Melbourne School of Population and Global Health - Theses
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ItemMental health of primary care attendees in Kota Kinabalu, Sabah( 2018)This PhD thesis aims to investigate the mental health problems, care and service among the government clinics in Sabah, Malaysia, focusing on one of the most densely populated districts of Kota Kinabalu. Background behind undertaking of this project was based on existing epidemiological facts and studies from Sabah and peninsular Malaysia is presented. The lack of adequate mental health services, mental health research, poverty, immigration and other specific issues that are discussed in the literature review. This is a cross-sectional, general health clinic-based study among primary care attendees in the Kota Kinabalu district of Sabah. Aim: The study was designed to determine the prevalence of common mental disorders among primary care attendees in Kota Kinabalu and to identify the associated factors. It also determined the treatment gap, disability and perceived need for psychiatric treatment and care and mental health service utilization among primary care attendees with probable common mental disorder. Method: Simple random sampling method was used to select patients at three government general outpatient clinics. A total of four hundred and eighty-one patients were invited to participate. Four hundred and thirty agreed and fifty-one patients (10.6%) refused. Respondents were further interviewed by trained interviewers using a standard proforma to obtain socio-demographic data and clinical profile, Patient Health Questionnaire (PHQ), Work and Social Adjustment Scale (WSAS), General Practitioner User Perceived Need Questionnaire and Mental Health Service Utilization Questionnaire. Results: The prevalence of common mental disorders among primary care attendees were 52.1%, with 224 out of 430 respondents having a probable common mental disorder. This was higher than the previous two studies done in West Malaysia, where the prevalence of mental disorder in the primary care setting was found to be 24.7% and 26.7% respectively. Ninety-five respondents (22.1%) had more than one psychiatric diagnosis. Using univariate analysis: young age, female, monthly income less than RM1000 (1AUD=RM2.97), unemployment, student, secondary/tertiary education and recent stressors were all significantly associated with common mental disorder (PHQ positive). Using a logistic regression method, five factors were significantly predictive of common mental disorders. These were young age (18-29 years of age), female gender, higher education, income less than RM1000 and history of being physically or sexually victimized. Two hundred and nineteen (97.8%) out of two hundred and twenty-four respondents with common mental disorder had some form of disability. One hundred and sixty-three (72.8%) were slightly disabled, thirty-seven respondents (16.5%) were moderately disabled and nineteen (8.5%) were severely disabled. There was a significant and consistent positive association between the moderate disability and co-morbid common mental disorder in nearly all items of disability. The severely disabled group was shown to have a positive association with co-morbidity in two of five items of disability. These were private leisure activities and family relationship. Two hundred and five, out of two hundred and twenty-four respondents with a common mental disorder were not receiving any treatment. This was a treatment gap of 91.5%. Twenty-four respondents sought help from a traditional healer, twelve went to other professional mental health services and only three were seen by psychiatrist. Only four patients had been admitted to a psychiatric ward. The most sought out mental health services in this population were counselling (49.1%) and mental health information (41.1%). The least common mental health service provided was for medication (20.5%). The most common reason given for not accessing mental health services or treatment was “I preferred to manage myself the problem”.
