Melbourne School of Population and Global Health - Theses
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Physical activity and asthma in youth: cause or consequence?
Asthma is the most common chronic disease in children, and often persists into and adulthood. Further, despite its known health benefits, it is estimated that more than 80% of the world’s adolescents are insufficiently physically active. Since both asthma and physical inactivity are significant problems in child and adolescent populations, it is essential to focus research on these populations. The relationship between asthma and physical activity is complex and controversial, and the temporality of these associations remains unclear. My doctoral work attempted to tease out these relationships. This work was divided into sections with distinct research questions, which together aimed to advance our current understanding of the relationship between asthma and physical activity in children and adolescents. Hence, this thesis contains two systematic reviews which were performed in order to understand the existing literature on the nature of the relationship between physical activity and asthma in children. These reviews are followed by three data analyses which employed a variety of statistical techniques to analyse data from questionnaires, accelerometry and clinical assessments collected by two well-established cohorts of Australian children: The Longitudinal Study of Australian Children (LSAC) and the HealthNuts study. The first of the two systematic reviews found no evidence that children and adolescents with and without asthma participated in different amounts of objectively measured physical activity. The second review, which aimed to investigate the effect of physical activity on subsequent asthma outcomes, found insufficient evidence to determine the effect of physical activity on subsequent asthma and lung function outcomes. Hence, in the first data analysis, I aimed to elucidate the direction of the association by investigating the possibility of bidirectionality. However, there was no evidence of longitudinal associations in either direction. Next, I compared the amount of time spent in moderate to vigorous physical activity (MVPA) between children and adolescents with and without asthma at 5 different ages and again found no evidence that youth with and without asthma engaged in differential amounts of time in physical activity. Finally, I investigated the effect of early wheeze and asthma on objectively measured physical activity in early childhood and again found no evidence that children who experience early life asthma and wheeze were less active at a later age. Thus, my thesis presents sustained and compelling evidence of a lack of association between asthma and physical activity in youth – in either direction. A number of implications can be drawn from these findings. First, physical activity campaigns targeted at children need not focus specifically on children with asthma. Second, the effect of physical activity on future asthma outcomes remains unclear. However, even without evidence that physical activity is beneficial for future asthma outcomes, physical activity should be encouraged from a young age for its many other health benefits.
Caries Risk Assessment Tools: The Evidence
Background Various caries risk assessment tools (CRATs) are currently used in the management of early childhood caries. The evidence to inform the selection of a specific tool is unclear, as CRATs differ in their content and development methodology, mostly due to the absence of a standard reporting and testing guideline. Risk-based and outcomes focused (the shift from volume to value) models of caries management have been gaining popularity in recent times as they attempt to prevent and manage the disease itself rather than its sequela. Risk-based models of oral health care attempt to stratify populations, with those most at-risk prioritised for care, while concurrently reducing unnecessary care for low-risk people. This becomes an important consideration when allocating resources in limited resource settings such as public dental services. If new models of caries management depend on an accurate and precise risk assignment, then evidence is needed to inform each step of the development and selection of CRATs. Without this essential body of work, risk-based models of caries management run the risk of not delivering the intended positive outcomes, for either the patient or the health care organisation. The aim of this PhD was to generate new knowledge on caries risk assessment tools for young children, to demonstrate their utility in models of caries management. Methods The philosophical underpinnings of my PhD research were informed by the value-based health care (VBHC) agenda. The theoretical foundations, including the intent, motivation and expectations for the research were guided by two socio-ecological conceptual frameworks – National Institute for Health and Clinical Excellence’s (NICE) conceptual framework for public health and the Fisher-Owens conceptual model of influences on child oral health. The PhD research was conducted as three separate research strands: Strand 1. The systematic review – provided evidence for the current state of knowledge including knowledge gaps for CRATs for young children, relating to content, development process, and testing methods, risk categorisation and use in practice; Strand 2. The calibration study – provided evidence for examiner inter- and intra-examiner reliability for the VicGen data and also generated new knowledge