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Young people, socioeconomic processes, and youth mental health promotion Laliberte, Shari 2015

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 YOUNG PEOPLE, SOCIO-ECONOMIC PROCESSES, AND YOUTH MENTAL HEALTH PROMOTION by Shari Laliberte  B.Sc.N. University of Victoria, 1996 M.N. University of Calgary, 2002  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Nursing)  THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver) August 2015 © Shari Laliberte, 2015 ii Abstract Little is known regarding current relational dynamics among young people, their mental health, and socio-economic processes and implications for mental health promotion initiatives. Social praxis, underpinned by a Hegelian-Marxist historical-dialectical perspective was used to deepen understanding regarding ways that young people’s socio-economic environments are influencing their mental health, their processes of seeking to realize their mental health, and mental health promotion from a socio-economic perspective. The experiences of 30 diverse young people between the ages of 15 and 28 years were explored and compared to ways that socio-economic determinants of mental health are addressed within provincial mental health policy. There were four central findings in this study. First, participant reflections indicated eight inter-related mental health needs as having relevance in this current socio-economic context. Second, needs and affective experiences are important sites for deepening understanding regarding the inter-relation between young people’s mental health and socio-economic processes. Participant reflections illustrate the relational nature of mental health. They show how mental health is a phenomenon that emerges from the inter-relation between young people and the socio-economic processes that young people participate in within their day-to-day lives. Affective states indicate the degree to which a young person’s mental health needs are met, and play an inter-related role with socio-economic processes in influencing young people’s engagement in socio-economic processes as they seek to realize their needs. Third, there are several key ways that individualistic, wealth-oriented capitalist socio-economic practices and processes threaten young people’s mental health needs across the socio-economic spectrum. Fourth, young people’s control over realizing their mental health needs is limited by the ways they are oriented to seeking realization of their mental health within the inner and inter-personal contexts of their lives, despite the important role that socio-economic processes play in enabling their needs. A close reading of mental health policies shows their positioning in support of capitalist socio-economic processes. This limits the potential of mental health promotion in supporting synergistic relations between young people and socio-economic processes in realizing young people’s mental health. Based on insights gained from this study, I propose multi-level approaches for future praxis-oriented mental health promotion initiatives.  iii Preface I drew insights from the field of continental philosophy and specifically Hegelian-Marxist scholarship to inform the approach to social praxis within this research. The purpose of this research was to explore relational dynamics among young people, their mental health, and socio-economic processes and implications for mental health nursing care and health promotion initiatives. UBC Behavioral Research Ethics Review Board Approval: Addressing socio-economic determinants in health promotion initiatives: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing Approval Certificate #: H11–01321    iv Table of Contents Abstract ..................................................................................................................................... ii	  Preface ...................................................................................................................................... iii	  Table of Contents ..................................................................................................................... iv	  List of Tables ......................................................................................................................... viii	  List of Figures ........................................................................................................................... ix	  Acknowledgements ................................................................................................................... x	  Chapter 1: Introduction ........................................................................................................... 1	  Gaps in Knowledge ................................................................................................................ 8	  Research Objectives Guiding this Study .............................................................................. 10	  Organization of Thesis ......................................................................................................... 11	  Chapter Two: Review of Current Knowledge ...................................................................... 14	  Introduction .......................................................................................................................... 14	  Perceived Socio-Economic Status and Mental Health and Substance Use .......................... 15	  Employment Status .............................................................................................................. 19	  Neighborhood-level Socio-Economic Disadvantage ........................................................... 22	  Gaps in Previous Research and Objectives Guiding this Study ........................................... 32	  Chapter Three: Research Design and Implementation ....................................................... 36	  Historical-Dialectical Ontology ........................................................................................... 37	  Research Methodology: Social Praxis ................................................................................. 42	  The Research Process ........................................................................................................... 47	  Phase I: Critical dialogue sessions and participatory documentary photography ......... 48	  Recruitment for engagement in first dialogue session ................................................ 48	  Introduction to research participants .......................................................................... 50	  Recruitment of participants within second dialogue session and participatory documentary photography .......................................................................................... 53	  Collecting data to explore young people’s views and experiences: Dialogue sessions and participatory documentary photography .............................................................. 54	  Data analysis ............................................................................................................... 