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ItemInterrupting knowledge, decolonising care: understanding mental health with a refugee-run NGO in Sydney, Australia( 2017)Any expression of medical pluralism will reflect the organisation and hierarchisation of its traditions of knowledge. My thesis attends to moments in which diverse understandings of mental affliction are negotiated, and sometimes even silenced, in the networks and relationships surrounding a Sydney NGO. Here, alongside this NGO run for and by people from Central Africa, I explore approaches to questions of what mental affliction is, various notions of who (mis)understands it, and how afflictions and their percieved misunderstanding are dealt with. In the process, the category of ‘mental health’ emerges and disappears, is challenged and negotiated, within jostling epistemological frames of understanding. To examine this therapeutic landscape, I prioritise modes of analysis that are sensitive to the fluctuating complexities of caring for community through existing, yet not always equitable, structures for such care. I draw on affect theory’s slowness and attunement to the unseen, often unarticulated forces that unfold in encounters, conversations and in what is articulated (Stewart 2017: 192). Affective scenes provide an access point to each chapter's textured study of the refugee-migrant community health assemblage, which is examined in terms of: historical context (Chapter One), NGO sector development (Chapter Two), education (Chapter Three), belief (Chapter Four), faith (Chapter Five), and care (Chapter Six). Through such attention, this thesis asks after what medical pluralism looks like when a group of people with histories of a range of healing traditions—psychiatry, cosmopolitan medicine, religious faith healing, and spiritual cleansing of curses—move to Australia? How were these different knowledge traditions treated and talked about? And how could one meaningfully study these pluralities?—what would anthropological research and ethnographic writing, as modes of knowledge creation, come up against in trying to engage with plural traditions of knowledge? Through representational sensibilities, moments of ethnographic attention and narratives that circle back and interrupt themselves, this thesis builds an argument for ambivalence towards conclusive uses of knowledge. Ambivalence is presented as a counter to the kinds of simplified understandings of diversity that are often salient in the migrant health and community development sector, and that are shown, through this ethnography to beget subtle, structurally violent effects. I frame such ambivalence as an act of care. Part examination of the tensions “between fragmentation and connectedness-in-the-making” (Biehl and McKay 2012: 1210), part portrait of the tensions held in suspense when crafting an ethnography of knowledge(s), my work seeks to contribute to the decolonisation of knowledge and care.
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ItemMental health service delivery for adolescents and young people: a comparative study between Australia and the UK( 2016)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.
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ItemMigration experience, resilience and psychological outcomes: an exploratory study of Iranian immigrants in Australia( 2015)Migration is often a challenging and life changing experience. The challenges of migration can provide opportunities for growth and resilience and can also adversely influence mental health and well-being. To explore these issues as they apply to Iranians who migrated to Australia, this study investigated resilience and the psychological outcomes of subjective well-being and psychological problems among Iranian immigrants living in Australia. A mixed methods design was employed. In the first part of this study, quantitative data were collected through an online questionnaire that included questions from the Migration and Settlement Questionnaire (MASQ), the Resilience Scale for Adults (RSA), the Personal Well-being Index (PWI), and the Depression Anxiety Stress Scale (DASS-21). The online survey was completed by 182 Iranian immigrants living in Australia. The second part of the study was a qualitative analysis, engaging individuals, who completed the questionnaire and were invited to participate in semi- structured interviews to complement the findings of the questionnaire. The quantitative findings of this study indicate lower levels of subjective well-being and higher levels of all the psychological problems explored here (psychological distress, depression, anxiety and stress). These were present in participants who were unemployed, had an incomplete tertiary education, or those who had lived in Australia for less than 5 years, and were younger and unmarried (p < 0.05). Higher levels of depression were found in participants who had experienced high levels of discrimination (p < 0.05). Lower levels of well-being and higher levels of anxiety were found in refugee participants (p < 0.05). Higher levels of well-being were reported by participants who had a proficient user of the English language. The incidence of these difficulties was as follows: depression (26%), anxiety (32%) and stress (25%). The quantitative findings have shown that resilience mediated the association between personal well-being and migration category, as well as marital status. It partially mediated the association between satisfaction with life as a whole and migration category. This study also suggests that resilience mediated the association between discrimination and depression. It partially mediated the association between marital status and the level of education, and psychological distress, anxiety or depression. Resilience also partially mediated the