related to the process for calibrating clinical examiners in caries diagnosis when conducting research with young children; and Strand 3: The CRAT testing – provided the evidence, based on an assessment of the reliability and validity required to inform the selection of a CRAT (CAMBRA CRAT used as the case study) for young children in the State of Victoria. Results The CRATs reported in the literature for use among children less than 6 years were: Caries Management By Risk Assessment (CAMBRA), Cariogram, National University of Singapore CRAT (NUS-CRAT), MySmileBuddy, Dundee Caries Risk Assessment Model, University of North Carolina Risk Assessment Models, University of Michigan pediatric dental clinic caries risk assessment sheet and American Academy of Pediatric Dentistry (AAPD) CRAT. For examiner reliability in the calibration study, Kappa scores for inter-examiner reliability ranged from 0.56 to 0.70 (moderate to good). In the in vivo community examination, using ICDAS caries codes only, weighted Kappa scores for inter-examiner reliability ranged from 0.50 to 0.64 (moderate to good). In the CRAT testing study, good reliability (inter and intra) was observed when using the CAMBRA CRAT. For the classic CAMBRA three-level risk categorisation (low, moderate and high), at 36 and 48 months of age, respectively, the area under the receiver operating curve was close to 0.50, which is indicative of a low ability for the CRAT to predict future caries development. Conclusion To conclude, this PhD study identified a major knowledge gap in the current state of evidence on the subject of caries risk assessment tools (CRATs); which was the lack of methodologically sound studies to provide the evidence to inform decision making on tool selection, for use in practice. The PhD study addressed this knowledge gap through methodologically rigorous research to demonstrate the process required to generate the evidence to inform the selection of a CRAT. The CAMBRA CRAT which was used as the case study in the PhD research was shown to be ineffective in predicting a caries outcome among young Victorian children.
Media reporting of Robin Williams’ suicide
Background Irresponsible media reporting of suicide can lead to suicidal acts, particularly if the subject of the reporting is a celebrity. When Robin Williams took his own life on 11 August 2014, media reporting in the United States was less than optimal, with many reports detailing the suicide method Williams used, romanticising his suicide, and failing to provide information on sources of help. The reporting was followed by an increase in suicides in the United States, as well as an increase in helpline calls. In Australia, the Mindframe guidelines provide media professionals with advice on ways to safely report on suicide. This thesis set out to determine whether the Australian reporting of Williams’ suicide adhered to the recommendations in the Mindframe guidelines and whether there were increases in suicides or calls to helplines in Australia following the media reporting of Williams’ suicide. Method The thesis involved three studies. In Study 1, relevant newspaper articles were identified through a systematic search process, and trained coders rated the articles for quality against criteria in the Mindframe guidelines. In Study 2, suicide data were extracted from the National Coronial Information System for the period 2001 to 2016 and interrupted time series regression analyses were conducted to determine whether there were changes in the number of suicides in the five month period immediately following Williams’ suicide. In Study 3, weekly calls data for the period 2013 to 2015 were provided by Australia’s two most prominent helplines, Lifeline and Beyond Blue. Again, interrupted time series regression analyses were conducted, this time to determine whether there was an increase in the average weekly number of calls received by each helpline one week and one month after the news of Williams’ suicide broke. Results Study 1 identified 303 newspaper articles, 67% of which adhered to at least eight of the 10 Mindframe guidelines. Study 2 found an 11% increase in suicides in the five month period following Williams’ death, largely accounted for by men aged 30-64 years and by people who died by hanging (the method Williams used). Study 3 provided strong evidence of an increase in calls to Lifeline and Beyond Blue in the week after Williams’ suicide was reported. This levelled out over the ensuing month. Conclusion Australian newspaper reporting of Williams’ suicide was largely consistent with the Mindframe guidelines. Despite this, there were increases in suicides in the immediate aftermath of his death, which is obviously a negative outcome. There were also increases in calls to helplines, which may be interpreted either as negative (i.e., suggesting that people’s levels of distress and feelings of suicidality were heightened) or positive (i.e., suggesting that people who might have otherwise been influenced to harm themselves called a helpline instead). It may be that Australians were exposed to reports that contravened safe reporting recommendations, particularly via overseas media and social media or that some Australian reports may have had unhelpful overarching narratives, despite largely adhering to the Mindframe guidelines. The Mindframe guidelines constitute international best practice but consideration should be given to whether certain recommendations within them should be further reinforced and whether more nuanced information about how stories should be framed could be provided.
