Melbourne School of Population and Global Health - Theses
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ItemA Cultural Adaptation of the World Health Organization’s Mental Health Gap Intervention Guide for use in Community Healthcare Centres, in Shenzhen, China( 2022-11)Over the last decade, China has instigated substantive national health system reform and established a new primary healthcare sector. Shenzhen, China’s flagship of innovation, rapidly developed a network of Community Healthcare Centres (CHC), doubled its medical workforce and now aspires to provide high quality person-centred care. Newly appointed doctors, however, have received limited mental health training and are insufficiently equipped to identify and manage depression. Against a backdrop of high depression prevalence and limited mental health literacy, most depression cases continue to go undetected and untreated. The World Health Organization’s (WHO) Mental Health Gap Intervention Guide (mhGAP- IG.v2), is a decision-support tool for non-specialists, to support assessment, management and follow-up of priority mental, neurological and substance use disorders, including depressive disorder. mhGAP-IG.v2 offers CHCs an evidence-based training resource, however, it requires adaptation to take account of China’s unique healthcare system and cultural context for mental health services. This PhD study is the first in China to involve primary healthcare in the adaptation of the depression component of mhGAP-IG.v2 for the community healthcare context. Designed as a mixed-methods study, it applies the Theoretical Domains Framework (TDF), innovative mental health workshops and the Delphi approach to: 1) explore the current barriers and enablers to depression care in the CHC setting; 2) to compare the mhGAP-IG.v2 against the current clinical practice; and 3) to elicit consensus among primary care doctors to inform the adaption of mhGAP-IG.v2. This research presents the proposed adaptation of mhGAP-IG.v2 for each step of assessment, management, and follow-up of depression. Proposed adaptations include: modifications of the format and content of symptom listings to reflect the cultural nuances; country-specific healthcare priorities and a life course approach for primary care; restructuring of the management section to better reflect CHC role as a key coordinator of intersectoral care; and full replacement of the follow-up section with action-oriented templates for a mental health treatment plan and follow-up review summary to support patient-centred care. Supplementary charts provide additional guidance for person-centred enquiry, the use of assessment instruments and managing patient information. Family members are incorporated as a vital resource to care. Increased attention to suicidal risk is emphasised throughout. The final form of the adapted depression component of mhGAP-IG.v2 will require further development and input from multiple stakeholders at local and national level.
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ItemAssessment of the completeness of death registration and estimation of national and subnational mortality in Nepal( 2022)Introduction Timely and quality mortality data provide important evidence to inform health policy and monitor the progress of local and national development goals. In Nepal, a civil registration and vital statistics (CRVS) system has operated for several decades. However, the system’s focus has been on legal and administrative aspects and no vital statistics have been produced from its data. Censuses and surveys collect mortality data, but they focus on early age mortality while adult mortality data suffer from quality and completeness issues. There is hence limited information about mortality in Nepal and reliance on model-based estimates provided by the Global Burden of Disease (GBD) Study and the United Nations (UN). This thesis aims to fill this knowledge gap in Nepal by assessing the completeness and quality of national mortality data sources, estimating the key national and subnational mortality indicators, assessing differentials in death registration completeness by socio-economic, demographic, and geographical characteristics and identifying the main barriers and enablers for death registration. Methods The empirical completeness method was used to measure the completeness of offline (paper-based) and online death registration and household deaths reported in the CRVS Survey 2015/16 by sex, province and ecological belt. The empirical completeness method estimates the completeness of death registration or reporting using data inputs of the registered crude death rate, under-five mortality rate, and the percentage of the population aged 65 years and above. These results together with a linear regression analysis of estimated true crude death rates and the empirical completeness method extension were used to estimate adult mortality and life expectancy at birth by sex, province, and ecological belt in 2017. The CRVS Survey 2015/16 was analysed using bivariate and logistic regression to assess characteristics that predict the likelihood of death registration. The nationally representative CRVS Survey was conducted in 2015 and 2016 and collected information about deaths reported to have occurred in the preceding three years (2013-2015). Responses