association between migration and anxiety. In addition, the quantitative findings of this study have shown that the resilience domains of personal and social competencies were the strongest predictors of PWI, psychological distress, depression or stress. Personal competency was the only key predictor of anxiety and satisfaction with life as a whole. An analysis of the qualitative results revealed two main themes that could be described as integration risk and integration protective, which contribute to well-being for Iranian immigrants in Australia. Integration risk factors that were linked to lower levels of well-being were common difficult emotions - grief of separation, social isolation, loneliness and acculturative stress. Other factors associated with being a refugee, pre-migration trauma and negative experiences in detention centres, unpleasant post-migration experience, the Australian English accent, extent of the difference between Australian and Iranian social and cultural norms, and the lack of knowledge about Australian laws and rights. Other themes include shorter duration in Australia; unemployment, underemployment and social and emotional concerns about limited work opportunities; having high educational qualifications at the time of migration; having started but not completed tertiary education; experiences of discrimination; a lack of knowledge about Iran and Iranian culture in Australia; family issues (e.g., conflict between parents and children); tensions over Iranian cultural practices (e.g., controversy surrounding the wearing of the Hijab); and internal community conflict (e.g., the issue of trust) were also associated with lower levels of well-being. Several protective factors were identified to reduce migration related distress and maintain Iranian immigrants’ well-being and to assist them with the process of adapting to life in Australia. These factors were positive personality traits, that is, spirituality, a sense of humour, personal competency and self-coping strategies; and supportive integration themes of English proficiency, access to an interpreter, a longer duration in Australia, understanding Australian culture, having a positive pre-migration view of Australia, experience of higher levels of gender equality, a general feeling of greater post-migration freedom, and multicultural experiences. In addition, other factors - of being married, higher education; meaningful employment; access to social and family support and strong social networks; engaging in Iranian cultural practices (e.g., celebrating Iranian national holidays) and being proud of their Iranian nationality were associated with higher levels of well-being. There were also some themes which seem to be a risk factor for some participants while served as a protective factor for others, for example, the level of education at the time of migration. This study has limitations that must be considered when interpreting the results. Findings of this study highlight the need for policy and program interventions to prevent and reduce psychological problems and suggest several possible approaches to promote the well-being of immigrants. These include improving employment opportunities, reducing discrimination, approaches that minimise the stress of the settlement process, and interventions that aim to strengthen resilience. This study thus highlights the need for further research to assess whether interventions that strengthen resilience can reduce psychological problems and promote the well-being of Iranians as well as other immigrant communities living in Australia.
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ItemArt, schizophrenia and becoming: a diffractive analysis investigating the productivity, connectedness and social contribution experienced by art-makers who live with schizophrenia diagnoses( 2016)This thesis investigates ten art-makers, who have been living with a diagnosis of schizophrenia for more than ten years. It uses in-depth research encounters and Deleuzoguattarian/Baradian thinking to investigate the role art-making plays in fostering wellbeing and community engagement. With a style of ethnography devised in response to the particular experiences of art-maker participants, it seeks to affirm difference, rather than conforming to traditional approaches that look for patterns of sameness. Using Deleuzian concepts, which re-think subjectivity to focus on connections and relations, and conceive schizophrenia as a process of change, the thesis engages with different assumptions about life and health in the analysis of participants’ experience. Notions of ‘finding expression for difficult experiences’ are found to be consistent to both a Deleuzian conception of ‘the work of art’, and the work of approaches that resist pathologising schizophrenia, such as Soteria, Open Dialogue and the Hearing Voices Movement. In using a Deleuzian conception of art as a way to make ‘sense’ of life, the thesis engages with a much broader territory than has traditionally been used to consider the role of art-making in the lives of people with schizophrenia diagnoses. It researches art as a powerful instrument of change in the lives of participant art-makers. The findings challenge presumptions about the limiting effects of mental health problems by showing that, as well as contributing to creatively rich and socially connected lives, engagement through the arts enables participants to become advocates for social inclusion and destigmatisation. This research has real life implications in policy making and as a springboard for more research into experiential wisdom, the expression of difference, and inclusion in the field of mental health. It has broader implications for thinking, knowing and doing on the ‘work of art’, in the fields of the arts, art therapy, and in education.