Associations between dietary factors, lung function and bronchial responsiveness in middle-aged and older Australians
Studies of relationships between dietary factors, lung function and bronchial responsiveness (BR) are limited and findings inconsistent. My aim was to investigate these relationships in middle-aged and older adults. A secondary aim was to identify a more suitable statistical method to assess factors associated with BR and compare its findings to those from the common regression model of the log-transformed dose-response slope (logDRS). I used data from two cross-sectional studies – the Tasmanian Longitudinal Health Study (TAHS) 2010 follow-up and the Chronic Obstructive Pulmonary Disease (COPD) Study. The TAHS is a respiratory study of Tasmanian school children born in 1961. In 2010-2012, an asthma and bronchitis enriched subsample completed spirometry, a methacholine challenge and a questionnaire. I used a linear mixed model (LMM) to examine “known” predictors of BR and compared the findings to those from regression of the logDRS. I used multivariable linear regression to investigate associations between fruit and vegetable intakes and lung function and LMMs to examine associations with BR. The COPD study is a population-based cross-sectional study of adults aged 45-69 years living in inner south-east Melbourne. A random subsample completed spirometry, a methacholine challenge, and questionnaires including a semi-quantitative food frequency questionnaire. I derived dietary patterns from nutrient intakes using principal component analysis and calculated an energy-adjusted dietary inflammatory index (E-DII) as a measure of the inflammatory potential of the diet. I examined associations between these dietary factors and lung function and BR using linear regression and LMMs, respectively. I explored sex, BMI, smoking, asthma status and atopy as effect modifiers of these associations. Results from the LMM differed to those from regression of the logDRS. In particular, sex predicted BR in the regression model but not the LMM. I found relationships between several dietary factors and lung function in those with current asthma only. In this group, higher vegetable intake, higher intakes of a “high potassium & magnesium” dietary pattern, indicating a diet high in fruits, vegetables and wholegrains, and higher intakes of a “low calcium & sugars” dietary pattern, indicating a diet high in vegetables and low in sugar and dairy products, were associated with better lung function. A higher E-DII, indicating a more proinflammatory diet high in animal products and low in fruits and vegetables, was associated with poorer lung function. I also found higher fruit intake was associated with increased BR. Conversely, in those with current asthma, higher scores for several dietary patterns were associated with less BR. In conclusion, I demonstrated results from an LMM can differ to those from regression of the logDRS, and recommend using the LMM to investigate factors associated with BR. My findings suggest a diet low in animal products and high in fruit, vegetables and wholegrains may be beneficial for lung function in adults with asthma. Therefore, a dietary modification program in this group may improve lung function and reduce the prevalence and severity of asthma and COPD. However, further studies are needed to establish causality of the diet-lung function associations and clarify relationships with BR.
Deciphering despair: A study of self-harm in the Australian asylum seeker population
Australia has had a policy of mandatory immigration detention for all ‘unlawful non-citizens’ since 1992. During periods when there have been a large number of boat arrivals, the vast majority of the detention population have been asylum seekers, referred to as ‘irregular maritime arrivals’. Whilst asylum seekers are at elevated risk of self-harm, and being detained is known to further increase such risk, until recently little has been known about self-harm across the Australian asylum seeker population. This is largely due to the lack of accessible data, and the Australian immigration authorities’ poor self-harm monitoring and reporting processes. This thesis fills a number of gaps in both the national and international literature. It comprises a review of the literature, undertaken in context of the policies governing Australia’s treatment of asylum seekers, and four discrete studies. The evidence generated in the production of this thesis sheds revealing light on Australia’s self-harm monitoring and reporting practices among asylum seekers, as well as the episode rates and key characteristics of self-harm, across the entire Australian asylum seeker population (including by processing arrangements, i.e., onshore detention, offshore detention [Nauru, Manus Island], community detention, and community-based arrangements). The findings reported in this thesis indicate that Australia’s self-harm monitoring and reporting practices are substandard and inconsistent when assessed against international guidelines; and that the burden of self-harm across the Australian asylum seeker population is substantial, particularly among detained asylum seekers. The findings also indicate that episode rates of self-harm are markedly high across all three main types of onshore immigration detention, in comparison with the general population, with average rates not observed to be lower in facilities with lower security features. Variations in the distribution of self-harm were also found according to time of day and month of the year, by processing arrangements. Moreover, high rates of attempted hanging were observed among those in closed immigration detention, compared with community-based settings, as well as in all three main types of onshore detention, and in both males and females. When taken together, the findings reported across the studies included in this thesis make a compelling argument for the expansion of community-based models for processing; tailored, culturally appropriate mental health services for asylum seekers, and the implementation of independent monitoring and reporting of self-harm by a panel of clinical experts who have the statutory power to investigate self-harm among asylum seekers. Targeted, evidence-based responses such as these are likely to contribute to improved mental health outcomes for asylum seekers, and should therefore be considered an urgent public health priority.