to this survey from households and service providers (local registrars) were examined to identify reasons for registration and non-registration of deaths, and ways to make death registration more convenient. Results The completeness of the offline death registration in Nepal was 69% in 2017 and had not increased since 2013. Completeness was higher for males (73%) than females (65%) and provincially it ranged from 90% in Gandaki to 39% in Karnali. The completeness of online death registration was 32% in 2019 and completeness of death reporting in the CRVS Survey was 75% in 2015 but just 54% in 2014. Adult mortality in Nepal in 2017 was estimated to be 159 deaths per 1000 population for males and 116 for females and varied by ecological belt (males: Terai 148 to Mountain 181; females: Hill 101 to Mountain 140) and province (males: Madhesh 129 to Karnali 224; females: Bagmati 92 to Sudurpashchim 159). Life expectancy at birth in Nepal was estimated 69.7 years for males and 73.9 years for females in 2017, being marginally higher than GBD estimates and higher than UN estimates. It also varied by ecological belt (male: Mountain 67.3 to Hill and Terai 70.3; female: Mountain 70.9 to Hill 75.6) and province (male: Karnali 64.9 to Madhesh 71.8; female: Sudurpashchim 69.6 to Province 1 77.0). Estimated subnational mortality indicators had a strong correlation with monetary poverty levels. CRVS Survey results showed that there was less likelihood of the registration of the deaths occurring in early age, in households with illiterate heads and in households with fewer communication facilities. The main reasons for registering a death according to households were for property entitlement transfer, social security access and other legal purposes (85% combined). Most deaths (70%) had not been registered by households because they believed they did not have to register them. Both households and service providers believed that organising mobile registration camps and promoting online registration and registration from the place of occurrence as ways to enable greater death registration in Nepal. Conclusion Each mortality data source in Nepal, including CRVS, has weaknesses in terms of completeness and quality. Subnational mortality indicators vary significantly, and these differences are plausible when compared with poverty levels. The differentials, barriers and enablers of death registration according to the CRVS Survey provide important evidence for the design of interventions to help Nepal achieve complete death registration. In particular, the continued roll-out of the online registration system will be important for Nepal to have a major source of timely and reliable mortality data in the future.
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ItemPreventing violence-related death and morbidity among people who have had contact with the criminal justice system( 2022)Although rates of violence globally have been decreasing in recent decades, the risk of experiencing violence remains disproportionally concentrated among people who experience marginalisation and disadvantage. Many of the health and social inequities that predispose people to experiencing violence are highly prevalent among those who have had contact with the criminal justice system. However, there is little evidence on the risk of violence victimisation in this population. This constrains our ability to design effective violence prevention strategies that can meet and respond to the needs of those who have had contact with the criminal justice system. My thesis aimed to fill this gap in the literature by generating novel evidence on the epidemiology of violence-related death and morbidity among young people and adults who have had contact with the criminal justice system. I conducted a narrative review of the literature, five discrete original research studies, and I produced a protocol for a systematic review and meta-analysis, and a letter to the Editor. I also extended the Public Health Approach to Violence by applying it, for the first time, to those who have had contact with the criminal justice system. My thesis findings indicate that young people and adults who have had contact with the criminal justice system have a risk of violence-related death and morbidity that is far greater than that of the general population. Among people who have had contact with the criminal justice system, women, Indigenous people, and those with mental health and/or substance use issues are particularly at risk. Evidence-informed violence prevention strategies are urgently needed in this population. The findings of my thesis can be used to inform the development of such strategies. Taken together, the evidence suggests that in order to be effective, a violence prevention approach for this population should address the health and social inequities that are both drivers of violence and disproportionately impact people who have had contact with the criminal justice system. Effective responses must also take into consideration the sex- and culturally-specific needs of those who have had contact with the criminal justice system. Until such action is taken, people who have contact with the criminal justice system will continue to experience violence victimisation at a rate that far exceeds that in the general population.