59	  Phase II: Meta-critical analysis of young people’s critical reflections in relation to mental health policy documents ...................................................................................... 60	  Data collection: Retrieval of B.C. Mental health policy documents .......................... 60	  Data analysis ............................................................................................................... 62	  Conceptual terms used for presenting findings from phases I and II of data analysis ... 67	   v Data quality: Validity criteria for judging the quality of agentic knowledge produced from this study ................................................................................................................. 68	  Reflexivity .................................................................................................................. 69	  Process and outcome validity ..................................................................................... 73	  Ethical considerations ..................................................................................................... 76	  Seeking informed consent ........................................................................................... 76	  Confidentiality ............................................................................................................ 80	  Honorariums ............................................................................................................... 81	  Minimizing the risks of psychological distress .......................................................... 82	  Conclusion ............................................................................................................................ 83	  Chapter Four: Dialectical Relations Among Young People, Mental Health, and Socio-Economic Processes ................................................................................................................ 84	  Introduction .......................................................................................................................... 84	  Young People’s Mental Health Needs ................................................................................. 85	  Eight Inter-Related Needs for Enabling Young People’s Mental Health in Their Day-to-Day Lives ............................................................................................................................. 88	  1. Physical survival, health and comfort ......................................................................... 88	  2. Authentic social connections ....................................................................................... 91	  3. Self-worth and self-determination ............................................................................... 94	  4. Self- and socio-environmental realization ................................................................... 97	  5. Learning and responsive education ........................................................................... 100	  6. Inspiration and perspective in life ............................................................................. 104	  7. Balance in life ............................................................................................................ 106	  8. Need for a secure future ............................................................................................ 108	  Inter-Relation of Young People’s Mental Health and Socio-Economic Processes ........... 109	  Affective States as Barometer of Need Realization ........................................................... 110	  Inter-Relation of Socio-Economic Processes and Affective States in Need Realization Processes ............................................................................................................................ 112	  Comparison to Policy Documents ...................................................................................... 114	  Chapter Five: Contradiction Between Young People’s Mental Health Needs and Wealth-Oriented Socio-Economics ...................................................................................... 119	  Introduction ........................................................................................................................ 119	  Monetized, Individualistic, Wealth-Oriented Production and Distribution Processes and Young People’s Mental Health Needs ............................................................................... 119	  The need for survival and self and socio-environmental realization within context of capitalist socio-economic processes .............................................................................. 121	  Employment experiences .......................................................................................... 121	  Gambling for money through panhandling and entrepreneurship ............................ 127	  Increasing the odds for a secure income through higher learning ............................ 129	  Increasing cost of living within wealth-oriented free markets ................................. 130	  The need for a secure future and inspiration in the context of endless economic growth132	  The need for self-worth, self-realization, and authentic social connections in context of wealth-oriented notions of success and beauty ............................................................. 135	   vi Media and advertising ............................................................................................... 137	  Social media .............................................................................................................. 140	  Schools and parental pressure ................................................................................... 141	  The need for social connections in context of the monetization of recreation (social life) and economic inequities ................................................................................................ 145	  Comparison to Policy Documents ...................................................................................... 148	  Chapter Six: Orienting Young People Inward To Seek Realization Of Their Needs Within The Inner And Inter-Personal Contexts Of Their Lives ...................................... 156	  Introduction ........................................................................................................................ 156	  Pragmatic Struggle: Orienting Young People Inward Through Material, Ideological and Social Dynamics that Evoke Insecurity, Hopelessness, and Shame .................................. 157	  Insecurity ....................................................................................................................... 159	  Hopelessness .................................................................................................................. 161	  Shame ............................................................................................................................ 171	  Seeking Realization of Mental Health Within Inner and Inter-Personal Contexts of Young People’s Lives .................................................................................................................... 