Improving respectful maternity care in Ethiopia: Health system constraints and mitigation approaches
The mistreatment of women during facility-based childbirth is a violation of women’s human rights that jeopardises their right to a safe, satisfying, and positive childbirth experience. In addition, such mistreatment is a significant deterrent to the utilisation of skilled birth services. In Ethiopia in 2019, 52.5% of women gave birth outside a health institution. There is compelling evidence that the level of mistreatment of women in the country is very high and women prefer home birth in part due to experienced or perceived mistreatment. Respectful maternity care (RMC) is a recommended practice that promotes the rights, dignity, confidentiality, and privacy of women during facility-based childbirth. However, there is a research gap on the barriers to the promotion of RMC and the effectiveness of RMC interventions in mitigating the mistreatment of women globally and in Ethiopia. This dissertation reports a study conducted in Ethiopia that aimed to identify health system constraints to the promotion of RMC in public hospitals and test a multicomponent intervention (staff training, placement of wall posters, and post-training onsite support for quality improvement) that was designed to promote RMC. The study used an interventional mixed methods design that included surveys of both women and service providers before and after the intervention, focus group discussions with service providers before and after the intervention, and in-depth interviews with key informants before the intervention. The quantitative and qualitative methods were integrated at the design, methods, and interpretation and reporting levels. Multilevel mixed effects modelling was used to evaluate the effectiveness of the intervention in reducing mistreatment. Hybrid thematic analysis that was guided by complex adaptive systems theory was used to identify health system constraints to the promotion of RMC and the complex interactions between various elements in the maternity care system. The study identified that the number of mistreatment components experienced by women was reduced by 18% after the RMC intervention and mistreatment was higher among women who had complications during childbirth and those who gave birth vaginally. Additionally, 29.7% of service providers who participated in the RMC training reported they had mistreated a woman in the 30 days before the training. The training improved the service providers’ awareness of the rights of women during childbirth and their perceptions and attitudes about RMC were positively influenced. Structural and systemic issues were the main challenges providers reported when trying to implement RMC in their contexts. Constraints in both system hardware (bed availability, infrastructure and supplies, financing, and health workforce) and system software domains (service providers’ mindset, staff motivation, and awareness of RMC) exhibited complex relationships and affected the promotion of RMC. This study substantiated that maternity care should be approached from a system-oriented perspective to bring a sustainable and lasting contribution. Additionally, the lessons learned through the implementation of the piloted RMC intervention, mainly the RMC training, are believed to play a significant role in future implementation studies aimed at scaling up a standalone or integrated pre-service or in-service RMC training in Ethiopia. The complex interactions between the various system elements in the maternity care system, which resulted in the poor status of RMC translates into the need for a broad spectrum and system-oriented RMC promotion approaches. There is a long journey ahead if the mistreatment of women in health facilities is to be eliminated in Ethiopia.
Psychosocial Working Conditions and Well-being of International Medical Graduates in Australia: Evidence from the MABEL longitudinal survey
Background: Shortages and maldistribution of medical practitioners, particularly in rural and remote areas, are some of the major challenges besetting health systems worldwide. In its primary attempt to offset these problems, Australia, like a range of high-income countries such as Canada, New Zealand, UK, and the USA, has been actively recruiting doctors from overseas to work in underserved areas. These international medical graduates (IMGs) represent an important segment of the Australian medical workforce, accounting for over 30 per cent of the active doctor population, with higher proportions in regional and remote locations. Over the last two decades, Australia has been drawing its IMG workforce from highly diverse source countries e.g. the UK, Ireland, India, Sri Lanka, Bangladesh, China, Egypt, Iran, and Zimbabwe, most of which differ markedly from Australia on the bases of language, culture, epidemiological profile and the quality of medical training and technology. Additionally, Australia has more recently been implementing policies to increase self-sufficiency of the medical workforce, which has implications for the career opportunities for IMGs in Australia. Since the turn of the second millennium, a substantial body of literature has developed on the experiences and migration outcomes of IMGs in Australia and other Organisation for Economic Co-operation and Development (OECD) countries. But within that body of literature, as confirmed in