Discretion in decision to receive COVID-19 vaccines and associated socio-economic inequalities in rates of uptake: a whole-of-population data linkage study from Australia.

OBJECTIVE: In Australia, first and second compared to third dose of a COVID-19 vaccine were implemented under different policies and contexts, resulting in greater discretion in decisions to receive a third compared to first and second dose. We quantified socio-economic inequalities in first and third dose to understand how discretion is associated with differences in uptake. STUDY DESIGN: Whole-of-population cohort study. METHODS: Linked immunisation, census, death and migration data were used to estimate weekly proportions who received first and third doses of a COVID-19 vaccine until 31 August 2022 for those with low (no formal qualification) compared to high (university degree) education, stratified by 10-year age group (from 30 to 89 years). We estimated relative rates using Cox regression, including adjustment for sociodemographic factors. RESULTS: Among 13.1 million people in our study population, 94% had received a first and 80% a third dose by 31 August 2022. Rates of uptake of first and third dose were around 50% lower for people with low compared to high education. Gaps were small in absolute terms for first dose, and at the end of the study period ranged from 1 to 11 percentage points across age groups. However, gaps were substantial for third dose, particularly at younger ages where the socio-economic gap was as wide as 32 percentage-points. CONCLUSION: Education-related inequalities in uptake were larger where discretion in decisions was larger. Policies that limited discretion in decisions to receive vaccines may have contributed to achieving the dual aims of maximising uptake and minimising inequalities.

Effects and significance of groundwater for vegetation: A systematic review.

Groundwater represents a critical water source for plants, especially during drought, with continuous groundwater availability widely associated with the presence of ecological refugia and the preservation of biodiversity during periods of adverse conditions. Here, we present a systematic quantitative literature review of global groundwater and ecosystem interactions to synthesise current knowledge and identify key knowledge gaps and research priorities through a management lens. Despite increasing research on groundwater dependent vegetation since the late 1990s, significant geographical and ecological biases are evident with papers focused on arid regions or areas with significant anthropogenic changes. Of the 140 papers reviewed, desert and steepe arid landscapes accounted for 50.7 % and desert and xeric shrublands were represented in 37.9 % of papers. A third of papers (34.4 %) quantified groundwater uptake by ecosystems and groundwater contributions to transpiration, with studies examining the influence of groundwater on vegetation productivity, distribution, and composition also well represented. In contrast, groundwater influences on other ecosystem functions are relatively poorly explored. The research biases introduce uncertainty in the transferability of findings between locations and ecosystems limiting the generality of our current understanding. This synthesis contributes to consolidating a solid knowledge base of the hydrological and ecological interrelationships for managers, planners, and other decision-makers that is relevant to the landscapes and environments they manage, so can more effectively deliver ecological and conservation outcomes.

SyncMRT: a solution to image-guided synchrotron radiotherapy for quality assurance and pre-clinical trials.

In this work, a new image guidance system and protocols for delivering image-guided radiotherapy (IGRT) on the Imaging and Medical Beamline (IMBL) at the ANSTO Australian Synchrotron are introduced. The image guidance methods used and the resulting accuracy of tumour alignment in in vivo experiments are often under-reported. Image guidance tasks are often complex, time-consuming and prone to errors. If unchecked, they may result in potential mis-treatments. We introduce SyncMRT, a software package that provides a simple, image guidance tool-kit for aligning samples to the synchrotron beam. We have demonstrated sub-millimetre alignment using SyncMRT and the small-animal irradiation platform (the DynamicMRT system) on the IMBL. SyncMRT has become the standard for carrying out IGRT treatments on the IMBL and has been used in all pre-clinical radiotherapy experiments since 2017. Further, we introduce two quality assurance (QA) protocols to synchrotron radiotherapy on the IMBL: the Winston-Lutz test and hidden target test. It is shown that the presented QA tests are appropriate for picking up geometrical setup errors and assessing the end-to-end accuracy of the image guidance process. Together, these tools make image guidance easier and provide a mechanism for reporting the geometric accuracy of synchrotron-based IGRT treatments. Importantly, this work is scalable to other delivery systems, and is in continual development to support the upcoming veterinary radiotherapy trials on the IMBL.

Australian women's perceptions and practice of sleep position in late pregnancy: An online survey.