174	  Individual-level strategies ............................................................................................. 174	  Actions with friends and family ..................................................................................... 178	  Comparison to Policy Documents ...................................................................................... 182	  Chapter Seven: Discussion and Implications ..................................................................... 190	  Introduction ........................................................................................................................ 190	  Summary of Findings From This Study ............................................................................. 191	  Mental health needs within current socio-economic contexts ....................................... 192	  Relational dynamics among young people, mental health, and socio-economic processes ........................................................................................................................ 194	  Contradictions between capitalist socio-economic dynamics and young people’s mental health needs ................................................................................................................... 197	  Individualism and mental health ............................................................................... 199	  Wealth-oriented socio-economics and mental health ............................................... 201	  Young peoples’ contradictory response patterns .......................................................... 204	  Opportunities for Social Praxis Within Future Mental Health Promotion Initiatives ........ 209	  Limitations of this Study .................................................................................................... 220	  Conclusion .......................................................................................................................... 222	  References .............................................................................................................................. 224	  Appendix A: Recruitment Process ...................................................................................... 254	  Appendix B: Recruitment Documents ................................................................................ 256	  Appendix B1: Information Letter ....................................................................................... 257	  Appendix B2: Recruitment Poster ..................................................................................... 261	  Appendix B3: Recruitment Brochure ................................................................................. 262	   vii Appendix C: Demographic Survey Form ........................................................................... 263	  Appendix D: Participants’ Demographic Information ..................................................... 270	  Appendix E: Guide for Facilitating Small Group (Individual) Dialogue Sessions ......... 277	  Appendix F: Informed Consent Forms ............................................................................... 281	  Appendix F1: Informed Consent Form for Phase I and II ................................................. 282	  Appendix F2: Adapted Informed Consent Form for Young People Who Were Homeless293	  Appendix F3: Informed Consent Forms for Participatory Documentary Photography Process ................................................................................................................................ 304	  Appendix G: Handouts for Research Participants ............................................................ 312	  Appendix G1: Know Your Rights as a Research Participant Handout .............................. 313	  Appendix G2: Child and Youth Mental Health Services Handout .................................... 315	  Appendix H: Training Guide for Documentary Photography ......................................... 317	    viii List of Tables Table 3.1	   Participants’ self-reported financial situation ................................................ 51	  Table 3.2	   Participants’ self-reported health status ......................................................... 52	  Table 3.3	   Participants’ overall wellbeing ........................................................................ 52	  Table 3.4	   First dialogue questions .................................................................................... 55	                ix List of Figures Figure 3.1	   Dialogue sessions sequence. .............................................................................. 59	   x Acknowledgements With deep gratitude, I write:  To the young people who participated in this study: This work would not have been possible had you not shared your knowledge and experiences so openly with me. I hope I have done justice to your visions and voices for a better world for young people. I look forward to your feedback on this work and to working with you and allies in building a better world for young minds.  To my academic supervisor, Colleen Varcoe, I have learned so much from you-from your metaphors, distinctions, sharing of your own experiences with critical research, your questions, and feedback. You are the kind of mentor I have come to aspire to be like- one who works from both her head and heart and whom walks her talk with her students. I am eternally grateful for your humor, wisdom, and patience, which supported my growth not only academically, but also personally. To my committee: Joy Johnson, I will never forget our first committee meeting and how you set a context of teamwork in this process. I also deeply appreciated your feedback and critical questions that deepened my evolving analysis. Kathy Teghtsoonian, I was continually grateful for your thought provoking questions and feedback. I also deeply appreciated your metaphors and distinctions, which were so helpful to me in understanding the nuances of qualitative data analysis. To Tina Thornton, amazing editor from Australia, thank-you for catching the last of those long-winded sentences of mine, for transforming the dissertation into UBC format, and being on call with formatting to help me in meeting final deadlines. Justin Love and Elizabeth Rivero, in your work as research assistants on this project: thank-you for your work engaging some of the young people who participated in this study and for tracking down digital cameras. Deep appreciation also goes to the following funding sources for this work: The Canadian Institutes of Health Research, Doctoral Research Award; Wil Evon McCreery Memorial Prize Research Award; Irene Goldstone HIV/AIDS and Social Justice Graduate Scholarship; Lyle Creelman Endowment Fund, UBC School of Nursing grant; and UBC Four Year Fellowship. Finally, thank-you to the examining committee for their helpful comments and feedback: Geertje Boschma, Shauna Butterwick & Denise Drevdahl. To my family, friends, mentors and colleagues: Mom, your enduring strength and depth of compassion have always been a deep source of inspiration to me in my life and in this work. Tom, thank-you for always playing devil’s advocate and your belief in me. My