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ItemA cross-sectional study of depression, anxiety and suicidal ideation and attempts among men who inject drugs in Delhi, India( 2014)Studies from high-income countries report a high prevalence of suicide and symptoms of common mental disorders among people who inject drugs (PWID), an important group for human immunodeficiency virus (HIV) prevention interventions. Research in India has largely overlooked the mental health of this high-risk group, including the risk factors for suicide and the impact of poor mental health on risky injecting and sexual practices. The aim of this study was to strengthen understanding of the common mental health problems faced by PWID in Delhi, India and the implications of these for suicide prevention and mitigation of HIV transmission risk. This study utilised data from a cross-sectional survey of 420 PWID recruited from needle and syringe programs (NSPs) in Delhi to generate a range of novel findings in relation to the four research questions: 1) What are the quality of life and socio-economic characteristics of PWID in Delhi? 2) What is the prevalence of symptoms of depression and anxiety and suicidal ideation and attempts? 3) What are the psychological and social correlates of suicidal ideation and attempts? 4) And, are symptoms of depression, anxiety and suicidal ideation associated with engagement in risky injecting and sexual practices? Descriptive findings profile the poor quality of life and psychosocial vulnerabilities of an impoverished and isolated sub-population of PWID. Their lives were characterised by health risk behaviours, broken and disrupted social relationships, extremely poor living conditions and a challenging broader community context. Additionally, a disconcertingly high prevalence of depressive and anxiety symptoms and suicidal ideation and attempts was observed. Significant risk factors differentiated suicidal PWID from non-suicidal PWID. Depressive and anxiety symptoms, in combination with social stressors including poor physical health, a long history of injecting drug use, experiences of violence, sexual abuse, housing insecurity, and strained marital and familial relationships were significant suicide risk factors and ought to be given due consideration in urgently needed suicide prevention strategies. The high prevalence of suicidality in this community is an important issue in and of itself, but it also has direct implications for HIV prevention. Needle / syringe sharing and unprotected sex were very common and suicidal thoughts were strongly associated with increased injecting and sexual risk behaviours. Strategies that address the drivers of suicidality in this sub-population could enhance HIV prevention efforts. The findings present a compelling case for the integration of mental health care into programs working with PWID in Delhi. Community-based initiatives are needed to increase access to appropriate mental health services, prevent suicide deaths, and mitigate HIV transmission risk.
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ItemFair care? Exploring the relationships between working conditions, educator mental health and care quality in family day care( 2015)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.
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ItemPsychological morbidity among women bereaved of a child in the 2008 Sichuan earthquake who have and have not given birth to a subsequent child( 2013)Background: Exposure to natural disasters and bereavement of a child are each associated with increased risk of mental health problems including depression, anxiety, post-traumatic stress disorder (PTSD) and complicated grief. People who have faced these circumstances simultaneously through losing a child, especially their only child, in a natural disaster may therefore have high vulnerability to psychological morbidity in the long-term, but to date there have been no systematic investigations. There is some evidence shown that adequate professional and social support and having seen the deceased child’s body prevent sustained psychological morbidity. However, the effect of having a subsequent child on women’s psychological status in this situation is unknown. The aims of this study were: a) to investigate the prevalence of symptoms of anxiety, depression, PTSD, and complicated grief in women thirty months after they had experienced the death of a child in the 2008 Sichuan earthquake in China; b) to compare the prevalence of symptoms of these non-psychotic psychological conditions between women who had given birth to a subsequent child and those who had not. Methods: Women aged 18-44 years old at the time of the earthquake who had been bereaved of a child aged up to 18 were eligible to participate. Data were collected via a cross-sectional survey by using individual structured local-language interviews that incorporated standardized psychometric measures. Findings: A total of 226 women provided complete data. Overall 34% (76/226) of the women had clinically significant symptoms of anxiety, 82% (186/226) of depression, 54% (132/226) of PTSD, and 89% (201/226) of complicated grief. In total 82% (186/226) of the women had symptoms of more than one psychological problem. The most prevalent co-morbidity was co-occurring symptoms of depression, PTSD and complicated grief (73/226, 32%). Symptoms of anxiety (OR: 3.37, 95%CI: 1.51-7.50), depression (OR: 9.47, 95%CI: 2.58-34.80), PTSD (OR: 5.11, 95%CI: 2.31-11.34) or PGD (OR: 10.73, 95%CI: 1.88-61.39) were significantly higher among women who had not had a child since the earthquake than those who had. Discussion: Despite the implementation of post-disaster interventions and increase in psychiatric services established in the area, psychological morbidity was widespread among women thirty months after bereavement of a child in this earthquake, but prevalence was lower among women with a subsequent child. Differences in roles and cultural norms between genders, inadequate social support and limited professional support and community interventions may contribute to these outcomes. The data indicated a need of stepped approach to long-term post-disaster interventions for these women. More evidence is required on the development and evaluation of the interventions, as well as the investigation on the development of the subsequent child as most of them being cared for by mothers with clinically significant psychological symptoms, which might reduce caregiving capabilities.
