Factors associated with common mental disorders during the transition to adulthood : do emerging adults and ‘early starters’ differ? Findings from an Australian birth cohort study

Background: Despite increasing diversity in pathways to adulthood, choices available to young people are influenced by environmental, familial and individual factors, namely access to socioeconomic resources, family support and mental and physical health status. Young people from families with higher socioeconomic position (SEP) are more likely to pursue tertiary education and delay entry to adulthood, whereas those from low socioeconomic backgrounds are less likely to attain higher education or training, and more likely to partner and become parents early. The first group are commonly termed ‘emerging adults’ and the latter group ‘early starters’. Mental health disorders during this transition can seriously disrupt psychological, social and academic development as well as employment prospects. Depression, anxiety and most substance use disorders have early onset during adolescence and early adulthood with approximately three quarters of lifetime psychiatric disorders having emerged by 24 years of age. Aims: This thesis aimed to explore the relationships between mental health, sociodemographic factors and family functioning during the transition to adulthood. Four areas were investigated: 1) The key differences between emerging adults and ‘early starters’, were examined and focused on a series of social, economic, and demographic factors as well as DSM-IV diagnoses; 2) Methodological issues associated with the measurement of depression and anxiety in young adults were explored by comparing a quantitative measure of symptoms of anxiety and depression (Achenbach’s YSR and YASR internalising scales) with DSM-IV diagnosed depression and anxiety. 3) The association between family SEP and DSM-IV depression and anxiety was examined in relation to the different pathways to adulthood. 4) Finally, the association between pregnancy loss, abortion and miscarriage, and DSM-IV diagnoses of common psychiatric disorders was assessed in young women who reported early parenting, experiencing a pregnancy loss, or who had never been pregnant. Methods: Data were taken from the Mater University Study of Pregnancy (MUSP), a large birth cohort started in 1981 in Brisbane, Australia. 7223 mothers and their children were assessed five times, at 6 months, 5, 14 and 21 years after birth. Over 3700 young adults, aged 18 to 23 years, were interviewed at the 21-year phase. Respondents completed an extensive series of self-reported questionnaires and a computerised structured psychiatric interview. Three outcomes were assessed at the 21-year phase. Mental health disorders diagnosed by a computerised structured psychiatric interview (CIDI-Auto), the prevalence of DSM-IV depression, anxiety and substance use disorders within the previous 12-month, during the transition (between ages of 18 and 23 years) or lifetime were examined. The primary outcome “current stage in the transition to adulthood” was developed using a measure conceptually constructed from the literature. The measure was based on important demographic markers, and these defined four independent groups: emerging adults (single with no children and living with parents), and three categories of ‘early starter’, singles (with no children or partner, living independently), those with a partner (married or cohabitating but without children) and parents. Early pregnancy loss was assessed using a measure that also defined four independent groups and was based on pregnancy outcomes in the young women This categorised the young women into those who were never pregnant, women who gave birth to a live child, and women who reported some form of pregnancy loss, either an abortion or a spontaneous miscarriage. A series of analyses were undertaken to test the study aims. Potential confounding and mediating factors were prospectively measured between the child’s birth and the 21-year phase. Binomial and multinomial logistic regression was used to estimate the risk of relevant outcomes, and the associations were reported as odds ratios (OR) and 95% confidence intervals (95%CI). Key findings: The thesis makes a number of important contributions to our understanding of the transition to adulthood, particularly in relation to the mental health consequences associated with different pathways. Firstly, findings from the thesis clearly showed that young people who parented or partnered early fared worse across most of the economic and social factors as well as the common mental disorders when compared to emerging adults. That is, young people who became early parents were also more likely to experience recent anxiety (OR=2.0, 95%CI 1.5-2.8) and depression (OR=1.7, 95%CI 1.1-2.7) than were emerging adults after taking into account a range of confounding factors. Singles and those partnering early also had higher rates of lifetime anxiety and depression than emerging adults. Young people who partnered early, but were without children, had decreased odds of recent depression; this may be due to the protective effect of early marriage against depression. It was also found that young people who form families early had an increased risk of cigarette smoking (parents OR=3.7, 95%CI 2.9-4.8) compared to emerging adults, but not heavy alcohol (parents OR=0.4, 95%CI 0.3-0.6) or recent illicit drug use. The high rates of cigarette smoking and tobacco use disorders in ‘early starters’ were explained by common risk factors related to early adversity and lower SEP. Having a child and early marriage may well function as a ‘turning point’ for some young people, it is not clear whether this is due to a conscious decision to disengage from a previous ‘substance using’ lifestyle or simply that they no longer have the time to devote to such activities because of child caring. In relation to the methodological issues associated with assessing common mental disorders in young adults, it was found that although the Achenbach empirical internalising scales successfully predicted both later DSM-IV depression (YSR OR=2.3, 95%CI 1.7-3.1) and concurrently diagnosed depression (YASR OR=6.9, 95%CI 5.0- 9.5) and anxiety (YASR OR=5.1, 95%CI 3.8- 6.7), the scales discriminated poorly between young people with or without DSM-IV diagnosed mood disorder. Sensitivity values (the proportion of true positives) for the internalising scales were surprisingly low. Only a third of young people with current DSM-IV depression (range for each of the scales was between 34% to 42%) were correctly identified as cases by the YASR internalising scales, and only a quarter with current anxiety disorder (range of 23% to 31%) were correctly identified. Also, use of the DSM-oriented scales increased sensitivity only marginally (for depression between 2-8%, and anxiety between 2-6%) above the standard Achenbach scales. This is despite the fact that the DSM-oriented scales were originally developed to overcome the poor prediction of DSM-IV diagnoses by the Achenbach scales. The internalising scales, both standard and DSM-oriented, were much more effective at identifying young people with comorbid depression and anxiety, with OR’s 10.1 to 21.7 depending on the internalising scale used. SEP is an important predictor of both an early transition to adulthood and the experience of anxiety during that time Family income during adolescence was a strong predictor of early parenting and partnering before age 24 but not early independent living. Compared to families in the upper quintile, young people from families with low income were nearly twice as likely to live with a partner and four times more likely to become parents (OR ranged from 2.6 to 4.0). This association remained after adjusting for current employment and education level. Children raised in low income families were 30% more likely to have an anxiety disorder (OR=1.3, 95%CI 0.9-1.9), but not depression, as young adults when compared to children from wealthier families. Emerging adults and ‘early starters’ from low income families did not differ in their likelihood of having a later anxiety disorder. Young women reporting a pregnancy loss had nearly three times the odds of experiencing a lifetime illicit drug disorder (excluding cannabis) [abortion OR=3.6, 95%CI 2.0-6.7 and miscarriage OR=2.6, 95%CI 1.2-5.4]. Abortion was associated with alcohol use disorder (OR=2.1, 95%CI 1.3- 3.5) and 12-month depression (OR=1.9, 95%CI 1.1- 3.1). These finding suggest that the association identified by Fergusson et al between abortion and later psychiatric disorders in young women may be due to pregnancy loss and not to abortion, per se. Conclusion: Findings from this thesis support the view that young people who parent or partner early have a greater burden of depression and anxiety when compared to emerging adults. As well, young women experiencing pregnancy loss, from either abortion or miscarriage, are more likely to experience depression and anxiety than are those who give birth to a live infant or who have never been pregnant. Depression, anxiety and substance use disorders often go unrecognised and untreated in young people; this is especially true in young people from lower SEP. Early identification of these common mental health disorders is important, as depression and anxiety experienced during the transition to adulthood have been found to seriously disrupt an individual’s social, educational and economic prospects in later life.