beautiful sisters, Tammy and Allison, your passionate love of life and the beautiful spirits you have brought (and are bringing) into this world, along with the young people of this world, were my greatest inspiration in this work. Peter Prontzos and Glenn Deefholts, you’ve become the dear older brothers I never had. Our philosophers’ cafes continually inspired me in this work. Peter, I’m also grateful for your suggestion to use the notion of self-determination to capture one of the themes in this work and your generous stream of emails with reports that aligned with this work, some of which have found their way into this report. Dima Alansari, for your depth of wisdom, our friendship, and the inspiration and sense of solidarity I experienced in hearing about your art-making, community-building projects. Viviane Josewski and Constance Bos, for your amazing friendship and sharing your beautiful hearts and minds with me on walks with our furry four  xi legged friends. Jennifer Pullin, for your integrity in all that you do and your incredible support from across the country in my recovery from surgery mid-way through studies. Cedar, for the hours you waited by my side with your loving presence. My director and colleagues at Vancouver Community College, Kathy Fukuyama, Dee Duncan, Margery Hawkins, Meridy Black, and Caroline Brunt, I am eternally grateful to your flexibility with my workload in the final stages of writing and your ongoing encouragement to ‘get er’ done.’ Your passion for pushing the bounds in nursing education was also a deep source of inspiration for me. Susan Duncan, for cheering me onto this academic path and your enduring support and belief in me. You have also been the kind of mentor I aspire to be like, in head and heart, in your policy advocacy work and your work in public health nursing education. Lorraine Wright, for your continuing influence on my thinking, from introducing me to Maturana and Varela to your guidance to look up up up! –in seeing the pattern that connects our lives. Deborah Littman, for your tireless work and all that I am learning from you in relational organizing, including a few of the questions that I used in this work to engage young people in dialogue.  xii  Joseph Laliberte (1946–2012)  Dad~ I dedicate this to you…for teaching me about the importance  of our connection to land and that we’re all in this together   1 Chapter 1: Introduction Epidemiological data indicate that up to 20% of children and adolescents suffer from disabling mental illnesses (Belfer, 2008, p. 26). Depression is the leading cause of disability for young people between 10 and 19 years of age and suicide is the third leading cause of death among adolescents worldwide (World Health Organization, 2014). Research has drawn attention to the important role that the environment plays in shaping patterns of child and youth mental health (CYMH) and distress (Butler-Jones, 2011; Hanvey et al., 2006; Health Canada, 1999, 2004; Joseph, 1999; Smythe, 2007; Strohschein, 2005; Weiss & Landrigan, 2000; World Health Organization, 2002). Based on the 2002 Health Behavior in School Age Children (HBSC) cross national survey, the most powerful social determinants of young people’s physical and emotional health include gender, family affluence, school conditions and the influence of peers on risk taking (Boyce, 2004, p. xvii; Health Canada, 2004, p. 8). Of these determinants, Health Canada (1999) has recognized poverty “as the single most significant determinant of a child’s level of health” (Evans & Stoddart cited p. 4). The Chief Public Health Officer of Canada has reported previous work that has shown that “of 27 factors identified as having an impact on child development, up to 80% were seen to improve as family income increases” (Butler-Jones, 2009, p. 30). Previous research underscores the important influence of socio-economic factors on child and youth mental health (CYMH).1 Findings are complex and at times unexpected, however, in relation to adolescent mental health. Reiss (2013) conducted a systematic review of 55 studies and found that children and youth who were of lower socio-economic status were two to three times more likely to develop mental health problems. Reiss further found that of individual-level socio-economic factors, an “overall correlation between at least one marker of socio-economic status and mental health problems was proven in 52 studies from a total of 23 countries” (Reiss, 2013, pp. 25–26). Similar to preceding work (West, 1997), Reiss found a decreased strength in                                                 1 I have used the term “youth” to be consistent with the use of this term in previous empirical literature. However, in response to the recognition of the importance of expanding use of the term “youth” to include those within their twenties (Furstenberg, 2008; Hicki, 2011), I have used the term “young people” throughout the remainder of this report to be inclusive of the range of young people that I invited to participate in this study who were between the ages of 13 and 30.   2 association between socio-economic status and youth mental health compared to children. This supports a review by West who reported several studies that found no relationship between a young person’s socio-economic status and mental health and distress. Researchers hypothesized that use of parental indicators of socio-economic status may not adequately capture young people’s experiences of their socio-economic context (Goodman et al., 2001; Goodman, Huang, Schafer-Kalkhoff, & Adler, 2007; Hamilton, Noh, & Adlaf, 2009). Subsequent work has thus explored young people’s perceptions of their socio-economic status (versus parental reports of socio-economic status) and found more consistent, albeit complex associations between perceived socio-economic status and young people’s mental health and substance use. For example, while some studies have found a strong association between perceived socio-economic status and indicators of youth mental health (Hamilton et al., 2009; Koivusilta, Rimpela, & Kautiainen, 2006; Piko & Fitzpatrick, 2001, 2007), other studies have produced contrasting results. In the context of shaming experiences, middle perceived socio-economic status has been found to have a protective effect on young people’s mental health compared to lower and upper perceived socio-economic status groups (Aslund, Leppert, Starrin, & Nilsson, 2009). Another study found that youth who rated themselves as middle perceived socio-economic status were at greater risk of poorer mental health outcomes compared to lower and upper perceived socio-economic status youth (Varga, Piko, & Fitzpatrick, 2014). There have also been unexpected findings in studies exploring the relationship between perceived socio-economic status and substance use. For example, Piko and Fitzpatrick (2007) found that young people evaluating themselves as lower and lower-middle class had a lower likelihood of reporting drinking and marijuana use. This finding is similar to some studies that have shown that young people of upper socio-economic status backgrounds are also vulnerable to greater levels of distress and behavioural challenges (e.g. Luthar & Latendresse, 2005). Complex