focus too – like embedding health impact assessments into local government’s power. We might be a long way away from that but in the meantime we can at least coordinate the message.
  4. We keep on with research to know that we are doing the right things, and doing things fairly.
    Not all of the conferences I went to had an ‘academic’ or scholarly focus, but thankfully, I walked away from each and every session knowing that the majority of attendees valued the role of research and evaluation, rigorous methods, or evidence-informed decision-making – all of this is achieved by furthering research and academic inquiry.
  5. It takes specific skills to advocate, and without advocacy, our concerns won’t be heard.
    Like me, you might not always feel comfortable with the term advocacy so let’s call it leadership, or whatever you like – either way, see points #2 and #3 above. We need to find smarter ways of communicating evidence and knowledge to influence decision-making.
  6. We all love a framework!
    I think every conference session I went to had a ‘framework’, ‘model’ or ‘tool’ which was ‘guiding’ or ‘underpinning’ or ‘informing’ their approach. Hopefully this is more than jargon, and actually means rigor and systematic ways of conceptualising and working – whether you’re in research, practice, or somewhere in between. So I think it’s a good thing, as long as we don’t get lost in translation!

What I think we gain and can offer from active participation at conferences:

  1. Disseminating research and practice.
    This is an obvious benefit, and the one most often used by conference organisers to lure you into spending $900 of your precious budget to be out of the office for two days, subjected to death-by-powerpoint, and forced to catch up on all your emails late at night after the welcome reception. But in order to ‘keep it real’ and stay connected to the broader health and wellbeing dialogue, attendance and active participation at conferences are actually an efficient way to communicate your work. Ok, so I might not feel that way when I’m standing next to my poster watching conference delegates walk straight past, making a bee-line for the coffee stand without an interest in my glossy artwork and data. But if you’re proactive to network, interact, present and tweet, it really is an chance to build the profile of your/your team’s work, and get others to know who you are and what you do.
  2. Networking and engagement.
    By signing up for conferences, we open ourselves to public scrutiny of our work, and let’s not forget those awkward moments of introducing yourself to that esteemed Professor or Policy-maker who has no idea who you are. But this is almost always a positive outcome. We meet new people with similar passions, discuss different contexts and ways of working, and maybe even score a new collaboration, friend, or new LinkedIn connection. The use of social media is really growing at public health conferences, engaging both participants and those who couldn’t attend in person. I’ve come away from every conference with lots of new follows and followers, which also boosts engagement of the research group and links in our other collaborators.
  3. Broadened thinking, new perspectives.
    Sitting in an early morning plenary deciding what to tweet really makes you think about what you think about the topic. In my early days at conferences I probably didn’t reflect much, and was more focused on staying awake and when the next coffee break was. But as a more experienced practitioner, I find that I am continually thinking, appraising, analysing and reflecting on what’s being said. I ask more questions, and use the breaks to chat (to anyone who’ll listen) about the perspectives emerging at the conference.
  4. Confidence.
    After meeting such a range of different people from different contexts, doing different jobs and working in different ways – you realise that you’re all doing good stuff and sharing the goal to promote public health. It’s a nice confidence boost to have your work verified in an international or national context, and helps you feel like you’re on the right track.
  5.  A break from routine.
    I work in an office, and I can’t say I get regular tea-breaks with cake and tropical fruit, nor am I offered a selection of mini-baguettes for lunch. Conferences are good for this. But I do think it is good to get away from the desk and reflect on your practice within a broader context. I always enjoy catching up with colleagues old and new, who are equally as nerdy and equally keen to get out of the office for a few days. Another emerging trend at conferences which is a very welcome break in a workday routine is tea-break flash-mob dances. Enough said.

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Repost from DECIPHer Blog: Improving the evidence base on adolescent health

This blog is a repost from DECIPHer  http://blog.decipher.uk.net/

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Improving the evidence base on adolescent health.

Dr. Ann Hagell from the Association for Young People’s Health (AYPH) looks at the implications of the latest ‘Key Data on Adolescence’ for research into adolescents’ health and health needs.

AYPH firmly believes that we need better, more accessible information about adolescent health.  We also believe that we need to do this by focusing on adolescents as a standalone age group, rather than merging them together with all children.  The experiences of young people are likely to vary according to age, and their health needs might also be different. To help professionals working with young people, AYPH publishes a compendium of statistics about young people’s health every two years.  We draw on data from government departments and other large representative surveys.  The latest edition (Key Data on Adolescence, 2013) has just come out.  What’s new about adolescent health data this time round?

First, in the last couple of years there has been a huge growth in interest in the social determinants of health, as well as in health outcomes.  Since the 2012 Marmot Review for the World Health Organisation, there has been an ongoing debate about reducing health inequalities and improving equality of access to services. Without equal access to resources and support, some young people are at a disadvantage, and we need to know how this affects their health.  Lack of access to services may be because of low income, living in temporary accommodation, or underachieving in education, all of which are associated with health. Data on under-25 unemployment rates are notable – young people have been disproportionately affected by economic recession. In 2011, the average proportion of ‘economically active’ under-25s (those looking for, or in, employment) in the EU was 21.4%, up from 19.7% in 2009. 