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Item“It’s a space for us to express our rights, to change ourselves and our community”: A feminist ethnographic study of Syrian refugee women’s experiences in and because of participating in a women and girl safe space in Beqaa valley, Lebanon( 2022)Women and girl safe space interventions are increasingly being implemented by multilateral agencies and, international and local non-governmental organisations (NGOs) in areas affected by forced displacement, disaster, and conflict interventions. Women and girl safe space interventions employ gender-segregated space and collective-based strategies in the pursuit of women’s empowerment. There is little research supporting the effectiveness of women and girl safe spaces in empowering women. Much of the existing research uses quantitative methods, and sheds little light on what actually happens in women and girl safe spaces, or the nature of women’s experiences participating in them. To address this, I conducted a feminist ethnographic study exploring Syrian refugee women’s experiences in and because of participating in a women and girl safe space in the Beqaa valley, Lebanon. My research sought to answer the questions: What were women’s experiences in and because of participating in the women and girl safe space? What power relations, practices, and structures facilitated these experiences? What role did their participation (if any) play in transforming gendered norms and power relations? Following the introduction chapter, I begin with an overview of the relevant literature, where I situate women and girl safe spaces implemented by development and humanitarian organisations as one type of ‘safe space’ and explore the current evidence on their effectiveness for empowering women. Using The Roestone Collective’s (2014) ‘safety from/safety for’ conceptual framework, I also explore the common threads across the design and implementation of women and girl safe spaces, linking these threads to the feminist development scholarship on collective empowerment. I then describe my research context in Beqaa, Lebanon. I introduce the intersecting histories of Lebanon and Syria and the 2011 Syrian conflict that led to the mass forced displacement of Syrians, followed by a description of the women and girl safe space where my research took place. I then present the transnational feminist methodological approach I took to my research, including my positionality, data collection methods and analysis, ethical considerations, and strengths and limitations of my study. Given my thesis-with-publication approach, I present my research findings in journal articles. The first journal article (Chapter 4) focuses on the empowering effects of participation in the women and girl safe space on Syrian women and the various safety-making practices and structures that facilitated those empowering effects. The second journal article (Chapter 5) focuses on complicating three dominant assumptions operating in the women and girl safe space – that Syrian women share a common identity; that women are allies and supportive of each other; and that women’s relationships are governed by non-hierarchical power relations – through vignettes that highlight differences, hierarchies, and conflict between women. The final journal article (Chapter 6) highlights the unintended negative consequences when meanings attached to empowerment were imposed by the organisation or not shared amongst women, putting forth several provocations for development and humanitarian practice. In the final chapter, I summarise the key findings across my research, which suggested there were empowering effects for women who participated in the women and girl safe spaces. I then bring together the different threads of the arguments I make across my individual findings chapters. I ultimately advocate for development and humanitarian organisations to embrace a collective self-determination approach, where women participating in women and girl safe spaces are empowered to develop its mandate actively and collectively over time. I also emphasise the importance of fostering ‘enabling’ relationships between participating women (and between participating women and staff), by recognising differences and responding proactively to disempowering or harmful dynamics. I then describe the contributions my research makes, strengths and limitations as well as future research questions, before ending with a final reflection.