findings have also been found in studies exploring the relationship between unemployment experiences and neighbourhood social disadvantage (NSD) and young people’s mental health outcomes. Unemployment has been associated with both positive mental health outcomes (Hagquist & Starrin, 1996) and negative mental health outcomes (Allen, 2014; Fryer, 1997; Hagquist & Starrin, 1996; Hammarstrom, 1994; Kieselbach, 2003). Some studies have found that unemployment experiences are mediated by social integration, unemployment benefits and economic deprivation (Hammer, 2000). Neighbourhood disadvantage has been  3 directly associated with young people’s mental health in some studies (Aneshensel & Sucoff, 1996; Dupere, Leventhal, & Lacourse, 2009) and not directly associated with mental health in other studies (Brenner, Bauermeister, & Zimmerman, 2011; Drukker, Kaplan, Schneiders, Feron, & van Os, 2006). This includes unexpected results in studies that have found associations between NSD and lower rates of alcohol and marijuana use and reduced effects of deviant peers on adolescent substance use (Snedker, Herting, & Walton, 2009). While one study showed a similar decreased association between inequities and substance use for 15-year-old youth compared to 11–13 year-old youth (Elgar, Roberts, Parry-Langdon, & Boyce, 2005), other studies have found positive associations between economic inequities and adolescent mental health. Goodman, Huang, Wade and Kahn (2003) found that lower household income, lower average school income, and greater (within) school-level income inequality were significantly associated with depressive symptoms. While Drukker et al. (2006) found that indicators of NSD were not associated with change in general health or mental health over a two-year period, they did find that exposure to greater disparity between individual level socio-economic status and NSD (e.g. high socio-economic status youth living in deprived neighborhoods) negatively impacted young people’s self-esteem and satisfaction. While inconsistencies and unexpected findings exist across this body of quantitative studies, qualitative studies exploring young people’s views regarding the meaning and determinants of mental health emphasize the importance of socio-economic factors such as employment for young people’s mental health. Furthermore, youth views studies2 extend previous empirical work by drawing attention to the importance of several socio-economic factors, several of which have not been explored in previous quantitative studies. These factors include: money, financial security and access to material resources (Harden et al., 2001; Oliver et al., 2008); worries about the ways that certain social locations are discriminated against by future employers (Leadbeater et al., 2008); school work load pressures (Oliver et al.), school performance, the ability to attend college or vocational school (Gampetro, Wojciechowski, & Amer, 2012) and availability of funds to pay for post-secondary educational programs (Leadbeater et al.); environmental pollution (Harden et al.; Oliver et al.), the built environment,                                                 2 Note that I included a few studies that explored youth’s views of health and wellbeing generally (in addition to mental health)  4 green space, public transportation (Ott, Rosenberger, McBride, & Woodcox, 2011), food and clothing (Gampetro et al., 2012); finding balance in life (White & Wyn, 2008); and corporate media and advertising in relation to young people’s self-worth (Stasiulis, 2002).  Importantly, despite the attention that young people have brought to the influence of broader socio-economic, or structural factors in relation to young people’s mental health, mental health promotion intervention studies primarily focus on addressing intra and inter-personal factors at the local community level. A previous comparison of youth views studies to youth mental health promotion intervention research (between 1990 and 2000) shows a discrepancy between the attention that young people have brought to the importance of structural factors3 in relation to their mental health and the lack of attention to addressing structural factors in intervention studies (Harden et al., 2001; Oliver et al., 2008). Harden et al. compared high quality mental health promotion intervention studies to youth views studies. They found that socio-economic determinants of mental health were identified by youth in 10 (of 12) qualitative studies exploring young people’s views of the determinants of mental health.4 However, of the high quality systematic reviews (N=7) and outcome evaluations (N=47) that were included in their in depth review, no evaluated interventions addressed the concerns identified by young people regarding the material and physical circumstances of young people’s day-to-day lives (Harden et al.; Oliver et al.). More broadly, in Harden et al.’s exploration of trends across 345 studies that included a mixture of outcome and process evaluations, non-intervention research, and systematic reviews, they found that only 32% of these studies addressed broader societal (i.e. socio-cultural and structural) factors.5 Most of the previous studies addressed individual level factors (psychological) (34%) and interpersonal and family factors (30%) (Harden et al.).                                                  3 Harden et al. 2001 use the notion of structural factors to refer to material aspects of young people’s lives such as their employment, income, access to resources, built and natural environments  4 For their more in depth review, they selected qualitative studies that sought to explore young people’s views regarding the meaning and determinants of mental health as a central focus of the study (as opposed to situating young people’s views within a particular theoretical or analytic framework or use of survey methods with pre-selected questions) 5 In Harden et al.’s (2001) report “society barriers and facilitators refer to the wider social world in which individuals and communities reside. These have been broken down into ‘socio-cultural’ factors referring to social and cultural identities (e.g. experiencing or overcoming discrimination on the grounds of sex or ethnicity) and ‘structural factors’ which cover those arising from the environmental, political, financial and legal context of individuals and communities (e.g. material resources, employment)” (p. 22).   