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ItemWhat is the most suitable disease management model for COPD?: Identifying effective and cost-effective programs for treating COPD( 2013)Pulmonary Rehabilitation (PR) has been developed to target the physical function recovery, and Cognitive-Behavioural Therapy (CBT) has become a potentially useful treatment for managing depression and anxiety disorders induced by COPD. However, it has been difficult for health providers to select appropriate program models because there has been insufficient knowledge of the effectiveness and the cost-effectiveness of these two programs. This thesis therefore aims to investigate in two important questions: 1. What is the optimal model of a PR program that can provide sustained effects with cost-effectiveness? 2. How can more information be provided about the effectiveness and cost-effectiveness of CBT programs by conducting more trials with more robust study designs? This thesis has two parts to its current study of the effectiveness and the cost-effectiveness of PR and CBT and Part B is built on the results from Part A: PART A of the thesis focuses on the effectiveness of PR and the potential cost-saving through reduction of hospital readmission. In previous studies there has been no empirical study measuring the long-term effects of PR up to one year. More importantly, previous meta-analysis studies do not consider the difference of the study designs in their analysis and so create the problem of "comparing apples with oranges." This study is the first study to apply systematic review, meta-analysis and meta-regression analysis to summarize those PR components that are the most critical in producing a lasting improvement for COPD patients. Statistical program, R, is applied for the meta-analysis and meta-regression analysis. Random-effect model is applied for the meta-analysis, and mixed-effect model is applied for the meta-regression analysis. The meta-analysis in this study is the first empirical research to demonstrate that PR components produce both short-term and long-term effects up to one year. The summarized effects indicate that PR components can improve HRQoL of COPD patients by an SGRQ score of -4.33, 95% CI(-5.8, -2.87) in the short-term and -3.7, 95% CI (-6.34,-1.06) in the long-term. The meta-regression analysis further identifies the critical components of PR, which produce the effects lasting up to one year, as the scheduled exercise and the home-based training. PART B: PART B gives the protocol of an economic evaluation alongside with a telephone-based CBT trial and is the first economic evaluation of telephone-based CBT for COPD patients. Cost-utility analysis and cost-effectiveness analysis are applied. A telephone-based program is believed to improve the accessibility of patients to the service. This economic evaluation uses the societal perspective with a life-long time-frame. Patients aged over 45 with stable COPD and mild to moderate depression or anxiety have been recruited. 70 patients are in each arms of the study. The study is a randomized-controlled trial. The time-frame of this trial is 16 weeks, including 8 weeks of treatment program and 8 weeks to observe the prolonged effects. The measurement of outcomes includes the effectiveness measurements of depression measurement - PHQ-9, anxiety measurement – BAI, and the disease-specific measurement of the COPD Assessment Test (CAT). For the utility measurement, AQOL-4D is applied. In order to capture the costs for COPD patients, new cost diaries and questionnaires are developed based on the characteristics of COPD patients. A Markov model will be established to extrapolate the effects beyond the clinical trial. Sensitivity analysis is also applied in order to explore the uncertainties of this study. The economic evaluation from this study will be a unique, current and important assessment for the management of COPD. Overall, this thesis highlights the home-based training of PR is an important component to produce lasting effects. This study does not show that PR components other than scheduled exercise training and home-based training produce significant impacts lasing for 1 year. It is recommended more robust study designs with appropriate time-frame is needed to investigate the effects of these PR components on HRQoL and reduction of hospital readmission. The economic evaluation protocol of this thesis further provides an opportunity to explore not only the effects of CBT for COPD patients, but also the cost-effectiveness of providing this service.
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ItemExamining Victoria’s disaster mental health capacity: towards systematic disaster mental health workforce and service planning( 2013)Natural disasters increasingly impact on the Victorian population, resulting in greater calls on mental health services and providers of psychosocial support. However, little is known about Victoria’s capacity to respond to the mental health consequences of major natural disasters. It is therefore timely to examine key indicators of Victoria’s disaster mental health service and workforce capacity and to examine the strengths and limitations of current approaches to building such capacity in view of future natural disasters. To this end, the current thesis examined key indicators of, and current approaches to building, Victoria’s disaster mental health service and workforce capacity in the context of the response to Australia’s largest bushfire disaster, the Victorian Black Saturday Bushfires. Through a series of four studies, this thesis investigated strengths and limitations of novel service delivery models and capacity building approaches, and the profile and capacity of the Victorian disaster mental health workforce. Study findings will inform a more strategic approach to disaster mental health workforce and service planning, sustainable capacity building and enhanced provision of best practice mental health support to disaster-affected Victorians in the future.