Using formative feedback to identify and support first year chemistry students with missing or misconceptions. A Practice Report

Students entering tertiary studies possess a diverse range of prior experiences in their academic preparation for tertiary chemistry so academics need tools to enable them to respond to issues in diversity in conceptual models possessed by entering students. Concept inventories can be used to provide formative feedback to help students identify concepts that they need to address to improve construction of subsequent understanding enabling their learning. Modular, formative learning activities that can be administered inside or outside of class in first year chemistry courses have been developed. These activities address key missing and mis-conceptions possessed by incoming student. Engagement in these learning activities by students and academics will help shift the culture of diagnostic and formative assessment within the tertiary context and address issues around the secondary/tertiary transition. This diagnostic/intervention framework is currently being trialed across five Australian tertiary institutions encompassing a large heterogeneous sample of students.

Fibroin-based materials support cultivation of limbal stromal cells

Purpose: The silk protein fibroin provides a potential substrate for use in ocular tissue reconstruction. We have previously demonstrated that transparent membranes produced from fibroin support cultivation of human limbal epithelial cells (Tissue Eng A. 14(2008)1203-11). We presently extend this body of work to studies of human limbal stromal cell (HLS) growth on fibroin in the presence and absence of serum. Methods: Primary cultures of HLS cells were established in DMEM/F12 medium supplemented with either 10% fetal bovine serum (FBS) or 2% B27 supplement. Defined keratinocyte serum-free medium (DK-SFM, Invitrogen) was also tested. The resulting cultures were analysed by flow cytometry for expression of CD34, CD90, CD45, and CD141. Cultures grown under each condition were subsequently passaged either onto transparent fibroin membranes prepared from purified fibroin or within 3D scaffolds prepared from partially-solubilised fibroin. Results: HLS cultures were successfully established under each condition, but grew more slowly and passaged poorly in the absence of serum. Cultures grown in 10% FBS were <0.5% CD34+ (keratocytes) and >97% CD90+ (fibroblasts). Cultures established in 2% B27 formed floating spheres and contained >8% CD34+ cells and reduced CD90 expression. Cultures established in DK-SFM displayed traces of epithelial cell growth (CD141), but mostly consisted of CD90+ cells with <1% CD34+ cells. Cells of bone marrow lineage (CD45) were rarely observed under any conditions. Cultures grown in 10% FBS were able to adhere to and proliferate on silk fibroin 3-D scaffolds and transparent films while those grown serum-free could not. Adhesion of HLS cells to fibroin was initially poorer than that displayed on tissue culture plastic. Conclusions: HLS cultures containing cells of predominantly fibroblast lineage can be grown on fibroin-based materials, but this process is dependent upon additional ECM factors such as those provided by serum.

A study of post diagnosis breast cancer concerns for women living in rural and remote Queensland. Part I : Personal concerns

The findings presented in this paper are part of a research project designed to provide a preliminary indication of the support needs of postdiagnosis women with breast cancer in remote and isolated areas in Queensland. This discussion will present data that focuses on the women’s expressed personal concerns. For participants in this research a diagnosis of breast cancer involves a confrontation with their own mortality and the possibility of a reduced life span. This is a definite life crisis, creating shock and needing considerable adjustment. Along with these generic issues the participants also articulated significant issues in relation to their experience as women in a rural setting. These concerns centred around worries about how their partner and families cope during their absences for treatment, the additional burden on the family of having to cope with running the property or farm during the participant’s absence or illness, added financial strain brought about by the cost of travel for treatment, maintenance of properties during absences, and problems created by time off from properties or self-employment. These findings accord with other reports of health and welfare services for rural Australian and the generic literature on psycho-oncology studies of breast cancer.

A study of postdiagnosis breast cancer concerns for women living in rural and remote Queensland. Part II : support issues

This paper presents the recent findings from a study on the postdiagnosis support needs of women with breast cancer living in rural and remote Queensland. The findings presented in this discussion focus on support needs from the perspective of the women experiencing breast cancer as well as health service providers. The tyranny of distance imposes unique hardships, such as separation from family and friends, during a time of great vulnerability for treatment, the need to travel long distances for support and follow-up services, and extra financial burdens, which can combine to cause strains on the marital relationship and family cohesion. Positive indications are, however, that the rural communities operate on strong, informal networks of support. This network of family, friends and community can, and does, play an active role in the provision of emotional and practical support.

Australian adolescent perceptions of parental support: Can it predict self-esteem among high and low SES groups?

Aims Physical activity has been shown to increase adolescent self-esteem. The aim of this investigation was to assess adolescent perceptions of parental support for physical activity endeavours, and its relationship with self-esteem among high and low SES groups. Methods Perceptions of parental support, and Rosenberg’s self-esteem (1965) were derived from the Children’s Physical Activity Correlates questionnaire, with scores ranging from 1 (lowest) to 4 (highest). Independent sample t-tests were conducted and Levene’s test indicated homogenous group variance, while Pearson’s r was employed to assess relationships between perceptions of parental support, and self-esteem. Results Overall, 111 (89%) and 64 (55%) high and low SES participants had complete data and were included in the analysis. The high SES differed for self-esteem (M = 3.39, SE = .05) from the low SES group (M = 2.75, SE = .08), t (173) = 6.82, p < .05, with a medium effect size (ES) r = .46. The high SES group scored higher for perceptions of parental support (M = 2.95, SE = .06) than the low SES group (M = 2.71, SE = .07), t (173) = 2.58, p < .05, with a low ES r = .04. Self-esteem was significantly correlated with parental support in both high (r = .34) and low (r = .47) SES groups. Conclusion Results indicate that perceptions of parental support may be a stronger indicator of self-esteem for low, than for high SES adolescents. Future physical activity strategies to promote self-esteem should involve parents as active facilitators.