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Item‘We don’t talk about ethics’: Recognising the ethical goals integrated within everyday alcohol and other drug work( 2022)The specialist field of alcohol and other drugs (AOD) is a complex area of healthcare. Although ethical dimensions are commonplace within AOD clinicians’ everyday settings, little research has sought to understand the ethical aspects of their everyday work with clients. This deficit has resulted in limited knowledge concerning ethics within everyday AOD work, and an associated lack of ethical guidance for AOD clinicians. The low profile of ethics within everyday AOD work is likely to have a negative impact upon AOD clinicians’ work. In response to this insight, I undertook a study using the framework of empirical ethics. My aim was to better understand ethics within everyday AOD clinical work, and to develop ethical guidance for AOD clinicians. I addressed two research questions to further these ends: what are the ethical dimensions of AOD practice? And how can ethical practice be enhanced? I undertook the research as an insider researcher. This research position involved concurrently working as a clinician whilst undertaking the research within the setting of a large community based and residential AOD service. My primary form of data collection involved semi-structured interviews with thirty experienced AOD clinicians. I collected further data through participant-observation, and by reflecting upon my own ethical and clinical practice. Analysis of the results, using applied thematic analysis, provides insight into participants’ skilful integration of ethics into their clinical work. I suggest that participants’ AOD practice is characterised by four ethical goals specific to AOD work: enabling access to care, facilitating change in substance use, challenging stigma, and keeping people safe. Participants balanced innovative ethical responses with respect for formal guidelines and accepted practice. Despite the demonstrated skilful engagement with ethics in their everyday work, participants only rarely explicitly identified this using ethical language. This inconsistent identification of ethics within clinical work meant that participants sometimes overlooked important ethical dimensions of clinical situations. Further explicit integration of ethics into everyday AOD settings can enhance clinicians’ ethical engagement within their everyday work. I make suggestions to encourage increased ethical engagement. These suggestions include raising awareness of the ubiquity of ethics in AOD; and diversifying of clinical language. I developed an ethics support framework aiming to support changes in practice. This novel framework, designed for use by clinicians within AOD settings, synthesises the research findings as a means of integrating recommendations into the AOD clinical setting and enhancing ethical practice within AOD.
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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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ItemEarly origins of childhood neurodevelopmental and emotional-behavioural disorders( 2022)Background: Neurodevelopmental disorders (NDD), including autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD), and emotional-behavioural disorders (EBD), such as internalising and externalising, are increasingly recognised as leading causes of morbidity in children. Identification of environmental influences and mechanisms that contribute to the increasing burden of these disorders remain a great challenge. Research objectives: I aimed to deeply investigate several early life (i.e., prenatal, perinatal, and postnatal) social and environmental factors and advance the understanding of downstream biological pathways –oxidative stress, inflammation, and telomere shortening– in early life, related to childhood ASD, ADHD and EBD. Method: Modern epidemiological approaches were applied to data from the Barwon Infant Study, a prospective birth cohort study of 1074 mother-infant pairs, to examine the prospective associations between early life factors, biological measures, and later neurodevelopmental and emotional-behavioural outcomes in young children. Results: In Chapter 4, I present my published findings that children with ASD symptoms at age two years are overrepresented in socioeconomically disadvantaged families and among mothers with poorer lifestyles and mental health challenges. A diverse range of early life modifiable risk factors, including maternal lifestyle factors during pregnancy and environmental air pollutants, may have an important role in the pathogenesis of ASD. In Chapter 5, I present my findings that greater maternal oxidative RNA damage during pregnancy is associated with increased childhood EBP, particularly emotional symptoms (depression and anxiety) at ages two and four years. Greater maternal oxidative RNA damage during pregnancy partly mediates the associations between several early life socioeconomic disadvantage indicators and prenatal lifestyle factors to increase EBP in young children. In Chapter 6, I present my published results that increased levels of the inflammatory biomarker, glycoprotein acetyls (GlycA), at birth were associated with greater EBD (internalising and externalising problems) at age two. The effects of several early life factors, such as socioeconomic disadvantage indicators, on internalising problems at age two were partly mediated by higher inflammation. In Chapter 7, I present my published findings of an inverse association between shorter telomere length at 12 months and subsequent ADHD symptoms in children at age two. Environmental air pollutants, such as infant secondhand smoke exposure at one month, were independently associated with shorter telomere length at 12 months and greater ADHD symptoms at age two. Conclusion: This thesis provides new knowledge from a deep investigation of the relationship between early life modifiable environmental risk factors and biological mechanisms of childhood ASD, ADHD, and EBD. My research may assist future preventative strategies and therapeutic efforts to target environmental insults and minimise oxidative stress and inflammation and accelerated telomere shortening in early life, particularly in high-risk groups, to reduce the incidence of these disorders and/or their impact on young children.