5 This lack of attention to addressing broader structural factors has also been found across regional health authorities in Canada. Within the Canadian health policy context, MacNeil (2012) conducted a cross-jurisdictional scan of all Canadian health region websites exploring interventions addressing social determinants of health, health equity and structural-level interventions.6 Based on his review of 2200 interventions, MacNeil found that 25% of interventions addressed equity and of these, 16% were structural in nature. Most interventions relied on direct interventions at the 1:1 level (e.g. bringing health services to underserved communities). Interventions providing fiscal support for citizens or formalized policies addressing environmental factors such as regulation were less common than individual level supports. Within the fields of mental health nursing, there is a longstanding trend towards theorizing and practicing health promotion at individual and interpersonal levels from a biomedical perspective. In analyzing trends in the British Journal of Nursing between 1992-2002, Ashmore, Cutcliffe and Collier (2002) suggested that an ongoing issue in the mental health nursing literature at that time was the “‘humanistic-biological’ debate“ (p. 504) in which tensions emerged between those who theorized and approached mental health from a cognitive-behavioral perspective informed by insights from the physical sciences, and those aligned with Nightingale’s axiom that “nurses do not heal anyone, nurses place people in the best position possible in order to let nature heal them” (p. 504). Despite recognition of the importance of understanding and promoting mental health at both micro (individual, interpersonal level) and macro (socio-cultural/political-economic/environmental) systemic levels, it has been argued that a micro-systemic perspective of mental health has dominated contemporary mental health nursing practice (e.g. Crowe 2000a/b). This hasn’t changed with more recent work exploring the barriers and supports to population level health promoting nursing practice, which has identified several barriers to addressing the broader social determinants of health in nursing practice (Cohen, 2006) and inter-disciplinary health promotion practice more broadly (Raphael, Curry-Stevens & Bryant, 2008).                                                 6 MacNeil defined structural interventions as “those which address health outcomes not on a case by case basis, but across larger populations” (p. vi).  6 B.C. British Columbia (B.C.), the context of this study, is a useful case example of the tendency to promote mental health at the individual level. Although it was acknowledged within the 2003 B.C. Child and Youth Mental Health Plan that “community capacity development is critical” and that “children’s environments can have a significant influence on their development and mental health” (B.C. Ministry of Children and Family Development, 2003, p. 13), policies and programs were oriented primarily along individual lines with the implementation of province-wide cognitive–behavioral therapy prevention programming and individually focused counseling services (A. Berland Inc., 2008). This tendency to focus on individual level supports for young people within the most recent 10-year mental health and substance use policy has continued (B.C. Ministry of Health Services & B.C. Ministry of Children and Family Development, 2010).  This tendency to individualize mental health programming is concerning in the context of broader cut backs to financial supports and social programs that have taken place in B.C. over the past decade. In the midst of the B.C. CYMH planning process in 2003, the B.C. government eliminated several programs that affect broader determinants of CYMH. As Liberals took office in 2002 several cut backs were made in women’s resource programs, child-care, housing, legal aid, apprenticeship-training programs including changes to minimum wage (Butterwick, Frisby, & Kolpakova, 2003; CBC News, 2009a, 2009b, 2009c; Early Learning and Child Care Research Unit, 2007a, 2007b; Laanela, 2009; Mazereeuw, 2009; Morrow, Hankivsky, & Varcoe, 2004). Changes to the B.C. Employment Standards Act eliminated the requirement for employers to obtain a permit to employ children between the ages of 12 and 14 and removed the role of the Employment Standards Branch in predetermining the suitability of worksites for child employees, thereby shifting responsibility to parents and children for ensuring safe worksites (Luke, 2009). Reported childhood injury claims increased significantly compared to years prior to the enactment of this law (Luke). Interviews and focus groups with 129 young people in B.C. found that 19% of them missed classes due to work; 46% reported being too tired and/or not having enough time to complete their homework, and/or participate appropriately in school because of too much work; and 16% reported having dropped out of school due to their work schedule and/or financial need (Montani & Perry, 2013). Most recently, B.C. has been identified as having the highest child poverty rates across Canada and the only province without a poverty reduction strategy (First Call: BC Child and Youth Advocacy Coalition, 2013; Ivanova, 2009).  7 B.C. has also been identified as having the worst levels of economic inequalities across Canadian provinces (MacLeod, 2014).	  More broadly, poverty and economic inequities have continued to rise. From 1980 to 2003, Canada’s child poverty rate7 remained high at 13.3% (UNICEF Innocenti Research Centre, 2012). Internationally, Canada ranked 24th out of 35 wealthy developed nations in child poverty rates in 2009 (Adamson, 2012). Analysts have drawn attention to the historic growth of economic inequities over the past 30 years and associated health gradients (Harvey, 2008). For example, the Canadian Centre for Policy Alternatives-Manitoba office (2010) reports that Census data show that the richest 20 percent of Canadians obtained median earnings increases of 16.4 percent whereas the poorest 20 per cent had a 20.6 percent drop in earnings since 1980. World wide, almost half of the world’s wealth is owned by one percent of the population with the richest 85 people owning the same wealth as the bottom half of the world's population (OXFAM, 2014). This context has been referred to variously as late- or post-modernity or late capitalism (Chouliaraki & Fairclough, 1990; Harvey, 1990), neoliberal capitalism (Harvey, 2005) and American Corporate Capitalism (Kasser, Cohn, Kanner & Ryan, 2007).  Several challenging trends have been documented in relation to young people within this broader economic context. Employment trends are toward flexibilization within the broader labor market in which labor has been casualized and labor protection policies deregulated (Harvey, 2005). Young people are disproportionately affected, including higher rates of unemployment compared to other age groups. In 2012, the unemployment rate for Canadian young people between 15 and 24 years of age was 14.3% compared to 6% for workers aged 25–54 and 55 and older (Bernard, 2013). While forming 16% of the labor market, Canadian young people between 15 and 24 years-of-age faced 50% of the job losses in the last recession (O’Rourke, 2012). In 2012, summer jobs were at their lowest since 1977 thus making it difficult to save for the costs associated with higher education and housing (O’Rourke). Of the available employment, the majority of jobs are part-time without benefits or career prospects (O’Rourke). The significant rise in tuition fees and student loans challenge young people’s access to education and ability to prepare themselves for their life’s work and career goals. The cost of a year’s tuition rose by 174% in British Columbia between 1991 and 2007; the average student                                                 7 The limitations of the term “child poverty” are recognized within this report. It is understood that child poverty is inclusive of their families.   