BACKGROUND: Going-to-sleep in the supine position in later pregnancy (≥28 weeks) has been identified as a risk factor for stillbirth. Internationally, public awareness campaigns have been undertaken encouraging women to sleep on their side during late pregnancy. AIM: This study aimed to identify sleep practices, attitudes and knowledge in pregnant women, to inform an Australian safe sleeping campaign. METHODS: A web-based survey of pregnant women ≥28 weeks' gestation conducted from November 2017 to January 2018. The survey was adapted from international sleep surveys and disseminated via pregnancy websites and social media platforms. FINDINGS: Three hundred and fifty-two women participated. Five (1.6%) reported going to sleep in the supine position. Most (87.8%) had received information on the importance of side-sleeping in pregnancy. Information was received from a variety of sources including maternity care providers (186; 66.2%) and the internet (177; 63.0%). Women were more likely to report going to sleep on their side if they had received advice to do so (OR 2.3; 95% CI 1.0-5.1). Thirteen (10.8%) reported receiving unsafe advice, including changing their going-to-sleep position to the supine position. DISCUSSION: This indicates high level awareness and practice of safe late-pregnancy going-to-sleep position in participants. Opportunities remain for improvement in the information provided, and understanding needs of specific groups including Aboriginal and Torres Strait Islander women. CONCLUSION: Findings suggest Australian women understand the importance of sleeping position in late pregnancy. Inconsistencies in information provided remain and may be addressed through public awareness campaigns targeting women and their care providers.

Examining area-level variation in service organisation and delivery across the breadth of primary healthcare. Usefulness of measures constructed from routine data.

BACKGROUND: Australia has a universal healthcare system, yet organisation and delivery of primary healthcare (PHC) services varies across local areas. Understanding the nature and extent of this variation is essential to improve quality of care and health equity, but this has been hampered by a lack of suitable measures across the breadth of effective PHC systems. Using a suite of measures constructed at the area-level, this study explored their application in assessing area-level variation in PHC organisation and delivery. METHODS: Routinely collected data from New South Wales, Australia were used to construct 13 small area-level measures of PHC service organisation and delivery that best approximated access (availability, affordability, accommodation) comprehensiveness and coordination. Regression analyses and pairwise Pearson's correlations were used to examine variation by area, and by remoteness and area disadvantage. RESULTS: PHC service delivery varied geographically at the small-area level-within cities and more remote locations. Areas in major cities were more accessible (all measures), while in remote areas, services were more comprehensive and coordinated. In disadvantaged areas of major cities, there were fewer GPs (most disadvantaged quintile 0.9[SD 0.1] vs least 1.0[SD 0.2]), services were more affordable (97.4%[1.6] bulk-billed vs 75.7[11.3]), a greater proportion were after-hours (10.3%[3.0] vs 6.2[2.9]) and for chronic disease care (28%[3.4] vs 17.6[8.0]) but fewer for preventive care (50.7%[3.8] had cervical screening vs 62.5[4.9]). Patterns were similar in regional locations, other than disadvantaged areas had less after-hours care (1.3%[0.7] vs 6.1%[3.9]). Measures were positively correlated, except GP supply and affordability in major cities (-0.41, p < .01). IMPLICATIONS: Application of constructed measures revealed inequity in PHC service delivery amenable to policy intervention. Initiatives should consider the maldistribution of GPs not only by remoteness but also by area disadvantage. Avenues for improvement in disadvantaged areas include preventative care across all regions and after-hours care in regional locations.

Inequalities in life expectancy in Australia according to education level: a whole-of-population record linkage study.