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ItemThe design, development and evaluation of a web-based educational lifestyle program for people with multiple sclerosis( 2022)Multiple sclerosis (MS) is an autoimmune inflammatory and degenerative disorder of the central nervous system, the clinical outcomes of which are extremely variable. There is good evidence that self-management programs focused on lifestyle modification can play an important role in the management of MS. One such self-management program, the Overcoming Multiple Sclerosis 7-step (OMS) program, has accumulated evidence for its role in improving health outcomes in populations of peope with MS. However, there are accessibility issues with delivering the OMS program to people with MS face-to-face, including costs, distance and physicality. The delivery of this and other self-management programs as digital health interventions (DHI) has the potential to overcome these limitations and meet the increasing desires of people with MS to have access to these programs. Therefore, the aim of this thesis was to demonstrate the feasibility of a web-based version of the OMS program, termed the Multiple Sclerosis Online Course (MSOC). This thesis presented two systematic reviews and meta-analyses related to study design of lifestyle and digital health interventions. This thesis then described the design and development process of the MSOC, novel in its approach and execution. Finally, this thesis demonstrated the feasibility of the MSOC and generated important data for redevelopment of the MSOC in preparation for the delivery of an effectiveness study. More broadly, this thesis provided insights for previously underexplored areas of digital health research in the context of self-management for people living with chronic diseases.
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ItemCaller’s experience of Lifeline and its impact in their lives( 2022)Despite an estimated 1,000 crisis lines worldwide, few studies have explored the phenomenology of crisis line use from the perspective of those who call the services. Little is known, accordingly, about the reasons for calling a crisis line, and the experiences of callers during and after calls. Crisis theory has informed the design and development of crisis lines, as has suicide prevention and counselling practice, yet there has been little assessment of the relevance of these theories and practices to callers’ experiences and life situations. As the importance of understanding people’s lived experiences of suicide and mental health conditions is being increasingly recognised by policy makers and funders, there is a need to better understand the experiences of those who call crisis lines, what aspects of the service they find helpful and why. This information is critical to inform future service improvement and quality assurance. It is also important in understanding the role of crisis lines in broader service systems, especially as they are often promoted during times of community-wide difficulties such has occurred during the COVID-19 pandemic and natural disasters. This research explores a gap in research knowledge on crisis lines. Aim The study described in this thesis aimed to better understand the experiences of callers to a crisis line, Lifeline Australia (Lifeline). It explored caller use of the service in the context of their lives. Knowledge was generated on the reasons for calling Lifeline and what aspects of service were helpful or otherwise. The impact of calls to Lifeline in people’s lives was explored, in both the immediate post-call period and over time. The research objectives for this study were: 1.To describe callers’ experiences of calling Lifeline. 2.To examine the extent to which callers’ self-reported benefits of calling Lifeline aligned with existing theory and knowledge about crisis lines. 3.To identify the contribution that Lifeline made in suicide prevention and mental health, and the implications that this has for the place of crisis lines in broader service systems. Methods The lack of previous research with callers to crisis lines may in part be due to a perceived difficulty with recruiting participants in an ethical and practical manner. This arises from the potential vulnerability of the callers and the importance of anonymity in service operations. This longitudinal qualitative study adopted an ethically appropriate recruitment process to approach callers at the end of a call to Lifeline and seek their agreement to participate. In total, 58 callers to Lifeline from varying backgrounds and locations agreed to do participate in this research. Those who participated in the study took part in semi-structured telephone interviews over a 12-month period, with most participants being interviewed several times during that period. The following research questions were used as the basis for the interviews: (a)Why do people call Lifeline? (b)What do callers want from Lifeline? (c)What effect does a call to Lifeline have on those who call? (d)What influence do calls to Lifeline have in people’s lives? A total of 140 