Disability-related inequalities in the prevalence of loneliness across the lifespan: trends from Australia, 2003 to 2020.

BACKGROUND: Experiencing loneliness can be distressing and increasing evidence indicates that being lonely is associated with poor physical and mental health outcomes. Cross-sectional studies have demonstrated that people with disability have increased risk of experiencing loneliness compared to people without disability. However, we do not know if these inequalities have changed over time. This study investigated the prevalence of loneliness for people with disability in Australia annually from 2003 to 2020 to examine whether disability-related inequalities in loneliness have changed over time, and disaggregated results for subgroups of people with disability by age group, sex, and disability group. METHODS: We used annual data (2003-2020) from the Household, Income and Labour Dynamics in Australia Survey. Loneliness was measured by a single question assessing the subjective experience of loneliness. For each wave, we calculated population-weighted age-standardised estimates of the proportion of people experiencing loneliness for people with and without disability. We then calculated the absolute and relative inequalities in loneliness between people with and without disability for each wave. Analyses were stratified by 10-year age groups, sex, and disability group (sensory or speech, physical, intellectual or learning, psychological, brain injury or stroke, other). RESULTS: From 2003 to 2020, the prevalence of loneliness was greater for people with disability, such that people with disability were 1.5 to 1.9 times more likely to experience loneliness than people without disability. While the prevalence of loneliness decreased for people without disability between 2003 and 2020, the prevalence of loneliness did not decrease for people with disability during this period. Inequalities in loneliness were more substantial for people with intellectual or learning disabilities, psychological disability, and brain injury or stroke. CONCLUSION: This study confirms that people with disability have increased risk of loneliness compared to people without disability. We add to the existing evidence by demonstrating that disability-related inequalities in loneliness have persisted for two decades in Australia without improvement. Our findings indicate that addressing inequalities in loneliness for people with disability is a critical public health concern given that loneliness is associated with a wide range of poor health outcomes.

Smoking Inequality Trends by Disability and Income in Australia, 2001 to 2020.

BACKGROUND: While policies to reduce smoking in many countries have been successful, disadvantaged groups (such as low-income groups) have only seen minor gains. People with disability are one such disadvantaged group and are more likely to smoke. However, evidence is limited on trends and inequalities in smoking for disabled people and on whether those also on low incomes are more likely to smoke. METHODS: We use annual data from 2001 to 2020 of the Household Income and Labour Dynamics in Australia survey. We use a Bayesian model to estimate smoking prevalence trends and inequalities for people with disability (2020, n = 1,370) and without disability (2020, n = 6,229) across the whole population and within income tertiles. To avoid reverse causation (smoking causing disability), we focus on younger people (15-44 years). RESULTS: Absolute reductions (per 100 people, [95% credible intervals]) in smoking were similar for people with (-13 [-16, -11]) and without disability (-15 [-16, -14]), with stable absolute but increasing relative inequalities. In the low-income group, absolute reductions in smoking prevalence for people with disability (-10 [-14, -6]) were smaller than in people without disability (-14 [-15, -12]), resulting in moderate evidence for increasing absolute inequalities (4 [0, 8]) and strong evidence for increasing relative inequalities. In high-income groups, disability-related absolute inequalities narrowed (-6 [-10, -3]), and relative inequalities were stable. CONCLUSIONS: Disabled people in Australia, especially those on low incomes, show signs of being left behind in efforts to reduce smoking.

The impact of Disability Insurance reassessment on healthcare use.

Several Organisation for Economic Co-operation and Development countries have constrained Disability Income Insurance (DI) eligibility and reassessed those on DI to encourage workforce participation. But these policies can also have unintended consequences. While receiving less income can directly worsen physical and mental health, the stress related to reassessment and the possibility of losing DI may also adversely affect mental health. This paper uses Australian population-wide administrative data to explore how a 2014 policy - where DI recipients under 35 were reassessed under stricter criteria - affected healthcare use. We exploit this age targeting using a difference-in-difference regression design and find that the policy increased nervous system drug prescriptions (which includes antidepressants). Our findings suggest that the reassessment of DI recipients, even without income loss, may have had a significant negative impact on their mental health. DI reassessment policies may have the unintended consequence of worsening mental health and this needs be considered when deciding if reassessment is worthwhile.