Social support promotes psychological well-being following a natural disaster

Receiving emotional support has consistently been demonstrated as an important factor associated with mental health but sparse research has investigated giving support in addition to receiving it or the types of support that predict well-being. In this paper the relationship between giving and receiving instrumental and emotional social support and psychological well-being during and following a natural disaster is investigated. A survey administered between four and six months after fatal floods was conducted with 200 community members consisting of men (n = 68) and women (n = 132) aged between 17 and 87 years. Social support experiences were assessed using the 2-Way Social Support Scale (2-Way SSS; Shakespeare-Finch & Obst, 2011) and eudemonic well-being was measured using the Psychological Well-Being Scale (PWBS; Ryff & Keyes, 1995). Hierarchical multiple regression analyses were used to examine expected relationships and to explore the differential effects of the four factors of the 2-Way SSS. Results indicated that social support shared significant positive associations with domains of psychological well-being, especially with regards to interpersonal relationships. Receiving and giving emotional support were respectively the strongest unique predictors of psychological well-being. However, receiving instrumental support predicted less autonomy. Results highlight the importance of measuring social support as a multidimensional construct and affirm that disaster response policy and practice should focus on emotional as well as instrumental needs in order to promote individual and community psychosocial health following a flooding crisis.

Multi-gene phylogenetic analysis of south-east Asian pest members of the Bactrocera dorsalis species complex (Diptera: Tephritidae) does not support current taxonomy

Bactrocera dorsalis sensu stricto, B. papayae, B. philippinensis and B. carambolae are serious pest fruit fly species of the B. dorsalis complex that predominantly occur in south-east Asia and the Pacific. Identifying molecular diagnostics has proven problematic for these four taxa, a situation that cofounds biosecurity and quarantine efforts and which may be the result of at least some of these taxa representing the same biological species. We therefore conducted a phylogenetic study of these four species (and closely related outgroup taxa) based on the individuals collected from a wide geographic range; sequencing six loci (cox1, nad4-3′, CAD, period, ITS1, ITS2) for approximately 20 individuals from each of 16 sample sites. Data were analysed within maximum likelihood and Bayesian phylogenetic frameworks for individual loci and concatenated data sets for which we applied multiple monophyly and species delimitation tests. Species monophyly was measured by clade support, posterior probability or bootstrap resampling for Bayesian and likelihood analyses respectively, Rosenberg's reciprocal monophyly measure, P(AB), Rodrigo's (P(RD)) and the genealogical sorting index, gsi. We specifically tested whether there was phylogenetic support for the four 'ingroup' pest species using a data set of multiple individuals sampled from a number of populations. Based on our combined data set, Bactrocera carambolae emerges as a distinct monophyletic clade, whereas B. dorsalis s.s., B. papayae and B. philippinensis are unresolved. These data add to the growing body of evidence that B. dorsalis s.s., B. papayae and B. philippinensis are the same biological species, which poses consequences for quarantine, trade and pest management.

Role salience and support as moderators of demand/conflict relationships in China

This study examined the effects of role demand on both work–family conflict and family–work conflict, and the moderating effects of role salience and support on these relationships. Based on 391 dual-career (managerial and blue-collar employees) couples from a Taiwanese company in China, the results of this survey study showed clear gender differences in the patterns of relationships observed. For men, the most important demands that negatively impacted on work–family conflict were frequency of overtime and frequency of socializing for work purposes (yingchou), and supervisory support buffered the negative impact of frequent overtime. For women however, strong supervisory support and low work role salience were more important for reducing work–family conflict, and there was no significant main effect found for any of the role demand factors. Furthermore, women with high work role salience were more likely to feel the impact of yingchou on work–family conflict. In the family domain, the most influential demand for men was hours spent on household tasks, but for women, it was the frequency of family-related leave. Interestingly, males reported higher family role salience than females and spouse support intensified rather than buffered the positive impact of hours spent on household tasks on family–work conflict for males.