BACKGROUND: Life expectancy in Australia is amongst the highest globally, but national estimates mask within-country inequalities. To monitor socioeconomic inequalities in health, many high-income countries routinely report life expectancy by education level. However in Australia, education-related gaps in life expectancy are not routinely reported because, until recently, the data required to produce these estimates have not been available. Using newly linked, whole-of-population data, we estimated education-related inequalities in adult life expectancy in Australia. METHODS: Using data from 2016 Australian Census linked to 2016-17 Death Registrations, we estimated age-sex-education-specific mortality rates and used standard life table methodology to calculate life expectancy. For men and women separately, we estimated absolute (in years) and relative (ratios) differences in life expectancy at ages 25, 45, 65 and 85 years according to education level (measured in five categories, from university qualification [highest] to no formal qualifications [lowest]). RESULTS: Data came from 14,565,910 Australian residents aged 25 years and older. At each age, those with lower levels of education had lower life expectancies. For men, the gap (highest vs. lowest level of education) was 9.1 (95 %CI: 8.8, 9.4) years at age 25, 7.3 (7.1, 7.5) years at age 45, 4.9 (4.7, 5.1) years at age 65 and 1.9 (1.8, 2.1) years at age 85. For women, the gap was 5.5 (5.1, 5.9) years at age 25, 4.7 (4.4, 5.0) years at age 45, 3.3 (3.1, 3.5) years at 65 and 1.6 (1.4, 1.8) years at age 85. Relative differences (comparing highest education level with each of the other levels) were larger for men than women and increased with age, but overall, revealed a 10-25 % reduction in life expectancy for those with the lowest compared to the highest education level. CONCLUSIONS: Education-related inequalities in life expectancy from age 25 years in Australia are substantial, particularly for men. Those with the lowest education level have a life expectancy equivalent to the national average 15-20 years ago. These vast gaps indicate large potential for further gains in life expectancy at the national level and continuing opportunities to improve health equity.

Characterization of the public transit air microbiome and resistome reveals geographical specificity.

BACKGROUND: The public transit is a built environment with high occupant density across the globe, and identifying factors shaping public transit air microbiomes will help design strategies to minimize the transmission of pathogens. However, the majority of microbiome works dedicated to the public transit air are limited to amplicon sequencing, and our knowledge regarding the functional potentials and the repertoire of resistance genes (i.e. resistome) is limited. Furthermore, current air microbiome investigations on public transit systems are focused on single cities, and a multi-city assessment of the public transit air microbiome will allow a greater understanding of whether and how broad environmental, building, and anthropogenic factors shape the public transit air microbiome in an international scale. Therefore, in this study, the public transit air microbiomes and resistomes of six cities across three continents (Denver, Hong Kong, London, New York City, Oslo, Stockholm) were characterized. RESULTS: City was the sole factor associated with public transit air microbiome differences, with diverse taxa identified as drivers for geography-associated functional potentials, concomitant with geographical differences in species- and strain-level inferred growth profiles. Related bacterial strains differed among cities in genes encoding resistance, transposase, and other functions. Sourcetracking estimated that human skin, soil, and wastewater were major presumptive resistome sources of public transit air, and adjacent public transit surfaces may also be considered presumptive sources. Large proportions of detected resistance genes were co-located with mobile genetic elements including plasmids. Biosynthetic gene clusters and city-unique coding sequences were found in the metagenome-assembled genomes. CONCLUSIONS: Overall, geographical specificity transcends multiple aspects of the public transit air microbiome, and future efforts on a global scale are warranted to increase our understanding of factors shaping the microbiome of this unique built environment.

Lateral segmental mandibulectomy reconstruction with bridging reconstruction plate and anterolateral thigh free flap: a case series of 30 consecutive patients.

Lateral posterior segmental mandibular defects present a reconstructive challenge and an osseous flap would be the gold standard to reconstruct such a defect. However, combining a mandibular reconstruction plate (MRP) with a soft-tissue free flap (to restore mucosal integrity and provide durable coverage of the plate itself) offers an alternative option for posterior segmental mandibular defects in patients who are not suitable for osseous reconstruction, or do not choose it. We retrospectively reviewed 30 consecutive patients (19 male and 11 female) who underwent reconstruction of a segmental mandibulectomy defect using a bridging MRP and anterolateral thigh (ALT) free flap. The mean (range) age was 67 (31-87) years. The American Society of Anesthesiologists' (ASA) status of the study population comprised Grade 1 (n = 10), Grade 2 (n = 18), and Grade 3 (n = 2). The majority of patients had oral cavity squamous cell carcinoma (n = 26) involving the mandible, two had osteoradionecrosis, and two mucoepidermoid carcinoma. Four patients had complications specific to the reconstruction, and flap loss occurred in one (96.7% success rate). Metalwork infection occurred in three, including one plate extrusion and one plate fracture. The median length of stay was 10 days, and mean (range) duration of follow up 23.3 (1-96) months. This technique is an alternative reconstructive option for the non-tooth-bearing mandible. Reconstructing a posterolateral segmental mandibulectomy defect with a bridging MRP and ALT free flap offers a robust reconstructive alternative with a favourable complication profile.

Animating inter-organisational resilience communication: A participatory social network analysis of water governance in the UK.