8 loan debt for Canadian students is between CDN$20,000 and $30,000 (except for Quebec at CDN$14,000) (O’Rourke, 2012). In 2012, the total cost of a 4-year degree for those not living at home was CDN$78,817 and over CDN$30,000 for a 2-year college program with the average student taking 14 years to pay off their student loans (O’Rourke). According to a Statistics Canada survey of post-secondary graduates in 2001, 52% of full-time 20–24-year-old students relied on employment to pay for tuition, while over 25% cited income from employment as the main way they pay for tuition (Canadian Federation of Students, 2013a). Of students who cease their post-secondary studies early, 36% cited financial reasons (Canadian Federation of Students, 2013b). Student debt challenges students’ ability to engage in their fields of study and to develop their careers. For example, with the need to repay loans young people struggle to engage in career-related volunteer experience to develop skills for their chosen field of study (Canadian Federation of Students, 2013a).  Recent contextual dynamics in which this study was situated include movements such as the Occupy Movement and the Quebec Student Movement.  The 2012 Quebec Student Movement focused on advocating for quality and accessible education, which was framed as being under threat due to the expansion of neoliberal economic policies within the post-secondary educational context (Ayotte-Thompson & Freeman, 2012). Broader movements against neoliberal economic policies include the Anti-globalization protests such as the World Trade Organization (WTO) protests in Seattle in 2001 and most recently the Occupy Movement (Roberts, 2015). The Occupy Movement began in 2011 with demonstrations occurring in 95 cities in 82 countries and across more than 600 communities in the United States (Roberts). Through the use of key slogans such as “we are the 99%,” this movement focused on challenging the growth of economic inequities, the expansion of neoliberal economic policies (Roberts) and austerity measures that were implemented after the 2008 financial crash (Mizen, 2015). Gaps in Knowledge  There are complex findings in previous empirical work and a discrepancy between the attention that young people have brought to the importance of socio-economic factors to their mental health and a lack of attention to addressing socio-economic factors in health promotion intervention research and policy. More work is thus needed to deepen understanding regarding relationships among young people, their mental health and socio-economic environments and  9 implications for health promotion initiatives. More specifically, knowledge regarding the relationship between socio-economic factors and youth mental health and implications for youth mental health promotion is limited in three key ways. First, pre-selected socio-economic factors that have been studied in relation to youth mental health within quantitative studies only partially addresses the many socio-economic factors that young people have identified as important influences on their mental health in youth views studies. Furthermore, quantitative studies do not enable a deeper exploration of the complex and dynamic interrelationship of diverse aspects of socio-economic life in relation to young people’s mental health. Second, while qualitative studies exploring youth views have identified several socio-economic factors that impact young people’s mental health, they have not explored how aspects of socio-economic life affect young people’s mental health. Third, of previous youth mental health promotion intervention studies, the majority of studies focus on addressing inner and inter-personal factors with a lack of attention to addressing constraining aspects of socio-economic life in relation to young people’s mental health. These limitations in previous empirical literature suggest the importance of deepening understanding regarding relationships among young people, their mental health, and various aspects of socio-economic life, as well as identifying directions for future mental health promotion initiatives in ways that take into account broader structural (socio-economic) factors.  Importantly, research exploring ways that health promotion initiatives can address broader socio-economic factors in relation to young people’s mental health needs to be done with attention to dominant and taken for granted ways of understanding mental health and mental health promotion that may limit possibilities for promoting mental health. Previous analytic work has drawn attention to the contested (and political) nature of concepts such as “mental health,” “mental health promotion,” and “socio-economic factors” (Bambra, Fox, & Scott-Samuel, 2005). Coppock and Hopton (2000) have shown that there is a lack of “a universally accepted theory of mental health and distress” (p. 176). Previous work has drawn attention to how mental health policies and programs are increasingly underpinned by a neoliberal (individualistic) perspective, which is reflected within the development of programs that focus on individual levels factors and that decontextualize mental health and distress (Carpenter, 2000; Donald, 2001; Moncrieff, 2006; Ramon, 2008; Teghtsoonian, 2009; Timimi, 2005, 2010). Western, biomedical approaches to child psychiatric care have been critiqued for their tendency to decontextualize and then to commercialize distress (Timimi, 2005, 2010). This has occurred through the application of  10 biomedical diagnostic and treatment approaches that obscure the influence of broader political, economic and socio-cultural trends on young people’s mental health (Timimi, 2005, 2010). It is thus important to develop knowledge in a way that brings continual attention to taken-for-granted assumptions.  Research Objectives Guiding this Study This study sought to deepen understanding regarding current and evolving relational dynamics among young people, mental health, and their socio-economic environments and implications for mental health promotion initiatives. In order to address the limitations of previous quantitative studies that have missed researching socio-economic factors identified as important by young people within youth views studies, and in order to ensure that recommendations for youth mental health promotion initiatives are responsive to young people’s needs and experiences, this approach to inquiry was grounded within young people’s lived experiences. In order to address the limitations of previous quantitative studies to deepening understanding of the complex, co-evolving and dynamic nature of socio-economic life in relation to mental health, and in order to address the dominance of individualistic perspectives within mental health promotion research, policy and practice, this approach to inquiry was relational and reflexive in nature. Explored more fully in Chapter three, this study was underpinned by a Hegelian-Marxist historical-dialectical perspective, which draws attention to exploring relationships as a fundamental unit of analysis in the inquiry process. Relationships are understood to be historical in nature, and thus co-evolving and dynamic. Relational dynamics among multiple aspects of socio-economic life, including the relationships between aspects of actual existing socio-economic life and the dominant and evolving ideas and ways of understanding socio-economic life are a central focus of inquiry. Reflexive inquiry draws attention to the inter-relationship between ideas and relationships in material life, scrutinizing the influence of dominant ideas and ways of understanding not only in relation to the foci of research, but also within the inquiry process itself.  