Exploring the conditions to support assessment for more equitable learning outcomes

NAPLAN RESULTS HAVE gained socio-political prominence and have been used as indicators of educational outcomes for all students, including Indigenous students. Despite the promise of open and in-depth access to NAPLAN data as a vehicle for intervention, we argue that the use of NAPLAN data as a basis for teachers and schools to reduce variance in learning outcomes is insufficient. NAPLAN tests are designed to show statistical variance at the level of the school and the individual, yet do not factor in the sociocultural and cognitive conditions Indigenous students’ experience when taking the tests. We contend that further understanding of these influences may help teachers understand how to develop their classroom practices to secure better numeracy and literacy outcomes for all students. Empirical research findings demonstrate how teachers can develop their classroom practices from an understanding of the extraneous cognitive load imposed by test taking. We have analysed Indigenous students’ experience of solving mathematical test problems to discover evidence of extraneous cognitive load. We have also explored conditions that are more supportive of learning derived from a classroom intervention which provides an alternative way to both assess and build learning for Indigenous students. We conclude that conditions to support assessment for more equitable learning outcomes require a reduction in cognitive load for Indigenous students while maintaining a high level of expectation and participation in problem solving.

Development and validation of an instrument to measure organizational cultures' support of business process management

The purpose of Business Process Management (BPM) is to increase the efficiency and effectiveness of organizational processes through improvement and innovation. Despite a common understanding that culture is an important element in these efforts, there is a dearth of theoretical and empirical research on culture as a facilitator of successful BPM. We develop the BPM culture construct and propose a validated instrument with which to measure organizational cultures’ support of BPM. The operationalization of the BPM culture concept provides a theoretical foundation for future research and a tool to assist organizations in developing a cultural environment that supports successful BPM.

Parent-teacher engagement : a coteaching and cogenerative dialoguing approach

The accumulated evidence from more than four decades of education research strongly suggests that parent involvement in schools carries significant benefits for students as well as for the success of schools (e.g., Henderson & Mapp, 2002). Governments in Australia and overseas have supported parent involvement in schools with a range of initiatives while parent groups have indicated a strong desire for expanded school roles that include participation in formal educational processes namely curriculum, pedagogy, and assessment. Research has also signalled the need for teachers to engage parents rather than adopt traditional parent-school involvement practices so that parents can participate as joint educators in their children's schooling alongside teachers (Pushor, 2001). Actually improving the quality of contact and relationships between parents and teachers to enable engagement however remains problematic. Coteaching and cogenerative dialoguing originally emerged as an innovative approach in the context of teaching secondary school science. Coteaching brings together the collective expertise of several individuals to expand learning opportunities for students while cogenerative dialogues refer to sessions in which participants talk, listen, and learn from one another about the process (Roth & Tobin, 2002a). Coteaching and cogenerative dialoguing reportedly benefits students academically and socially while rewarding educators professionally and emotionally through the support and collaboration they receive from fellow coteachers. These benefits ensue because coteaching theoretically positions teachers at one another's elbows, providing new and different understandings about teaching based on first-hand perspectives and shared goals for assisting students to learn. This thesis proposes that coteaching and cogenerative dialoguing may provide a vehicle for improving quality of contact and relationships between parents and teachers. To investigate coteaching and cogenerative dialoguing as a parent-teacher engagement mechanism, interpretive ethnographic case study research was conducted involving two parents and a secondary school teacher. Sociological ideas, namely Bourdieu's (1977) fields, habitus, and capitals, together with multiple dialectical concepts such as agency|structure (Sewell, 1992) and agency|passivity (Roth, 2007b, 2010) were assembled into a conceptual framework to examine parent-teacher relationships by describing and explaining cultural production and identity construction throughout the case study. Video and audio recordings of cogenerative dialogues and cotaught lessons comprised the chief data sources. Data were analysed using qualitative techniques such as discourse and conversation analysis to identify patterns and contradictions (Roth & Tobin, 2002a). The use of quality criteria detailed by Guba and Lincoln (2005) gives credence to the way in which ethical considerations infused the planning and conduct of this research. From the processes of data collection and analyses, three broad assertions were proffered. The findings highlight the significance of using multiple coordinated dialectical concepts for analysing the affordances and challenges of coteaching and cogenerative dialogues that include parents and teachers. Adopting the principles and purposes of coteaching and cogenerative dialoguing promoted trusting respectful relationships that generated an equitable culture. The simultaneous processes and tensions between logistics and ethics (i.e., the logistics|ethics dialectic) were proposed as a new way to conceptualise how power was redistributed among the participants. Knowledge of positive emotional energy and ongoing capital exchange conceived dialectically as the reciprocal interaction among cultural, social, and symbolic capitals (i.e., the dialectical relationship of cultural|social|symbolic capital) showed how coteaching and cogenerative dialoguing facilitated mutual understandings, joint decision-making, and group solidarity. The notion of passivity as the dialectical partner of agency explained how traditional roles and responsibilities were reconfigured and individual and collective agency expanded. Complexities that surfaced when implementing the coteaching and cogenerative dialoguing approach were outweighed by the multiple benefits that accrued for all involved. These benefits included the development of community-relevant and culturally-significant curricula that increased student agency and learning outcomes, heightened parent self-efficacy for participating in and contributing to formal educational processes, and enhanced teacher professionalism. This case study contributes to existing theory, knowledge and practice, and methodology in the research areas of parent-teacher relationships, specifically in secondary schools, and coteaching and cogenerative dialoguing. The study is particularly relevant given the challenges schools and teachers increasingly face to meaningfully connect with parents to better meet the needs of educational stakeholders in times of continual, complex, and rapid societal change.