Resilience as a concept and resilience assessment as a practice are being explored across a range of social, ecological and technical systems. In this paper, we propose a new method and visualisation approach for interrogating the communication of resilience within organisational networks, using participatory social network analysis and message passing. Through an examination of the UK water sector organisational network, represented by multiple co-produced network graphs, we identify organisations having a key role in the communication of resilience regulatory and evidence messages, as well as highlighting the potential role of complexity tools in strategy formulation. Animations are presented showing the dynamics of resilience communication, which is discussed. Reflections on the use of participatory social network analysis are explored, as the method opens new doors to potentially examine how network changes could alter communication. Key insights highlight that perceived responsibilities for resilience in the UK water sector rest with a small core of organisations; water customers play a limited role in the two-way communication of resilience and water sector organisations do not communicate widely on resilience with other sectors (such as energy). Additionally, who an organisations' neighbours are and what catalyses a message to be passed are important in determining how quickly messages spread. Results lead to a recommendation that high level governmental and policy organisations should engage to a greater extent with new resilience knowledge and consider the use of complexity tools in policy making. Policy in relation to resilience is not keeping pace with such knowledge, limiting the communication and learning of organisations who ardently follow policy and regulation. For inter-organisational cooperation to make a difference to water governance, such organisations need to be encouraged to communicate and embed the latest approaches in relation to resilience and complexity thinking and practice.

A Monte Carlo model of synchrotron radiotherapy shows good agreement with experimental dosimetry measurements: Data from the imaging and medical beamline at the Australian Synchrotron.

Experimental measurement of Synchrotron Radiotherapy (SyncRT) doses is challenging, especially for Microbeam Radiotherapy (MRT), which is characterised by very high dynamic ranges with spatial resolutions on the micrometer scale. Monte Carlo (MC) simulation is considered a gold standard for accurate dose calculation in radiotherapy, and is therefore routinely relied upon to produce verification data. We present a MC model for Australian Synchrotron's Imaging and Medical Beamline (IMBL), which is capable of generating accurate dosimetry data to inform and/or verify SyncRT experiments. Our MC model showed excellent agreement with dosimetric measurement for Synchrotron Broadbeam Radiotherapy (SBBR). Our MC model is also the first to achieve validation for MRT, using two methods of dosimetry, to within clinical tolerances of 5% for a 20×20 mm2 field size, except for surface measurements at 5 mm depth, which remained to within good agreement of 7.5%. Our experimental methodology has allowed us to control measurement uncertainties for MRT doses to within 5-6%, which has also not been previously achieved, and provides a confidence which until now has been lacking in MRT validation studies. The MC model is suitable for SyncRT dose calculation of clinically relevant field sizes at the IMBL, and can be extended to include medical beamlines at other Synchrotron facilities as well. The presented MC model will be used as a validation tool for treatment planning dose calculation algorithms, and is an important step towards veterinary SyncRT trials at the Australian Synchrotron.

Searching for the Optimal Treatment for Metallo- and Serine-ß-Lactamase Producing Enterobacteriaceae: Aztreonam in Combination with Ceftazidime-avibactam or Meropenem-vaborbactam.

Objective: Metallo-ß-lactamase (MBL)-producing Enterobacteriaceae, particularly those that co-harbor serine ß-lactamases, are a serious emerging public health threat given their rapid dissemination and the limited number of treatment options. Pre-clinical and anecdotal clinical data support the use of aztreonam in combination with ceftazidime-avibactam against these pathogens, but other aztreonam-based combinations have not been explored. The objective of this study was to evaluate the in vitro activity and compare synergy between aztreonam in combination with ceftazidime-avibactam and meropenem-vaborbactam against serine and MBL-producing Enterobacteriaceae via time-kill analyses. Methods: 8 clinical Enterobacteriaceae strains (4 Escherichia coli and 4 Klebsiella pneumoniae) co-producing NDM and at least one serine ß-lactamase were used for all experiments. Drugs were tested alone, in dual ß-lactam combinations, and in triple drug combinations against all strains. Results: All strains were resistant to ceftazidime-avibactam and meropenem-vaborbactam and 7/8 (87.5%) strains were resistant to aztreonam. Aztreonam combined with ceftazidime-avibactam was synergistic against all 7 aztreonam-resistant strains. Aztreonam combined with meropenem-vaborbactam was synergistic against all aztreonam-resistant strains with the exception of an OXA-232-producing K. pneumoniae strain. Neither triple combination was synergistic against the aztreonam-susceptible strain. Likewise, neither dual ß-lactam combination was synergistic against any strain. Conclusions: These data suggest that aztreonam plus meropenem-vaborbactam has similar activity to aztreonam plus ceftazidime-avibactam against Enterobacteriaceae producing NDM and other non-OXA-48-like serine ß-lactamases. Confirmation of these findings in future in vitro and in vivo models is warranted.