Does employment status mediate the association between disability status and mental health among young adults? Evidence from the Household, Income and Labour Dynamics in Australia (HILDA) survey.

OBJECTIVE: Young adults with disabilities are less likely to be employed and more likely to have poor mental health than peers without disabilities. Growing evidence shows that social determinants of health may be causally related to mental health outcomes of people with disabilities. We aimed to assess if the disability to mental health association was mediated by employment status among young adults aged 20-35 years. METHODS: Four consecutive years (2016-2019) of data from the Household, Income and Labour Dynamics in Australia survey were used to conduct a causal mediation analysis. We decomposed the total causal effect of disability status on mental health (Short Form-36 Mental Health Inventory-5) into the natural direct effect from disability to mental health and the natural indirect effect representing the pathway through the employment mediator (being employed; being unemployed or wanting to work). RESULTS: 3435 participants (3058 with no disabilities, 377 with disabilities) were included in the analysis. The total causal effect of disability status on mental health was an estimated mean decrease in mental health of 4.84 points (95% CI -7.44 to -2.23). The indirect effect, through employment status, was estimated to be a 0.91-point decline in mental health (95% CI -1.50 to -0.31). CONCLUSIONS: Results suggest disability has an effect on the mental health of young adults; a proportion of this effect appears to operate through employment. The mental health of young adults with disabilities could potentially be improved with interventions to improve employment outcomes among this group, and by supporting individuals with disabilities into suitable employment.

A systematic review of the impact of the COVID-19 pandemic on the mental health of adolescents and young people with disabilities aged 15-29 years.

BACKGROUND: The COVID-19 pandemic has exacerbated the psychological burden on young people around the world and may have disproportionately large impacts for young people with disabilities. This review aims to systematically review the quantitative evidence on the impact of the COVID-19 pandemic on the mental health of young people with disabilities and evaluate the quality of included studies. METHODS: A systematic search was conducted using 5 electronic databases. The quality of the studies was assessed using the SIGN risk of bias assessment tool. A narrative synthesis was performed to synthesize the results of included studies. RESULTS: The initial search yielded 1935 studies, of which two met the eligibility criteria, one longitudinal study and one cross-sectional study, both assessed to be of low quality. In the cross-sectional study, young people with intellectual and developmental disabilities self-reported an increase in mental health symptoms. The longitudinal study found no evidence of a change in mental health symptoms from pre-pandemic to during the pandemic among young people with autism spectrum disorder, although these individuals reported negative impacts of the COVID-19 pandemic on their emotional or mental health. CONCLUSIONS: The findings of this review provide some weak evidence of a negative impact of the COVID-19 pandemic on the mental health of young people with disabilities. Importantly, the findings highlight the lack of research in this area. More research is needed to investigate the impact of the pandemic on the mental health of young disabled people, in order for governments to develop emergency preparedness plans to safeguard the well-being of this population.

Disability and loneliness in the United Kingdom: cross-sectional and longitudinal analyses of trends and transitions.

BACKGROUND: Loneliness can have a detrimental impact on health, yet little is known about the association between disability and loneliness. METHODS: Secondary analysis of three waves of data collected between 2017 and 2020 by the UK's annual household panel study, Understanding Society. Direct age-standardisation was used to compare the prevalence of loneliness at each wave and the persistence of loneliness across all three waves for participants with/without disabilities aged 16-65 years. Transitional probabilities for the stability of loneliness, the stability of non-loneliness, the onset of loneliness and the offset of loneliness between consecutive waves were also estimated. RESULTS: At each wave, the prevalence of loneliness was significantly higher among respondents with disabilities than respondents without disabilities; these inequalities persisted with no evidence of change over time. The prevalence of persistent loneliness was 46% for respondents with disabilities compared with 22% for respondents without disabilities. Risk factors for the likelihood of persistent loneliness included disability, financial stress, not living as a couple, living in rented accommodation, being female and not being employed. The probability of the onset and stability of loneliness between successive waves were markedly higher for people with disabilities compared with people without disabilities. CONCLUSION: Adults with disabilities were more likely to experience loneliness, become lonely and remain lonely over time than their peers. Policies and interventions aimed at reducing loneliness should ensure that they are accessible and effective for people with disabilities. Further research is needed to explore the health outcomes of persistent loneliness among people with/without disabilities.

