Melbourne School of Population and Global Health

This thesis explores policy and service delivery for adolescent and young adult or ‘transition age’ mental health service users aged 16-25 across different jurisdictions in the UK and Australia. The study explores the implications that policy formulation and implementation have for service delivery in these different contextual settings; and examines how young people (who are at a vulnerable stage developmentally in terms of mental health), have their access to services affected by the existing policy framework. A policy analysis was conducted along with qualitative interviews in six case sites (three in the UK and three in Australia). The thesis adopted a critical realist approach using a laminated cross-sectional interview strategy that was developed to include interviews with national policy makers; local policy makers and service managers; staff working within services; and the young people whom were accessing services as the recipients of policy. Findings from this thesis explore how young people use risk escalation as a way of managing delays to treatment and how practitioners identify particular difficulties for young people transitioning in services when they are due to ‘step up’ into more acute services, or ‘step down’ to a less intensive service. The thesis explores the implications and unintended consequences for young people of policy including processes of ‘cost-shunting’ and ‘resource envy’ at local and national levels. Finally, the thesis offers some learning for systems working to support 16-25 year olds through demonstrating the importance of the dual role of ‘curing’ and ‘caring’ in mental health services.

Child care quality matters to children’s lives now and in the future, hence it matters to the wellbeing and prosperity of society. The quality of child care in family day care is particularly critical as it is provided by one practitioner in their home during formative years of a child’s development. In Australia approximately 14,000 family day care providers operate regulated home-based child care services for over 130,000 children annually. Working conditions are testing in family day care. Most Australian family day care is supplied through a sole operator, small business model in relative isolation under increasing government requirements. This intrinsically rewarding work is conducted in exchange for poor external compensation, including low respect and income. Working conditions in family day care are likely to risk providers’ mental health and, in turn, children’s experiences and outcomes. Hence understanding what promotes, protects or diminishes the mental health of providers is vital. This study aims to understand the relationship between working conditions, provider mental health and care quality in family day care with a view to informing mental health promotion interventions. In order to address this aim I used a mixed methods design that included a systemic review, semi-structured interviews and an epidemiological survey. This investigation adopts a critical inquiry perspective and references theories of social exchange and emotional labour. This research revealed that a substantial proportion of family day care educators (42%) reported moderate to severe psychological distress, and that it is very likely to compromise the quality of their child care practice, as care quality and educators’ mental health are intertwined. Exhibiting and/or having good mental wellbeing was part of a caring identity that providers needed to be seen as a good family day care educator. Hence, emotional labour was routinely practiced to protect educators’ care quality, their caring identities and their livelihoods. Most educators reported overcommitment to family day care. Demonstrating overcommitment bolsters their caring identities and was a response to high demands and poor working conditions in a job that has great individual responsibility. The research established that educators’ mental health is diminished by unfair and poor quality working conditions, which are common in family day care. These conditions are largely created at the macro level by welfare state and market actions that are underpinned by gender and class inequities. However, at a meso level, educators’ mental wellbeing could be somewhat protected and promoted by interactions with family day care coordination scheme staff and clients (parents and children) that were respectful, fair and supportive, both personally and professionally. An integrated conceptual model is presented that uses the study findings and key theories from the research to connect the macro, meso and micro context of family day care. The model shows that educators have little opportunity to improve their working conditions and that interventions targeted at the individual level to promote their mental health will carry with them serious negative consequences. This research demonstrates that upstream, macro level interventions that take into account the roles of structural determinants in creating exploitative conditions in family day care are needed to promote the mental health of educators. The success of such interventions will bring benefits to educators, children in their care, and the communities and societies in which they live.

Melbourne School of Population and Global Health - Theses

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