Pharmacokinetics and Dialytic Clearance of Isavuconazole During In Vitro and In Vivo Continuous Renal Replacement Therapy.

The pharmacokinetics (PK) and dialytic clearance of isavuconazole in vitro and in 7 solid organ transplant patients undergoing continuous renal replacement therapy (CRRT) were evaluated. In vivo, mean (± SD) plasma PK parameters of isavuconazole were: C max 4.00±1.45 mg/L, C min 1.76±0.76 mg/L, t ½ 48.36±29.78 h, Vss 288.78±182.11 L, CLss 4.85±3.79 L/h, and AUC 54.01±20.98 mg ⋅ h/L. Transmembrane clearance represented just 0.7% of the total isavuconazole clearance. These data suggest that isavuconazole is not readily removed by CRRT and no dose adjustments are necessary.

Try to see it my way: exploring the co-design of visual presentations of wellbeing through a workshop process.

AIMS: A 10-month project funded by the NewMind network sought to develop the specification of a visualisation toolbox that could be applied on digital platforms (web- or app-based) to support adults with lived experience of mental health difficulties to present and track their personal wellbeing in a multi-media format. METHODS: A participant co-design methodology, Double Diamond from the Design Council (Great Britain), was used consisting of four phases: Discover - a set of literature and app searches of wellbeing and health visualisation material; Define - an initial workshop with participants with lived experience of mental health problems to discuss wellbeing and visualisation techniques and to share personal visualisations; Develop - a second workshop to add detail to personal visualisations, for example, forms of media to be employed, degree of control over sharing; and Deliver - to disseminate the learning from the exercise. RESULTS: Two design workshops were held in December 2017 and April 2018 with 13 and 12 experts-by-experience involved, respectively, including two peer researchers (co-authors) and two individual-carer dyads in each workshop, with over 50% of those being present in both workshops. A total of 20 detailed visualisations were produced, the majority focusing on highly personal and detailed presentations of wellbeing. DISCUSSION: While participants concurred on a range of typical dimensions of wellbeing, the individual visualisations generated were in contrast to the techniques currently employed by existing digital wellbeing apps and there was a great diversity in preference for different visualisation types. Participants considered personal visualisations to be useful as self-administered interventions or as a step towards seeking help, as well as being tools for self-appraisal. CONCLUSION: The results suggest that an authoring approach using existing apps may provide the high degree of flexibility required. Training on such tools, delivered via a module on a recovery college course, could be offered.

Text-message responsiveness to blood glucose monitoring reminders is associated with HbA1c benefit in teenagers with Type 1 diabetes.

AIMS: To evaluate an 18-month text-messaging intervention in teenagers with Type 1 diabetes and to assess factors associated with text responsiveness and glycaemic benefit. METHODS: Teenagers with diabetes (N = 147), aged 13-17 years, received two-way text reminders at self-selected times to check blood glucose levels and reply with blood glucose results. RESULTS: At baseline, the participants (48% boys, 78% white, 63% pump-treated) had a mean ± sd age of 14.9 ± 1.3 years, diabetes duration of 7.1 ± 3.9 years and HbA1c concentration of 69 ± 12 mmol/mol (8.5 ± 1.1%). The mean proportion of days with ≥1 blood glucose response declined over time (0-6 months, 60 ± 26% of days, 7-12 months, 53 ± 31% of days, 13-18 months, 43 ± 33% of days). Over 18 months, 49% responded with ≥1 blood glucose result on ≥50% of days (high responders). Regression analysis controlling for baseline HbA1c revealed no significant change in HbA1c from baseline to 18 months in high responders (P = 0.54) compared with a significant HbA1c increase in low responders (+0.3%, P = 0.01). In participants with baseline HbA1c ≥64 mmol/mol (≥8%), high responders were 2.5 times more likely than low responders to have a clinically significant [≥5.5 mmol/mol (≥0.5%)] HbA1c decrease over 18 months (P < 0.05). In participants with baseline HbA1c <64 mmol/mol(<8%), high responders were 5.7 times more likely than low responders to have an 18-month HbA1c <58 mmol/mol (<7.5%; P < 0.05). CONCLUSIONS: Teenagers with Type 1 diabetes who responded to text reminders on ≥50% of days over 18 months experienced clinically significant glycaemic benefit. There remains a need to tailor interventions to maintain teenager engagement and optimize improvements.