Trends in mental health inequalities for people with disability, Australia 2003 to 2020.

OBJECTIVE: Cross-sectional studies have demonstrated that people with disability have substantial inequalities in mental health compared to people without disability. However, it is not known if these inequalities have changed over time. This study compared the mental health of people with and without disability annually from 2003 to 2020 to investigate time trends in disability-related mental health inequalities. METHODS: We use annual data (2003-2020) of the Household, Income and Labour Dynamics in Australia Survey. Mental health was measured using the five-item Mental Health Inventory. For each wave, we calculated population-weighted age-standardised estimates of mean Mental Health Inventory scores for people with and without disability and calculated the mean difference in Mental Health Inventory score to determine inequalities. Analyses were stratified by age, sex and disability group (sensory or speech, physical, intellectual or learning, psychological, brain injury or stroke, other). RESULTS: From 2003 to 2020, people with disability had worse mental health than people without disability, with average Mental Health Inventory scores 9.8 to 12.1 points lower than for people without disability. For both people with and without disability, Mental Health Inventory scores decreased, indicating worsening mental health, reaching the lowest point for both groups in 2020. For some subpopulations, including young females and people with intellectual disability, brain injury or stroke, mental health inequalities worsened. CONCLUSION: This paper confirms that people with disability experience worse mental health than people without disability. We add to previous findings by demonstrating that disability-related inequalities in mental health have been sustained for a long period and are worsening in some subpopulations.

Use of Parental Disability Trajectories to Identify Adolescents Who are Young Carers.

Being a young carer can have significant impacts on the lives of children and adolescents. Identifying young carers is difficult, making the provision of support challenging for service providers. This sample contained 4464 Australian children/adolescents across 11 years (49% female, aged 6/7 years at baseline, and 16/17 years at final wave). Group-based trajectory modeling was applied to examine parental disability trajectories across 5 waves of data collection. Associations between estimated trajectories and unpaid/informal caring at age 16/17 years were then assessed. Three trajectory groups were identified: consistently-low (80%), low-increasing-high (10%) and moderate-high (10%) levels of parental disability. There was strong evidence that caring was elevated in the low-increasing-high group compared to the consistently-low group, and moderate evidence of elevation in the moderate-high group. By identifying adolescents with increased odds of becoming young carers, this study shows that parental disability may be an important way for service providers to identify and support young carers.

COVID-19 vaccination coverage and vaccine hesitancy among Australians with disability and long-term health conditions.

ISSUE ADDRESSED: COVID-19 vaccination is the cornerstone of managing Australia's COVID-19 pandemic and the success of the vaccination program depends on high vaccination coverage. This paper examined differences in COVID-19 vaccination coverage and vaccine hesitancy for people with disability, long-term health conditions, and carers - subgroups that were prioritised in Australia's vaccination program. METHODS: Using data from 2400 Australians who participated in two waves of the Taking the Pulse of the Nation survey in April and May 2021, we described vaccination coverage and hesitancy among people with disability, severe mental health conditions, severe long-term health conditions, frequent need for assistance with everyday activities, and carers. RESULTS: Vaccination coverage was estimated to be 8.2% in the population overall and was similar for people with disability, those with frequent need for assistance, and carers. It was higher for people with severe long-term health conditions (13.4%) and lower for people with severe mental health conditions (4.3%). Vaccine hesitancy was high overall (35.6%) and was similarly high across the priority groups, with only small differences for people with disability, severe long-term health conditions and frequent need for assistance. CONCLUSIONS: This study highlights a lack of difference in vaccination coverage for people with disability, long-term health conditions, and carers compared to the general population. So what? Sub-optimal vaccination coverage for people in the priority groups leaves many people at significant risk of serious disease or death if exposed to COVID-19, particularly in light of easing of disease-control restrictions across Australia and the emergence of new variants.