Text messaging to support off-campus clinical facilitators of undergraduate student nurses

Managing large cohorts of undergraduate student nurses during off-campus clinical placement is complex and challenging. Clinical facilitators are required to support and assess nursing students during clinical placement. Therefore clear communication between university academic coordinators and clinical facilitators is essential for consistency and prompt management of emerging issues. Increasing work demands require both coordinators and facilitators to have an efficient and effective mode of communication. The aim of this study was to explore the use of Short Message Service (SMS) texts, sent between mobile phones, for communication between university Unit Coordinators and off-campus Clinical Facilitators. This study used an after-only design. During a two week clinical placement 46 clinical facilitators working with first and second year Bachelor of Nursing students from a large metropolitan Australian university were regularly sent SMS texts of relevant updates and reminders from the university coordinator. A 15 item questionnaire comprising x of 5 point likert scale and 3 open-ended questions was then used to survey the clinical facilitators. The response rate was 47.8% (n=22). Correlations were found between the approachability of the coordinator and facilitator perception of a) that the coordinator understood issues on clinical placement (r=0.785, p<0.001,), and b) being part of the teaching team (r=0.768, p<0.001). Analysis of responses to qualitative questions revealed three themes: connection, approachability and collaboration. Results indicate that SMS communication is convenient and appropriate in this setting. This quasi-experimental after-test study found regular SMS communication improves a sense of connection, approachability and collaboration.

Paper, prices and politics : an evaluation of the Swedish support to the Bai Bang project in Vietnam : a Sida evaluation report

Sweden’s protest against the Vietnam War was given tangible form in 1969 through the decision to give economic aid to the Government of North Vietnam. The main outcome was an integrated pulp and paper mill in the Vinh Phu Province north-west of Hanoi. Known as Bai Bang after its location, the mill became the most costly, one of the longest lasting and the most controversial project in the history of Swedish development cooperation. In 1996 Bai Bang produced at its full capacity. Today the mill is exclusively managed and staffed by the Vietnamese and there are plans for future expansion. At the same time a substantial amount of money has been spent to reach these achievements. Looking back at the cumbersome history of the project the results are against many’s expectations. To learn more about the conditions for sustainable development Sida commissioned two studies of the Bai Bang project. Together they touch upon several important issues in development cooperation over a period of almost 30 years: the change of aid paradigms over time, the role of foreign policy in development cooperation, cultural obstacles, recipient responsibility versus donor led development etc. The two studies were commissioned by Sida’s Department for Evaluation and Internal Audit which is an independent department reporting directly to Sida’s Board of Directors. One study assesses the financial and economic viability of the pulp and paper mill and the broader development impact of the project in Vietnam. It has been carried out by the Centre for International Economics, an Australian private economic research agency. The other study analyses the decision-making processes that created and shaped the project over a period of two decades, and reflects on lessons from the project for development cooperation in general. This study has been carried out by the Chr. Michelsen Institute, a Norweigan independent research institution.