interviews were audio recorded and transcribed verbatim. Thematic analysis of data was undertaken supported by NVivo 12 to code the data and organise it into a thematic framework. Results Participants called Lifeline because they were highly distressed or upset and unable to continue to bear this emotional intensity or internal turmoil. There were unable to cope with day to day living activities or find ways to think about what they could do next. They needed someone to talk to, so they could get some relief from the distress they felt. Some felt profound loneliness and needed a connection with another person. Often the distress was associated with an event or circumstance in their lives that had a significant effect on them. Often, the event was a shift in the dynamic of complex relationships with family or others. Many participants were juggling various issues and circumstances in their lives and the elevation of one of these had generated the sense of being unable to cope anymore. Overall, participants were in a state of crisis when they called Lifeline. Some participants were suicidal when they called Lifeline. A few were in immediate danger with a plan and intent to end their lives. Mostly, they called Lifeline to interrupt these powerful urges and to keep safe. A few called Lifeline before their suicidal urges had reached a crisis point. The experiences of participants in this study demonstrate that a call to Lifeline can de-escalate this crisis state. It can serve to prevent the loss of life or interrupt destructive behaviours from advancing further. This aligns with the research studies undertaken on crisis lines and supports their effectiveness in crisis intervention and for suicide prevention. Non-judgemental listening and empathetic responses were sought from telephone counsellors. Participants identified that they wanted to feel welcomed when they called, accepted for who they were and allowed to talk about the situations, issues, or emotions that they wanted to discuss during the call. They sought someone who authentically cared for them and their wellbeing. They valued telephone counsellors who could be responsive, creative, and skilled during the interaction to provide support in ways that were meaningful and tailored to the caller’s needs. This set of attributes for the telephone counsellors related to befriending, a set of techniques that has been associated with Lifeline and many but not all other crisis lines from their establishment. Participants identified service operational characteristics that they valued, such as their calls being answered quickly, ideally in less than 10 minutes, and the low or no cost associated with the call. The opportunity to call Lifeline on an anonymous basis, as is typical of most crisis lines, was also valued by participants who saw this as ensuring they could disclose information about their situations without fear that this information could be linked to their identity and used against them. Participants also identified the importance of being supported in their struggles, encouraged to draw on their own strengths in tackling life’s difficulties and enabled to adopt a greater level of self-determination in their lives. They sometimes used the call to Lifeline as an opportunity to check their thoughts on a problem, as a sounding board. They wanted telephone counsellors that could challenge them at times and offer different perspectives. They needed telephone counsellors who had sufficient life experience themselves to be able to do so meaningfully. An important finding from this study was that calls to Lifeline did not always go well and when this occurred, participants experienced negative outcomes. Dissatisfaction with the call was often related to the lack of authenticity by the telephone counsellor or deficiencies in their competency to respond to a person in crisis. Participants were especially critical of telephone counsellors that stuck to a process during the call rather than applying flexibility in their responses to the person’s needs. Sometimes, participants had experienced inappropriate practices. They recalled a profound negative impact on their wellbeing when this occurred. Most of those who participated in this study called Lifeline on multiple occasions and a few called continually. Often, participants experienced ongoing difficulties in their lives. Mostly, they called Lifeline purposely for emotional release and so they could better cope with complex cycles of challenge and struggle. A small number of participants reported their calls to Lifeline had become habitual and unproductive, however many participants stated that calling Lifeline over time had helped them to make improvements in their lives. It became apparent that calls to Lifeline had reinforced many callers’ motivation to make improvements in their lives and had assisted many to cope with periods of turmoil along the way. Implications This study confirmed that calls to Lifeline contribute positive outcomes through crisis support and suicide prevention in the Australian population, as intended in the Lifeline model of service. Lifeline