The impact of disability on employment and financial security following the outbreak of the 2020 COVID-19 pandemic in the UK.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic may have a greater impact on people with disabilities than non-disabled people. Our aim was to compare the short-term impact of the 2020 COVID-19 pandemic and first lockdown on the employment and financial security of working age adults with and without disabilities in the UK. METHODS: Secondary analysis of data collected in Wave 9 and the special April, May and June COVID-19 monthly surveys of 'Understanding Society', the UK's main annual household panel study. RESULTS: During the first 3 months of the introduction of the COVID-19 lockdown in the UK, respondents with disability were more likely than their peers to be working reduced hours and experience higher levels of financial stress. These differences were attenuated, but not eliminated, when estimates were adjusted to take account of pre-lockdown financial status. CONCLUSIONS: Working age adults with disability were particularly disadvantaged by the financial impact of the COVID-19 lockdown in the UK. The UN Secretary-General António Guterres has stated the need for a disability-inclusive COVID-19 government response. The results of our analysis suggest that these pleas have either not been heeded, or if measures have been implemented, they have so far been ineffectual in the UK.

Overt acts of perceived discrimination reported by British working-age adults with and without disability.

BACKGROUND: Exposure to discrimination can have a negative impact on health. There is little robust evidence on the prevalence of exposure of people with disabilities to discrimination, the sources and nature of discrimination they face, and the personal and contextual factors associated with increased risk of exposure. METHODS: Secondary analysis of de-identified cross-sectional data from the three waves of the UK's 'Life Opportunities Survey'. RESULTS: In the UK (i) adults with disabilities were over three times more likely than their peers to be exposed to discrimination, (ii) the two most common sources of discrimination were strangers in the street and health staff and (iii) discrimination was more likely to be reported by participants who were younger, more highly educated, who were unemployed or economically inactive, who reported financial stress or material hardship and who had impairments associated with hearing, memory/speaking, dexterity, behavioural/mental health, intellectual/learning difficulties and breathing. CONCLUSIONS: Discrimination faced by people with disabilities is an under-recognised public health problem that is likely to contribute to disability-based health inequities. Public health policy, research and practice needs to concentrate efforts on developing programs that reduce discrimination experienced by people with disabilities.

Promoting proactive bystander responses to racism and racial discrimination in primary schools: a mixed methods evaluation of the 'Speak Out Against Racism' program pilot.

BACKGROUND: Racism and racial discrimination are fundamental causes and determinants of health and health inequalities globally, with children and adolescents particularly vulnerable. Racial discrimination is a common stressor in the lives of many children and adolescents, with growing evidence of negative associations between racial discrimination and multiple domains of child and adolescent health. Addressing racism and racial discrimination must be core public health priorities, even more so among children and young people. Schools are key settings in the lives of children and adolescents and become increasingly more important to identity formation. School communities, teachers and peers greatly influence children and adolescents' beliefs about race and difference. Schools are therefore key sites for the delivery of population-based programs to reduce racism and promote proactive bystander behaviour and healthy resistance to racism among all children and adolescents as well as among the adults. METHODS: This study examines the feasibility and acceptability of the 'Speak Out Against Racism (SOAR)' program, a whole of school, multi-level, multi-strategy program that aimed to promote effective bystander responses to racism and racial discrimination in primary schools. A mixed-methods, quasi-experimental design was used. Students in Years 5 and 6 (10-12 years) across six schools completed surveys pre- and post- intervention (N = 645; 52% female; 6% Indigenous, 10% Middle Eastern, African, Latinx or Pacific Islander, 21% Asian, 52% Anglo/European). Focus groups with students and interviews with staff collected qualitative data about their experiences of the program and their views about the program's perceived need, implementation, impacts and suggested improvements. RESULTS: Quantitative data showed student prosocial skills and teacher inter-racial climate improved in intervention schools compared to comparison schools. Qualitative data highlighted teacher attitudinal and behaviour change regarding racism, and student reduced interpersonal racial discrimination, improved peer prosocial norms, commitment to anti-racism, knowledge of proactive bystander responses and confidence and self-efficacy to intervene to address racism. CONCLUSIONS: This study provides quantitative evidence of the potential of the SOAR program to improve the prosocial skills of students and their perceptions of the inter-racial school climate provided by their teachers. This program also provided qualitative evidence of the potential to promote teacher and student attitudinal and behavioural change. Further refinement and testing of the program in a large scale implementation trial is recommended.