the scoping review presented in Chapter 3 of this thesis, few have attempted to study how IMGs rate the general quality of their lives amidst their changing professional and social circumstances. In that context, the overarching goal of this thesis was to add and extend this scarce literature by investigating the effect of changes in the psychosocial conditions of IMGs on their general life satisfaction (subjective well-being or SWB) in Australia. Within this, the three broad research aims were 1) to investigate the difference in SWB and its drivers between international and domestic medical graduates (DMGs), 2) to examine the effect of changes in working conditions on the SWB of IMGs relative to DMGs and 3) to explore the effect of recent regulatory changes on the SWB of IMGs. Methods: The thesis used eight waves of survey data from the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal study of Australian doctors from 2009 to 2016. It applied standard econometric panel regression models to address the research aims in three separate chapters (i.e. Chapters 4–6). The thesis relied upon the theory of ‘Job Demands-Resource (JD-R)’ model of Demerouti, Bakker et al. (2001) to define and operationalise work-related psychosocial risk factors into components of job demands and job resources. Results: Chapter 4 addressed the first aim of the thesis by examining any subjective well-being (SWB) difference and its drivers between the IMG and DMG groups using the Oaxaca and Ransom’s (1994) linear decomposition method. The results showed that the IMG group was more likely to report lower SWB than DMGs (p-value<0.001). The well-being gap (of 0.101) was small and largely attributable to the groups’ differences in observable characteristics such as psychosocial and demographic factors. Most notably, the IMG group was worse off with respect to self-reported financial security, exposure to work-related psychosocial risk factors, and community integration. These results therefore highlight the importance of the workplace and community context in understanding the well-being difference between IMGs and DMGs. Chapter 5 addressed the second aim of the thesis. Using a fixed effect linear regression analysis, it examined the effect of changes in psychosocial conditions on changes in SWB of IMGs and tested whether the estimated effect sizes differed between IMG and DMG groups, and within IMGs by key subgroups. Results indicated that exposure to high work-related psychosocial risk factors and a low sense of community integration were associated with statistically significant declines in SWB among study participants (p-value<0.01). However, no statistically significant differences in the estimated effect sizes were observed between IMG and DMG groups. Within the IMG sample, the effects varied by arrival cohort, country of training, and specialty. In particular, and unsurprisingly, the SWB of the newly settled group of IMGs (<10 years) appeared to be more affected by poor peer support and a low sense of community integration, compared to their long-established (>10 years) counterparts. Counter-intuitively however, the SWB of relatively advantaged IMGs from majority English-speaking Commonwealth countries (e.g., the UK, Republic of Ireland, Canada) showed stronger declines under low job control (autonomy) than their non-majority English-speaking counterparts. Furthermore, compared to specialist IMGs, the SWB of hospital non-specialists from all socio-linguistic groups was more affected by exposure to excessive psychological and physical workloads. Collectively, these results demonstrate the importance of psychosocial risk factors to the general well-being of medical doctors, with specific IMG cohorts at particular risk. Notably, the results confirmed the importance of addressing the support needs of newly settled IMGs for an extended period, often to date restricted to initial employment in workforce shortage areas of Australia. Chapter 6 addressed the third research aim by examining the impact of a specific policy changes on IMGs’ well-being and labour supply decisions. Using a random effect model with a difference-in-differences (DiD) estimator, this chapter explored the heightened risk of de-registration of recently arrived IMGs when announcements made by the Medical Board of Australia in 2013 reinforced the policy of de-registration if Australian Medical Council (AMC) clinical exams had not been passed within 3 years. Results revealed a statistically significant increase in hours spent on educational activities and an accompanying decline in the level of SWB among limited registrants. These results suggested the relevance of regulatory actions on the behaviour and well-being of IMGs. Thus, while registration decisions in Australia are often made on the basis of public protection, there is a need to closely monitor how such decisions might be impacting the well-being of the targeted professionals. Implications: Overall, the findings provided novel empirical evidence relating to the experiences of IMGs in Australia, measured by their SWB, with important stratifications highlighting the diverse experiences and psychosocial needs of this highly heterogeneous group. Ensuring a conducive psychosocial work environment can be useful in promoting the general well-being of medical practitioners, especially IMGs who still remain an important part of Australia’s medical workforce.