Postnatal depression in Central Vietnam

Postnatal depression (PND) is a significant global health issue, which not only impacts maternal wellbeing, but also infant development and family structures. Mental health disorders represent approximately 14% of global burden of disease and disability, including low and middle-income countries (LMIC), and PND has direct relevance to the Millennium Development Goals of reducing child mortality, improving maternal health, and creating global partnerships (United Nations, 2012; Guiseppe, Becker & Farmer, 2011). Emerging evidence suggests that PND in LMIC is similar to, or higher than in high-income countries (HIC), however, less than 10% of LMIC have prevalence data available (Fisher, Cabral de Mello, & Izutsu 2009; Lund et al., 2011). Whilst a small number of studies on maternal mental disorders have been published in Vietnam, only one specifically focuses on PND in a hospital-based sample. Also, community based mental health studies and information on mental health in rural areas of Vietnam is still scarce. The purpose of this study was to determine the prevalence of PND, and its associated social determinants in postnatal women in Thua Thien Hue Province, Central Vietnam. In order to identify social determinants relevant to the Central Vietnamese context, two qualitative studies and one community survey were undertaken. Associations between maternal mental health and infant health outcomes were also explored. The study was comprised of three phases. Firstly, iterative, qualitative interviews with Vietnamese health professionals (n = 17) and postpartum women (n = 15) were conducted and analysed using Kleinman's theory of explanatory models to identify narratives surrounding PND in the Vietnamese context (Kleinman, 1978). Secondly, a participatory concept mapping exercise was undertaken with two groups of health professionals (n = 12) to explore perceived risk and protective factors for postnatal mental health. Qualitative phases of the research elucidated narratives surrounding maternal mental health in the Vietnamese context such as son preference, use of traditional medicines, and the popularity of confinement practices such as having one to three months of complete rest. The qualitative research also revealed the construct of depression was not widely recognised. Rather, postpartum changes in mood were conceptualised as a loss of 'vital strength' following childbirth or 'disappointment'. Most women managed postpartum changes in mood within the family although some sought help from traditional medicine practitioners or biomedical doctors. Thirdly, a cross-sectional study of twelve randomly selected communes (six urban, six rural) in Thua Thien Hue Province was then conducted. Overall, 465 women with infants between 4 weeks and six months old participated, and 431 questionnaires were analysed. Women from urban (n = 216) and rural (n = 215) areas participated. All eligible women completed a structured interview about their health, basic demographics, and social circumstances. Maternal depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) as a continuous variable. Multivariate generalised linear regression was conducted using PASW Statistics version 18.0 (2009). When using the conventional EPDS threshold for probable depression (EPDS score ~ 13) 18.1% (n = 78) of women were depressed (Gibson, McKenzie-McHarg, Shakespeare, Price & Gray, 2009). Interestingly, 20.4% of urban women (n = 44) had EPDS scores~ 13, which was a higher proportion than rural women, where 15.8% (n = 34) had EPDS scores ~ 13, although this difference was not statistically significant: t(429) = -0.689, p = 0.491. Whilst qualitative narratives identified infant gender and family composition, and traditional confinement practices as relevant to postnatal mood, these were not statistically significant in multivariate analysis. Rather, poverty, food security, being frightened of your husband or family members, experiences of intimate partner violence and breastfeeding difficulties had strong statistical associations. PND was also associated with having an infant with diarrhoea in the past two weeks, but not infant malnutrition or acute respiratory infections. This study is the first to explore maternal mental health in Central Vietnam, and provides further evidence that PND is a universally experienced phenomenon. The independent social risk factors of depressive symptoms identified such as poverty, food insecurity, experiences of violence and powerlessness, and relationship adversity points to women in a context of social suffering which is relevant throughout the world (Kleinman, Das & Lock, 1997). The culturally specific risk factors explored such as infant gender were not statistically significant when included in a multivariable model. However, they feature prominently in qualitative narratives surrounding PND in Vietnam, both in this study and previous literature. It appears that whilst infant gender may not be associated with PND per se, the reactions of close relatives to the gender of the baby can adversely affect maternal wellbeing. This study used a community based participatory research approach (CBPR) (Israel.2005). This approach encourages the knowledge produced to be used for public health interventions and workforce training in the community in which the research was conducted, and such work has commenced. These results suggest that packages of interventions for LMIC devised to address maternal mental health and infant wellbeing could be applied in Central Vietnam. Such interventions could include training lay workers to follow up postpartum women, and incorporating mental health screening and referral into primary maternal and child health care (Pate! et al., 2011; Rahman, Malik, Sikander & Roberts, 2008). Addressing the underlying social determinants of PND through poverty reduction and violence elimination programs is also recommended.