The double burden of poverty and marital loss on the mental health of older Australian women; a longitudinal regression analysis using 17 annual waves of the HILDA cohort.

PURPOSE: Compared to men, older women have poorer mental health and are more vulnerable to poverty, especially when living alone. However, few studies have examined how gender, marital status and poverty are inter-related and are associated with mental health. This study examines the gendered associations between relative poverty, marital status and mental health in older Australians. METHODS: Drawing on 17 waves of the HILDA Survey, fixed-effects longitudinal regression analysis was utilised to examine the association between: (1) relative poverty (< 50% median household income) and mental health (MHI-5); (2) marital status and poverty, in a cohort of Australians aged 65 + years. We then examined effect modification of the association between relative poverty and mental health by marital status. RESULTS: Within-person associations, stratified by gender, showed that women in relative poverty reported poorer mental health than when not in relative poverty, however no association was observed for men. Being divorced/separated was associated with increased odds of relative poverty for women, but not men. Widowhood was strongly associated with relative poverty in women, and also among men, albeit a smaller estimate was observed for men. There was no evidence of effect modification of the relationship between relative poverty and mental health by marital status for either men or women. CONCLUSION: This study provides evidence that relative poverty is a major determinant of mental health in older Australian women. Addressing gender inequities in lifetime savings, as well as in division of acquired wealth post marital loss, may help reduce these disparities.

Gendered associations between household labour force participation and mental health using 17 waves of Australian cohort data.

PURPOSE: There is some evidence that employed women report more time pressure and work-life penalties than employed men and other women; however little is known about whether this exerts a mental health effect. This analysis examined associations between household labour force arrangements (household-employment configuration) and the mental health of men and women. METHODS: Seventeen waves of data from the Household Income and Labour Dynamics Survey (2001-2017) were used. Mental health was measured using the Mental Health Inventory (MHI-5). A six-category measure of household-employment configuration was derived: dual full-time employed, male-breadwinner, female-breadwinner, shared part-time employment (both part-time), male full-time/female part-time (modified male-breadwinner, MMBW), and female full-time/male part-time. Using fixed-effects regression methods, we examined the within-person effects of household-employment configuration on mental health after controlling for time-varying confounders. RESULTS: For men, being in the female-breadwinner configuration was associated with poorer mental health compared to being in the MMBW configuration (ß-1.98, 95% CI - 3.36, - 0.61). The mental health of women was poorer when in the male-breadwinner configuration, compared to when in the MMBW arrangement (ß-0.89, 95% CI - 1.56, - 0.22). CONCLUSION: These results suggest that the mental health of both men and women is poorer when not in the labour force, either as a man in the female-breadwinner arrangement, or as a woman in the male-breadwinner arrangement. These results are particularly noteworthy for women, because they pertain to a sizeable proportion of the population who are not in paid work, and highlight the need for policy reform to support women's labour force participation.

Breadwinners and Losers: Does the Mental Health of Mothers, Fathers, and Children Vary by Household Employment Arrangements? Evidence From 7 Waves of Data From the Longitudinal Study of Australian Children.

In Australia, as in many industrialized countries, the past 50 years have been marked by increasing female labor-force participation. It is popularly speculated that this might impose a mental-health burden on women and their children. This analysis aimed to examine the associations between household labor-force participation (household employment configuration) and the mental health of parents and children. Seven waves of data from the Longitudinal Study of Australian Children were used, comprising 2004-2016, with children aged 4-17 years). Mental health outcome measures were the Strengths and Difficulties Questionnaire (children/adolescents) and 6-item Kessler Psychological Distress Scale (parents). A 5-category measure of household employment configuration was derived from parental reports: both parents full-time, male-breadwinner, female-breadwinner, shared-part-time employment (both part-time) and father full-time/mother part-time (1.5-earner). Fixed-effects regression models were used to compare within-person effects, controlling for time-varying confounders. For men, the male-breadwinner configuration was associated with poorer mental health compared with the 1.5-earner configuration (ß = 0.21, 95% confidence interval: 0.05, 0.36). No evidence of association was observed for either women or children. This counters prevailing social attitudes, suggesting that neither children nor women are adversely affected by household employment configuration, nor are they disadvantaged by the extent of this labor-force participation. Men's mental health appears to be poorer when they are the sole household breadwinner.