"Place" and sexual and reproductive health in Australia
Sexual and reproductive health are significant public health concerns, and come with considerable costs to be individuals and the public, whether physical, emotional, mental or financial. There have been calls, particularly internationally, for responses to sexual and reproductive health issues to take an ecological perspective, addressing the multiple levels of influence on people’s health outcomes, such that interventions may potentially be more effective and enduring. ‘Place based’ approaches to health engage with ecological understandings of health, and a small body of literature has applied this framework to sexual and reproductive health. Few have done so within the Australian context, however. The aim of this thesis was to improve understanding of whether and how geographic location may be impacting on the sexual and sexual and reproductive health of Australians. In order to do so, three objectives were addressed: 1 - to explore associations between geographic location and sexual and reproductive health outcomes in Australia; 2 - to explore associations between geographic location and sexual and reproductive health risk behaviours in Australia; and 3 - explore the mechanisms by which geographic location may be affecting sexual and reproductive health behaviours and outcomes. Chapters 1 to 3 are introductory chapters, including a review of relevant literature pertaining to both sexual and reproductive health, and to conceptual frameworks which may inform place-based approaches to understanding health. Chapters 4, 5 and 6 present analyses of associations between ‘place’ and sexual and reproductive health outcomes and behaviours. Chapter 4 comprises a publication in analysing associations between country-level income inequality and notifications of Neisseria gonorrhoea in females. It finds that higher levels of income inequality were significantly associated with higher rates of notification for gonorrhoea. Chapters 5 and 6 report on analyses of a national dataset of prescribing data for the subdermal contraceptive implant and the levonorgestrel intra-uterine device, respectively, finding associations between living outside major cities and higher rates of prescription of long-acting contraceptives. The analyses also tested associations between proximity to specialist health services, such as Aboriginal Medical Services and Family Planning Clinics, but found little evidence of significant association. Chapter 7 presents the finding of a qualitative analysis of interviews with key informants in rural and regional areas of Australia, exploring mechanisms though which characteristics of their local communities may be affecting the sexual and reproductive health of young people. Participants were able to articulate a broad range of factors related to their location that were affecting these – and other – outcomes, including: the social context, broader social and political structures, local structural elements, and geographic location. Informed by findings from the qualitative analysis, Chapter 8 explores associations between alcohol availability and prevalent chlamydia at the level of postcode, multilevel analyses, finding no evidence of significant associations. Together, these analyses have contributed to a small body of Australian literature which takes a place-based approach to sexual and reproductive health outcomes. Showing associations at various levels, it emphasises the potential utility of taking an ecological approach to interventions designed to improve sexual and reproductive health – from the national level to the level of individuals.
Is it ever ethically justifiable for clinicians or the state to restrict or refuse ART access?
Individuals seeking to reproduce non-sexually require access to assisted reproductive technologies (ART) in order to pursue their dream of forming a family. A widespread view in the literature on reproductive rights, and in the broader community, holds that access to ART treatment constitutes a component of reproductive liberty. On this view, decisions about utilising ART sit within the same autonomy and privacy that is universally accorded to sexual reproduction. This implies that restricting or refusing ART access to anybody seeking to have a child non-sexually violates their right to reproduce. I reject this view, and the arguments that underpin it. The grounds upon which clinicians or the state can justifiably restrict or refuse access to available ART treatment form the basis of this thesis. I commence this thesis with a critical analysis of moral theory on reproductive rights, exploring how the right to reproduce has been understood as a liberty, and then as a right in the philosophical and bioethical literature. I suggest that the way the term ‘reproduction’ is understood in the literature goes beyond the elements of the biological process of human reproduction itself. In short, I demonstrate that reproduction includes the begetting and bearing of a child that is born but does not include rearing within its definitional scope. This position represents an original and, I argue, theoretically significant departure from current understandings of reproduction in the literature. I identify two positions in the literature on reproductive rights: the predominant and dissenting. I critique both. The predominant position fails to adequately recognise the collaborative nature of all reproductive projects – both sexual and non-sexual. The importance of this point then attaches to the grounds upon which ‘others’ asked to assist with non-sexual projects have either a liberty or duty to assist. The predominant position holds that the reproductive right is only negative, but then argues this negative right protects positive claims to ART treatment within its scope, which I demonstrate is conceptually inconsistent. The predominant position regards fertility clinicians as morally devoid automata, whereas I argue that the clinician has assertable moral rights and responsibilities within the treatment paradigm. ART produces a child. This other-regarding nature of reproduction is also substantively unrecognised in the predominant position. I broadly support the dissenting position, which argues for the interests and wellbeing of the future ART child to be taken into consideration in ART treatment access decision-making. However, I demonstrate that the rights of the future child do not compete directly with the reproductive desires of the hopeful parent. Rather, I propose that the competing interests are the hopeful parents and all the others collaboratively involved in the reproductive project. Next, I sketch out sexual and non-sexual reproductive projects, identifying each of the stages and who does what at each stage. This then informs my critical analysis of the grounds upon which each individual is involved in a non-sexual reproductive project. I conclude that clinicians and the state have moral rights to restrict or refuse to be involved in non-sexual reproductive projects, because they have a measure of moral responsibility towards the future ART child, who they are causally involved in creating. While Derek Parfit’s ‘non-identity problem’ is often cited as an objection to considering the interests of the future ART child, I additionally demonstrate that my position can accommodate Parfit’s argument.