Early Evidence for Northern Salmonid Fisheries Discovered using Novel Mineral Proxies.

Salmonid resources currently foster socioeconomic prosperity in several nations, yet their importance to many ancient circumpolar societies is poorly understood due to insufficient fish bone preservation at archaeological sites. As a result, there are serious gaps in our knowledge concerning the antiquity of northern salmonid fisheries and their impacts on shaping biodiversity, hunter-gatherer adaptations, and human-ecological networks. The interdisciplinary study presented here demonstrates that calcium-magnesium phosphate minerals formed in burned salmonid bones can preserve at ancient northern sites, thus informing on the early utilization of these resources despite the absence of morphologically classifiable bones. The minerals whitlockite and beta magnesium tricalcium phosphate were identified in rare morphologically classifiable Atlantic salmonid bones from three Mid-Holocene sites in Finland. Large amounts of beta magnesium tricalcium phosphate were also experimentally formed by burning modern Atlantic salmonid and brown trout bones. Our results demonstrate the value of these minerals as proxies for ancient northern salmonid fishing. Specifically, the whitlockite mineral was discovered in hearth sediments from the 5,600 year old Yli-Ii Kierikinkangas site on the Iijoki River in northern Finland. Our fine sieving and mineralogical analyses of these sediments, along with zooarchaeological identification of recovered bone fragments, have confirmed for the first time that the people living at this village did incorporate salmonids into their economies, thus providing new evidence for early estuary/riverine fisheries in northern Finland.

COMPARISON OF PERSONAL DOSE EQUIVALENT Hp(10) IN 137CS RADIATION BETWEEN THE PRIMARY STANDARDS LABORATORIES OF JAPAN AND AUSTRALIA USING BeO OSL PERSONAL DOSEMETERS.

A comparison of personal dose equivalent Hp(10) for 137Cs radiation was conducted between the primary standards laboratories of Japan and Australia. A set of 120 commercially available passive BeO OSL dosemeters were used (Dosimetrics GmbH, Munich). The aim was to investigate the precision which could be obtained with this technique, and to confirm the personal dose equivalent delivery methods in each standards laboratory. A dose of 5 mSv was delivered to 40 dosemeters in each country, and 40 dosemeters were used as controls. The result of the comparison was a ratio of Hp(10) in Japan to Australia of 1.006 with a combined standard uncertainty of 3.2%. The statistical uncertainty was 0.32% indicating that passive dosemeters can be used for comparisons of high precision.

Emotional labour and aboriginal maternal infant care workers: The invisible load.

BACKGROUND: The term 'emotional labour' has been used to describe the competing demands on midwives to empathize with clients whilst maintaining a level of professional detachment. Previous research indicates that when individuals experience difficulty managing these emotions, burnout may result. Aboriginal health care workers often have roles with large emotional demands, as they are relied upon heavily to engage clients in care. However, the concept of emotional labour has received little attention in relation to this group. AIM: To explore potential sources of emotional labour for Aboriginal Maternal Infant Care workers in a maternity care program for Aboriginal women in South Australia. The program involves these workers providing care for women in partnership with midwives. METHODS: We employed a phenomenological approach. Thirty in-depth interviews were conducted with staff and clients of the program. Recorded interviews were transcribed and coded and emerging themes identified. FINDINGS: This workforce undertakes extensive emotional labour. Key sources include the cultural and family obligations they have to clients, complex social needs of many clients, and potential for community backlash when poor perinatal outcomes occur. A lack of respect for the role within the workplace further contributes to these experiences. CONCLUSION: This study found that the responsibilities inherent to the role as both cultural broker and carer create significant emotional labour for workers. Recommendations to address this and enhance the sustainability of this workforce include: recognition and valuing of emotional work by management and other staff, enhancing cultural awareness training, and building stress-relieving activities into the workplace.