performs a distinct role in the service system, as a support service. The experience of crisis impacts on people’s mental health and suicidal states and there is a need for a service that is accessible and equipped to respond to crisis. The service model for Lifeline which established a mixed use of non-directive and directive counselling approaches was supported by the experiences of participants in this study as suitable to the expectations and needs that they had of the service. Conceivably, the mixed approach could be used to an even greater extent to offer more flexibility and responsiveness to callers’ presenting needs. However, it was the befriending interaction as an authentic, accepting, form of support that incorporates the principles of empowerment and self-determination that was seen by participants as the most important and beneficial characteristic of the service. The specific characteristics of service that callers sought could be used to define service quality for crisis lines and monitored in feedback about caller experiences. This would include the convenience of making a call cheaply and at all times of day, with the assurance it would answered quickly, the anonymity of the service, the non-judgemental outlook of the telephone counsellor, the experience of being listened to and being welcomed and cared for by the telephone counsellor. Similarly, feedback could be sought to identify when unsatisfactory experiences of telephone counsellor approach and competency arise. The themes identified in this study surrounding the effects of a call to Lifeline could be applied as measures of intended outcomes from use of the service: better able to cope; less distressed; suicide prevented; able to take steps for change. Sub-themes associated with these themes could further refine these measures. These present as an alternative, consumer-informed, set of outcomes measures for crisis lines. As a challenge across previous studies of crisis lines has been the disjointed and inconsistent choice of measures of outcome or effectiveness, this study proposes a consumer-informed basis for future outcome description and the creation of measures of effectiveness. Crisis Theory, Coping Theory and Crisis Prevention as frameworks for crisis support services were found to relate to the experiences of participants in this study, especially those who called Lifeline on multiple occasions. Many participants benefited from multiple contacts with Lifeline to build their coping capabilities and to identify positive steps to make improvements in their lives. This aspect of crisis lines has not been addressed in previous studies. These longer-term benefits of crisis lines deserve greater recognition. Conclusion This study contributes to our understanding of crisis lines as important services within the community and reinforces existing research knowledge that suggests they often provide benefits to those who use them, as well as performing a crisis intervention role in suicide prevention. The more in-depth approach to caller experiences that this study adopted, however, has challenged the conceptualisation of crisis lines only as services of ‘last resort’ that provide immediate safety intervention and referrals. It is apparent that they perform a longer-term capability building and crisis prevention/recovery function for many of those who call on multiple occasions. While crisis lines perform crisis intervention as immediate responses to a crisis, their role within a service system should not be restricted to this.
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ItemGastroesophageal reflux disease and Barrett’s oesophagus: exploring determinants and explaining sex differences in the effects of diet, adiposity, and Helicobacter pylori infection( 2022)Background The incidence of oesophageal adenocarcinoma has been rising in many high-income countries, including Australia. The prognosis has unfortunately remained poor over time. Most oesophageal adenocarcinoma cases are diagnosed at an advanced stage, reflecting the untapped potential for evidence-informed early interventions. Barrett’s oesophagus (BE) is the precursor of oesophageal adenocarcinoma, and gastroesophageal reflux disease (GERD) is their common primary determinant. While there is an accumulating body of evidence on the modifiable risk factors of these diseases, longitudinal studies of onset of GERD and BE are scarce. Furthermore, there is a notable male predominance in the progression from GERD to BE and oesophageal adenocarcinoma, yet the reasons for sex disparities in disease progression remain largely unknown. Objectives and Methods This thesis aims to study the distribution and determinants of GERD and BE, with a focus on exploring and explaining sex differences in the effects of diet, adiposity, and Helicobacter pylori infection. The aim encompasses four objectives, addressed by five analyses within the Melbourne Collaborative Cohort Study (MCCS) in Australia. Data on the determinants and potential confounders were measured at cohort recruitment (1990-94). Telephone interviews were conducted