Development of modified cognitive behavioural therapy for depression in Sri Lanka
Depression is an important public health issue in Sri Lanka and an essential component of its treatment is psychotherapy. Standard Cognitive Behavioural Therapy (CBT), the most widely used psychotherapy in depression. originates in the West which has a culture and value system different from Sri Lanka. Despite multiple parallels and points of overlap between Buddhism, the majority religion in Sri Lanka, and CBT, the latter is underused in Sri Lanka. This thesis aimed to design a culturally modified cognitive behavioural therapy for depression in Sri Lanka. The thesis was conducted in two phases. Phase 1 aimed to gather the necessary information to modify the existing CBT manual to suit Sri Lanka. Phase 2 aimed to evaluate the feasibility and effects of the modified CBT manual developed in Phase 1. Phase 1 used a mixed methodology. A wide range of stakeholders including patients, carers, medical practitioners, psychologists, traditional healers and religious leaders took part in this phase of the study. The semi-structured interviews used were audio recorded, transcribed and translated. The data were analysed based on systematic content and question analysis by identifying emerging categories and themes. These results were used to develop a culturally modified CBT manual. Phase 2 was of an experimental prospective design. Patients with depression were recruited from Colombo North Teaching Hospital, Ragama, Sri Lanka, by convenient sampling. Participants were provided with 6 sessions of psychotherapy fortnightly as per the modified CBT manual and were followed up for 6 months. This was in addition to the usual treatment. Outcomes were assessed using the validated Hamilton Rating Scale for Depression (HRSD), Beck Depression Inventory II (BDI), and Global Assessment of Function (GAF) scales. Briefer and fewer psychotherapy sessions, a more didactic style of therapy and greater emphasis on behavioural therapy, family involvement in therapy and use of local literature in explaining therapy, were identified as necessary modifications to standard CBT by the participants of Phase 1. Phase 2 saw the participation of 12 patients, the majority of whom were females. Their average length of treatment for depression was 3.1 years. Their HRSD, BDI and GAF scores improved significantly at weeks 10 and 26 with better scores at 10 weeks. All patients believed that psychotherapy was useful and practical. A majority (73%, 8/11) reported the modified psychotherapy as providing them something significantly different from treatment as usual. All the clinicians reported modified CBT as being ‘feasible’ and ‘easily deliverable’. This thesis suggests that culturally modified CBT for depression is an acceptable and practical treatment option in Sri Lanka
Identification of key messages for a national suicide prevention media campaign
The suicide rate in Australia has increased over recent years, indicating a need for novel suicide prevention interventions. A large proportion of people at risk of suicide do not seek professional help, but rather express their suicidal thoughts to close friends and family members. However, expressions of suicidal thoughts to family and friends can be indirect and ambiguous, and consequently can be missed or misunderstand, leading to dismissive response and missed opportunities for suicide prevention. A suicide prevention media campaign aimed at family members and friends may be one useful population-level suicide prevention strategy to encourage greater recognition of suicide risk and appropriate helping actions in response to suicidal communications. Current evidence for what messages would be acceptable and appropriate for inclusion in such as campaign, however, is limited. The research described in this thesis was undertaken to develop suicide prevention messages to include in an Australian suicide prevention campaign aimed at family and friends of adults at risk of suicide. To understand what messages would be most important to include, five studies were undertaken and are described in this thesis. Study 1 was an expert consensus study involving suicide prevention professionals and people with lived experience of suicide risk. This study established which suicide prevention actions these experts believe are the most important to encourage in a suicide prevention campaign aimed at family and friends. Study 2 was an online survey study involving people with lived experience of suicide risk that aimed to assess the most and least helpful actions taken by others in response to their suicidal communications. Studies 3 to 5 used data from a nationally representative telephone survey conducted with Australian adults. Study 3 examined Australian adults’ confidence and intentions to help a person close to them at risk of suicide. Study 4 examined helping actions given and received in response to suicidal communications. Study 5 assessed the relationships between beliefs in suicide ‘myths’ and helping intentions and actions. Overall, the findings from these studies show that Australian adults are confident and willing to assist a person close to them at risk of suicide. They intend to undertake, and indeed do undertake, a number of appropriate helping actions toward people close to them who are at risk of suicide. These appropriate actions include listening and talking to the person at risk and encouraging them to seek professional help. However, Australian adults also largely fail to ask important risk assessment questions, and commonly undertake actions that do not conform to best practice in suicide prevention. Such non-recommended actions include telling the person at risk ‘what they have going for them’ and telling them that their suicide would hurt their family and friends. A substantial minority of Australian adults also believe in suicide myths, including those related to encouraging suicidal thoughts by talking about suicide. The combined results of these studies have been utilised to make recommendations regarding the most useful messages to include in an Australian suicide prevention campaign aimed at family members and friends at people at risk of suicide.