Hierarchical Models for International Comparisons: Smoking, Disability, and Social Inequality in 21 European Countries.

BACKGROUND: International comparisons of social inequalities in health outcomes and behaviors are challenging. Due to the level of disaggregation often required, data can be sparse and methods to make adequately powered comparisons are lacking. We aimed to illustrate the value of a hierarchical Bayesian approach that partially pools country-level estimates, reducing the influence of sampling variation and increasing the stability of estimates. We also illustrate a new way of simultaneously displaying the uncertainty of both relative and absolute inequality estimates. METHODS: We used the 2014 European Social Survey to estimate smoking prevalence, absolute, and relative inequalities for men and women with and without disabilities in 21 European countries. We simultaneously display smoking prevalence for people without disabilities (x-axis), absolute (y-axis), and relative inequalities (contour lines), capturing the uncertainty of these estimates by plotting a 2-D normal approximation of the posterior distribution from the full probability (Bayesian) analysis. RESULTS: Our study confirms that across Europe smoking prevalence is generally higher for people with disabilities than for those without. Our model shifts more extreme prevalence estimates that are based on fewer observations, toward the European mean. CONCLUSIONS: We demonstrate the utility of partial pooling to make adequately powered estimates of inequality, allowing estimates from countries with smaller sample sizes to benefit from the increased precision of the European average. Including uncertainty on our inequality plot provides a useful tool for evaluating both the geographical patterns of variation in, and strength of evidence for, differences in social inequalities in health.

Experiences of racial discrimination and cardiometabolic risk among Australian children.

Cardiometabolic disease is a leading cause of adult morbidity and mortality globally. There is considerable evidence that childhood adversity is associated with markers of cardiometabolic disease risk in childhood, including obesity, blood pressure trajectories, and chronic inflammation. Experiences of racial discrimination may be an important, yet under explored, form of childhood adversity influencing childhood cardiometabolic risk. This study aimed to examine associations between self-reported racial discrimination and cardiometabolic risk markers among children. A total of 124 children (73 female) aged 11.4 years (SD 0.71) participated in the study. Most children (n = 79) identified as being from an Indigenous or an ethnic minority background. Markers of cardiometabolic risk were BMI, waist circumference, weight height ratio, systolic and diastolic blood pressure, and five inflammatory markers (C-reactive protein (CRP), Interleukin (IL)-1ß, IL-6, IL-8, and TNF-α). Results showed that two or more reported experiences of racial discrimination were associated with increased BMI z-score (Beta 0.58, 95% CI 0.18, 0.99), waist circumference (Beta 4.91 cm, 95% CI 0.71, 9.1), systolic blood pressure (Beta 2.07 mmHg, 95% CI 0.43, 3.71) and IL-6 (Beta 0.13, 95% CI 0.00, 0.27) and marginally associated with TNF-α (Beta 0.22, 95% CI -0.09, 0.54) after adjusting for socio-demographic covariates. Findings from this study suggest the need to address racism and racial discrimination as important social determinants of cardiometabolic risk and of the inequitable burden of cardiometabolic disease experienced by those from Indigenous and minoritized ethnic backgrounds.

Does disability modify the relationship between labour force status and psychological distress among young people?