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Second, there’s been an increased interest in adolescent accidents and mortality.  Adolescence is generally a healthy age but young people aged 10-24 do die, often from preventable causes.  The main causes of mortality are external, rather than diseases or other natural causes. The most common preventable, external causes of death in this age group include traffic accidents, intentional self-harm and violence.

Common preventable, external causes of deaths among young people aged 10-24 years in the UK

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Source: Patton et al. (2012) ‘Health of the world’s adolescents: a synthesis of internationally comparable data’
Lancet 379(9826):1665-1675
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Third, many health trends are very positive for this age group.  Smoking rates among those aged 11-15 have halved in the last 10 years.  More young people abstain from drinking alcohol now than several decades ago. The proportion reporting that they have used illegal drugs in the last year has also been falling for at least a decade.  Teenage conceptions have fallen too, and in England and Wales they are at the lowest level since records began in 1969.

Proportion of 11-15 year olds who were regular smokers in England by gender, 2001-2011

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Source:  ‘Smoking, drinking and drug use among young people in England in 2011’  Health and Social Care Information Centre.

Fourth, we attempted for the first time to pull together the available data on health promotion and use of health services.  This proved to be quite a challenge, as there is little directly relevant data for this age group. On the other hand, it is clear that young people form a substantial group of users of primary health care, particularly young women.  They also draw on a wide range of other community based services. Tailoring services to their needs, and supporting clinicians in understanding issues of confidentiality, are both very important.

Finally, there are a number of other topics where we desperately need new, robust data.  One example is mental health. The last Office of National Statistics survey of child and adolescent mental health took place in 2004.  Those data have been incredibly useful and are still widely cited.  We need to know what has happened since then.

So the picture is nuanced.  Many overall trends are very positive, but within this we need to keep the focus on sub-groups of young people who may be at a disadvantage compared to their peers.  All young people deserve the support they need to be healthy.  Good data allow us see where help might be most important.



Dr. Ann Hagell is Research Lead at the Association for Young People’s Health (AYPH).

This blog is based on AYPH’s recent publication, ‘Key Data on Adolescence 2013’, which is available to download free on the AYPH website

Disasters impacting communities all over the world.

At the international conference on The Demography of Disasters, I was overwhelmed with the amount of deaths resulting from overseas disasters that killed hundreds of thousands of people. It struck me that the 2009 Victorian bushfires seem on such a small scale compared to this. As I have been working on a project for three years now (looking at the medium to long term impacts from the 2009 Victorian bushfires), I feel that I have some understanding of the huge impact it has, and continues to have, on many people and communities. Therefore I can only imagine the impact on these other countries when such loss has occurred. Especially as these countries are at high risk of future disasters and are usually under resourced to prepare, respond and recover from these. This is a massive challenge for recovery and resilience work within these areas. But imagine if we had that many people die within Victoria? How come there is such a large difference in the death toll between these countries and our own? Is it that these countries are highly populated, even in their rural areas? Or is it because we have greater resources and preparedness mechanisms in place to prevent such large scale impacts?

Over the two days, it was emphasised that disaster recovery efforts need to be tailored to the particular area in which they occur. This is due to variability of culture and traditions, which can both assist and hinder the resilience process. Change in anyone’s life is difficult, especially after a disaster, therefore attempting to restore traditions is important but the difficulty within these countries is that at times it’s more dangerous to restore these traditions than change. The cultural relevance within Victorian communities differs greatly from these countries, which further complicates the applicability of these learnings in different contexts.

Throughout the conference there were many different presentations, exploring the impact on communities after a disaster. However, many of the areas being presented were at constant high risk of disasters. Recovery planning needs to occur after a disaster along with planning for the possibility of another disaster, as they are at high threat of one occurring within their lifetime. This threat needs to be accounted for in regards to resilience and future preparedness.

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Trees recovering from the Victorian 2009 bushfires.

Some of the presenters completed studies in Asian countries – however, some of the limitations of their studies included not knowing or understanding the local context and how their research findings fit into this. To overcome this many of these researchers collaborate with others within the country or the particular rural area in which the research is being completed. For our study: Beyond Bushfires: Community, Resilience and Recovery (www.beyondbushfires.org.au) we have also taken on this approach. We have many stakeholders from local areas within the participating communities which include residents, local government, NGO’s. As part of the research process we are taking back our initial findings to our community partners and asking them for assistance in interpreting these in terms of what they mean locally. This knowledge adds another level of understanding and allows for non-fire related impacts to be accounted for.

There is a shift in the social environment being just as important as the physical environment in the countries that were presented. However, as this is a major focus of our study – hopefully we can add some interesting evidence to this literature. So stay tuned to not only to this blog but the emerging findings that the Beyond Bushfires team has to report later this year.

If you would like to keep updated with the project to join the Beyond Bushfires email list please send an email to: info-beyondbushfires@unimelb.edu.au