in 2007-10 to collect information on GERD and BE. I conducted four analyses using the full cohort, including 12,000 to 21,000 participants (~59% women; age 49-59 or 49- 63 years depending on the exclusion criteria), and one nested case-control study, including 425 GERD cases with 622 controls and 169 BE cases with 685 controls. I first estimated the incidence risk of GERD and BE and described their demographic and lifestyle determinants (Objective 1). I then investigated, in separate analyses, the potential effect of diet on risk of GERD and BE, including possible effect modification by sex (Objective 2). For Objective 3, I estimated the extent to which GERD mediated the effect of adiposity on risk of BE, overall and for men and women separately. Lastly, in the nested case-control study, I estimated the sex-specific effect of Helicobacter pylori infection on risk of GERD and BE, i the extent to which GERD mediated the effect of H. pylori on BE, and explored sex differences in H. pylori-induced gastritis patterns as a potential mechanism for effect modification by sex (Objective 4). Effects were estimated using logistic regression models including potential confounders as covariates. Effect modification by sex was assessed by comparing regression models with and without an interaction term between the determinant and sex (Objective 2, 3, and 4). For Objective 3 and 4, mediation by GERD was quantified using causal mediation analysis. Odds ratios (for all analyses), risk ratios and risk differences (for Objective 3 and 4), and 95% confidence intervals were reported. Results The incidence of GERD and BE in the MCCS were comparable to those estimated by existing studies in high-income western countries. GERD and BE shared similar lifestyle determinants but had different demographic determinants. In terms of sex, women had slightly higher risk of GERD, but men had 2-fold higher risk of BE and earlier onset of GERD symptoms. For diet and risk of GERD, total fruit and citrus were inversely associated with risk; fish, chicken, cruciferous vegetables, and carbonated beverages were positively associated with risk. Effect modification by sex was observed for nutrient intakes: for men, fat intake increased risk of GERD, whereas carbohydrate intake reduced its risk. No association between nutrient intakes and risk of GERD was observed for women. For diet and risk of BE, leafy vegetables, fruit, citrus, tomato, and with weaker evidence, fibre from vegetable and fruit, beta-cryptoxanthin, lutein and zeaxanthin, and lycopene were inversely associated with risk. High-fat or added-sugar discretionary food, and with weaker evidence, dietary fat, alpha-carotene, and tea intake, were positively associated with risk of BE. There was no evidence for effect modification by sex. Sex modified the effect of adiposity on risk of GERD, and with weaker evidence, BE. Adiposity increased risk of GERD and BE, with a stronger effect observed for women than men. With weaker evidence, adiposity also modified the effect of GERD on BE, with the weakest effect observed in those with obesity compared with overweight and normal weight. For women, approximately half of the total effect of obesity on risk of BE was mediated by GERD. For men, one-quarter of the effect was mediated by GERD. Sex also modified the effect of H. pylori infection on risk of GERD and BE. For men, higher risks of GERD and BE were observed in those H. pylori seronegative compared with ii seropositive; one-third of the excess risk of BE in those seronegative was mediated by GERD. No association was observed for women. Among those H. pylori seropositive, atrophic antral gastritis, a gastritis pattern that might lead to reduced acid production and less erosive reflux, was more common in men than women. Conclusion This thesis investigated the distribution and determinants of GERD and BE in a large prospective cohort, which, with careful analysis planning, improved causal inference of the findings. This may be particularly important for public health guidelines on lifestyle modifications to prevent GERD. It is necessary to distinguish risk factors from triggers of symptoms, as behavioural modification for symptom relief is common. For example, my findings suggest dietary components commonly considered as triggers of symptoms do not necessarily contribute to the pathogenesis of GERD. Collectively, the thesis findings highlight sex differences in the effects of determinants as a possible contributing factor to sex disparities in disease progression from GERD to BE. In addition, the thesis explored potential mechanistic pathways that may explain how sex modifies the effect of adiposity and H. pylori infection. The findings add novel knowledge to the literature and guide future analyses to consider the complex interactions between determinants. With thorough considerations for study design and data analysis, future epidemiological research on modifiable determinants would help refine evidence, inform guidelines and interventions, and ultimately contribute to the control of GERD, BE, and oesophageal adenocarcinoma in populations.