OBJECTIVE: To examine the association between labour force status, including young people who were unemployed and having problems looking for work, and psychological distress one year later. We then assessed whether this association is modified by disability status. METHODS: We used three waves of cohort data from the Longitudinal Surveys of Australian Youth. We fitted logistic regression models to account for confounders of the relationship between labour force status (employed, not in the labour force, unemployed and having problems looking for work) at age 21 years and psychological distress at age 22 years. We then estimated whether this association was modified by disability status at age 21 years. RESULTS: Being unemployed and having problems looking for work at age 21 years was associated with odds of psychological distress that were 2.48 (95% CI 1.95 to 3.14) times higher than employment. There was little evidence for additive effect measure modification of this association by disability status (2.52, 95% CI -1.21 to 6.25). CONCLUSIONS: Young people who were unemployed and having problems looking for work had increased odds of poor mental health. Interventions should focus on addressing the difficulties young people report when looking for work, with a particular focus on supporting those young people facing additional barriers to employment such as young people with disabilities.

Gendered working environments as a determinant of mental health inequalities: a systematic review of 27 studies.

BACKGROUND: 'Gendered working environments' describes the ways in which (1) differential selection into work, (2) variations in employment arrangements and working hours, (3) differences in psychosocial exposures and (4) differential selection out of work may produce varied mental health outcomes for men and women. The aim of this study was to conduct a systematic review to understand gender differences in mental health outcomes in relation to the components of gendered working environments. METHODS: The review followed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search approach and focused on studies published in 2008-2018. The protocol for the review was prospectively registered with PROSPERO (CRD42019124066). FINDINGS: Across the 27 cohort studies included in the review, we found that (1) there was inconclusive evidence on the effect of occupational gender composition on the mental health of men and women, (2) women's mental health was more likely to be affected by long working hours than men's; however, precarious employment was more likely to be negatively associated with men's mental health, (3) exposure to traditional constructs of psychosocial job stressors negatively affected the mental health of both women and men, and (4) unemployment and retirement are associated with poorer mental health in both genders. INTERPRETATION: The findings from this review indicate that gendered working environments may affect the mental health of both men and women, but the association is dependent on the specific exposure examined. There is still much to be understood about gendered working environments, and future research into work and health should be considered with a gender lens.

'I'm proud of how far I've come. I'm just ready to work': mental health recovery narratives within the context of Australia's Disability Employment Services.

BACKGROUND: Employment is recognised as facilitating the personal and clinical recovery of people with psychosocial disability. Yet this group continue to experience considerable barriers to work, and, constitute a significant proportion of individuals engaged with Disability Employment Services (DES). Recognition of the role of recovery-oriented practice within DES remains limited, despite these approaches being widely promoted as best-practice within the field of mental health. METHODS: The Improving Disability Employment Study (IDES) aims to gather evidence on factors influencing employment outcomes for Australians with disability. Descriptive analysis and linear regression of IDES survey data from 369 DES participants, alongside narrative analysis of data collected through 56 in-depth interviews with 30 DES participants with psychosocial disability, allowed us to explore factors influencing mental health, well-being and personal recovery within the context of DES. RESULTS: Psychosocial disability was reported as the main disability by 48% of IDES respondents. These individuals had significantly lower scores on measures of mental health and well-being (44.9, 48.4 respectively, p ≤ 0.01), compared with respondents with other disability types (52.2, 54.3 p ≤ 0.01). Within this group, individuals currently employed had higher mental health and well-being scores than those not employed (47.5 vs 36.9, 55.5 vs 45.4 respectively, p ≤ 0.01). Building on these findings, our qualitative analysis identified five personal recovery narratives: 1) Recovery in spite of DES; 2) DES as a key actor in recovery; 3) DES playing a supporting role in fluctuating journeys of recovery; 4) Recovery undermined by DES; and, 5) Just surviving regardless of DES. Narratives were strongly influenced by participants' mental health and employment status, alongside the relationship with their DES worker, and, participants' perspectives on the effectiveness of services provided. CONCLUSION: These findings re-iterate the importance of work in supporting the mental health and well-being of people with psychosocial disability. Alongside access to secure and meaningful work, personal recovery was facilitated within the context of DES when frontline workers utilised approaches that align with recovery-orientated practices. However, these approaches were not consistently applied. Given the number of people with psychosocial disability moving through DES, encouraging greater consideration of recovery-oriented practice within DES and investment in building the capacity of frontline staff to utilise such practice is warranted.