Melbourne School of Population and Global Health - Theses
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ItemWorking it out: A social epidemiological analysis of labour force status, mental health, and disability among young Australians( 2022)Background Young people with disabilities are more likely to have poorer employment and mental health outcomes. However, the relationship between labour force status, mental health, and disability is less understood among young people, despite improvements in employment outcomes representing a feasible way to reduce the mental health inequalities experienced by young people with disabilities. This thesis aims to a) quantify the effect of labour force status on the mental health of young people with disabilities, b) explore which groups of young people with disabilities are most at risk of poorer labour force outcomes and c) identify and appraise existing research exploring how employment conditions and psychosocial workplace exposures impact the mental health of young people when they are in employment. Methods Four of five studies in this thesis used nationally representative Australian data sources. Studies I and II used effect measure modification to assess whether disability status modified the association between labour force status and mental health. The third study used causal mediation analysis to quantify the total causal effect of disability status on the mental health of young adults, and then determine the amount of the effect that operates through employment status. Study IV used group-based trajectory modelling and multinomial logistic regression to identify patterns of disability throughout early life and associations with labour force outcomes as a young adult. The fifth study used systematic review methods to ascertain existing knowledge regarding the associations between employment conditions and psychosocial workplace exposures and mental health among young people. Results Studies I and II indicated unemployment is associated with poorer mental health among young people, with Study II additionally finding that disability status modified the employment status-to-psychological distress relationship such that young people with disabilities who were unemployed had significantly higher levels of distress. Expanding on these results, Study III revealed that two consecutive years of reporting a disability led to a clinically significant decline in mental health, with part of this decline operating through employment status. Trajectory modelling in Study IV identified four distinct patterns of disability status, and regression modelling suggested individuals in the low-increasing trajectory were at increased risk of unemployment in early adulthood, while individuals with a consistently high prevalence of disability were at increased risk of being not in the labour force. Studies identified in the systematic review were limited in scope and quality, precluding a focus on young people with disabilities and highlighting a need for higher quality research. Conclusion These findings indicate that improving employment outcomes among young people with disabilities would likely contribute to reductions in the mental health inequalities experienced by this group. Improving existing programs, supports, and other interventions to help secure employment for young people with disabilities who want to work is a feasible way to improve the mental health of this group. However, further research must clarify how employment conditions and psychosocial workplace exposures are associated with mental health outcomes to ensure that employment for young people with disabilities optimizes mental health outcomes.
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ItemInvestigating people-centred mental health care in Timor-Leste( 2020)Despite the increased emphasis placed on people-centred mental health care in low- and middle-income countries (LMICs), until this study, there has been no systematic investigation of the paradigm outside Western high-income country settings. Timor-Leste, a lower middle-income country in South-East Asia, is in the process of strengthening its national mental health system to align with people-centred approaches to mental health care. This thesis critically investigates people-centred mental health care in community settings, mental health services, and the mental health system in Timor-Leste. This study aimed to enhance the understanding of the acceptability and feasibility of people-centred mental health care in Timor-Leste. The study's primary aim was to inform Timor-Leste's ongoing mental health system strengthening, and its secondary aim was to identify potential implications for the implementation of the people-centred paradigm in other LMICs. The study employed mixed-methods framed through a socio-ecological lens to understand the people-centred mental health care paradigm in Timor-Leste across multiple levels of analysis. In-depth semi-structured interviews were conducted with 85 stakeholders from different groups across national and sub-national sites. Informal observation in government and non-government mental health and social care services and a review of publicly available documents were also undertaken. A quantitative complex systems analysis was employed to measure intersectoral collaboration in the national mental health system. At the community level, the study found a family-centred ecology of mental health in which the needs, preferences and rights of individuals were subordinated to those of their family. Timorese people with mental illness experienced multi-faceted social exclusion, but also had opportunities for social inclusion. At the mental health service level, sociocultural and medical power hierarchies shaped decision making. Priorities for mental health care for families, communities, service providers, decision makers and civil society were influenced by Timor-Leste's broader development context and its lack of resources for health services. At the mental health system level, holistic understandings of health and well-being and the need to overcome resource restrictions provided opportunities for intersectoral collaboration in mental health. A split in stewardship for mental health governance between health and social sectors was detected. There was also limited participation in mental health system governance by people with mental illness, their families and communities. The study evinced that employing a socio-ecological framework allowed for a deeper consideration of Timor-Leste's sociocultural and development contexts while acknowledging the common elements in people-centred mental health care. The findings present a compelling case for the consideration of both individual and collective care and social rights in global mental health. The implementation of peoplecentred mental health care should be viewed as a staged process to account for limited resources, capacities and priorities for countries. The findings highlight the vacuum of research on the power relations inherent in the concept of people-centred mental health care, its implementation and the hierarchies of knowledge on which the paradigm is based. Accounting for local cultural knowledge and understandings will strengthen the design and implementation of people-centred mental health care in LMIC settings.