Compulsory community treatment in the context of mental health reform in Victoria, Australia
Background The use of Community Treatment Orders (CTOs) in the treatment and care of those with severe mental illness continues to attract debate and remains controversial despite increasing use in many countries. Mental health legislation is driven by the policy directions of the government of the day, and also reflects community attitudes and expectations. In recent years there has been an increasing focus on individual rights as reflected in the expectation that use of restrictive interventions and compulsion will be kept to a minimum. These changes in policy and law have occurred in parallel with a reduction in bed-based services, and in Victoria, a reduction in service availability overall on a per capita basis. The objective of this thesis was to examine the processes involved in civil commitment under mental health legislation and factors that influence this, and to seek the views of those who provide the most direct care and support in the community. The thesis sought to determine whether subsequent care is influenced by the manner of discharge from a compulsory order, and the impact of new legislation with a greater emphasis on human rights. The thesis considers the changes in rates of compulsory care following reform of mental health legislation in the context of ratification of the United Nations Convention on the Rights of Persons with Disabilities. The thesis also considers the influence of substance use on whether compulsory care is instituted, and the experience of those who care for people with severe mental illness. Methods This thesis incorporates four studies. Studies one to three use the Victorian state-wide data system of mental health service utilisation. Two separate cohorts of people who had been on a CTO for at least three months were followed for two years. The first covered service utilisation for two years following the end of a CTO during 2008 – 2010, and the second from 2014 – 2016. This enabled consideration of the role of external review such as by the Mental Health Review Board in discharge and continuity of care planning, a comparison between two different legislative regimes, and the impact of clinical factors such as having substance use disorder in addition to severe mental illness. Study four incorporated a mixed qualitative/quantitative survey posted to carers who were members of two carer support and advocacy groups. This study sought to understand the views and experience of people who cared for those with severe mental illness such as schizophrenia. Through these studies the candidate sought to determine: whether the mode of termination of a CTO was related to subsequent service utilisation; whether the intention of legislative reform to reduce the use of compulsory treatment was supported by comparison between service utilisation after a CTO under the Mental Health Act (1986) and Mental Health Act (2014); and whether co-morbid substance use resulted in greater likelihood of being made a compulsory patient. Main Findings Study 1 found that the way a CTO ended influenced subsequent treatment as a compulsory patient. If the CTO ended suddenly the person was more likely to require use of the mental health act in the future. Study 2 showed that there had been a reduction in the use and duration of orders under the Mental Health Act (2014) compared to the Mental Health Act (1986). There was also an increase in the number of CTOs varied to an inpatient order by the authorised psychiatrist. Study 3 found that having a substance use disorder increased the use and duration of compulsory orders. This related to those with schizophrenia and mood disorders, with the latter more likely to return to inpatient care. The study raised the question of how effectively or otherwise mental health services and drug and alcohol treatment services work together. Study 4 showed that most of the carers who responded supported the use of CTOs. They reported considerable negative experience of care-giving. Conclusions The Victorian mental health service system has changed greatly over the past decades. Legislation has been reformed to meet contemporary expectations of oversight and regulation, including the introduction of CTOs. However, the intent of legislative reform may have been limited by the system failing to keep pace with population growth. The research raises questions about how we care for those with severe mental illness in the community and the impact the current service system has on carers and other support services. Reforming mental health legislation does not, of itself, result in improved patient outcomes or experience of care. Under the current system of care, the thesis supports continuing use of CTOs, but with greater emphasis on clinical engagement and care planning with other relevant care providers, including family or carers. This research occurred in the context of growing disquiet regarding the mental health service system and the subsequent commissioning of a Royal Commission.