In this study I viewed mental health, the socio-economic environment, and mental health promotion as political concepts (Bambra, Fox & Scott-Samuel, 2005). I assumed that notions of mental health/promotion and socio-economic determinants of mental health within mental health policies would be reflective of dominant assumptions. I thus explored young people’s views and  11 experiences of how their socio-economic environments affected their mental health in relation to how notions of mental health/promotion and socio-economic determinants of mental health were discursively taken up in mental health policy. This served to not only deepen understanding of current relational dynamics among young people, their mental health and aspects of their socio-economic environment, but also to deepen analysis of the positioning of mental health policy in relation to young people and the broader socio-economic environment. This helped to inform insights regarding ways to orient mental health promotion initiatives to address constraining aspects of socio-economic life for young people’s mental health and to build on previous health promotion work.   This study was guided by the following objectives: 1. To deepen understanding regarding ways that young people’s current socio-economic environments are influencing their mental health and young people’s processes of realizing their mental health.  2. Identify opportunities for developing mental health promotion initiatives in ways that address current socio-economic dynamics that are constraining young people’s mental health. Organization of Thesis Within this report, I start in chapter two by presenting a more detailed review of the empirical literature exploring the relationship between socio-economic factors in relation to young people’s mental health. I highlight gaps in previous research that informed the direction of this research project. I also present insights from previous analytic work that has highlighted dominant assumptions that underpin notions of mental health/promotion in ways that draw attention away from the influence of broader contextual factors. This literature shows the contested nature of notions of mental health and socio-economics and served to justify my use of a praxis-oriented approach to inquiry, underpinned by a Hegelian-Marxist historical-dialectical perspective.  12 In Chapter Three, I present the ontological and epistemological perspectives that informed the approach to inquiry in this study. I provide an overview of the Hegelian-Marxist historical-dialectical perspective that informed my positioning of this research as a process of social praxis, and which informed my relational and reflexive approach to inquiry. This perspective was important for guiding my analysis of relational dynamics among young people, their mental health and aspects of their socio-economic environment to inform the identification of possibilities for future praxis-oriented mental health promotion initiatives oriented to addressing constraining aspects of socio-economic life for young people’s mental health. I then provide an overview of the process of social praxis undertaken in this study, which occurred in two phases. Within the first phase, I engaged thirty diverse young people between the ages of 15 and 28 years of age in audio-recorded individual, dyadic or small group dialogue sessions. Sixteen of these young people were then engaged in second dialogue sessions at which preliminary themes from analysis of the first sessions were discussed and their perspectives on opportunities for change explored. Of this second group of participants, seven were engaged in participatory documentary photography to explore their experiences of the relationship between socio-economic life and young people’s mental health and opportunities for change. Within the second phase I engaged in a process of meta-critique in which I compared participant’s experiences to the ways that notions of mental health/promotion and socio-economic determinants of mental health are discursively taken up and addressed in two sets of British Columbia provincial policy documents. I explored how mental health policy is positioned in relation to young people and broader socio-economic processes in order to identify ways of building on existing work to address constraining aspects of socio-economic life for young people’s mental health. I conclude this chapter by defining concepts that supported my presentation of findings in this study. In Chapters Four, Five and Six I present analyses of the data in relation to the retrieved policy documents. Specifically, in Chapter Four I focus on the ways that young people’s mental health needs and affective states are two key sites for deepening understanding regarding relationships among young people, their mental health and socio-economic processes. This chapter draws attention to the mutual dependency between young people and their socio-economic environments in processes of realizing young people’s mental health needs.  13 In Chapter Five, I present an analysis of the ways that socio-economic dynamics contradicted participants’ mental health needs. I show how, within young people’s economic contexts in which mental health resources have been monetized, two central and inter-related capitalist socio-economic dynamics challenged participants’ mental health needs in several key ways. These included first, individualistic production and distribution processes; and second, practices oriented to fostering capital (wealth) creation and accumulation. These capitalist dynamics challenged participants’ mental health needs across socio-economic positions, or approaches to seeking income, and within their positioning as consumers. In Chapter Six, I describe participants’ patterns of response to the contradictory dynamics presented in Chapter Five and show the ways that young people are oriented inward toward seeking realization of their mental health needs within their inner and inter-personal lives, despite the ways that socio-economic processes fundamentally mediated their ability to realize their mental health needs. Within the concluding sections of each of these three findings chapters, I present a comparison of these findings with a close reading of provincial policy documents. I highlight the positioning of mental health policies and programs in relation to young people and socio-economic processes. I demonstrate how, within the policy documents young people are positioned to enable capitalist socio-economic processes at the same time that these processes threaten young people’s mental health needs. I show how this prioritization of capitalist socio-economic processes undermines the stated goals of the mental health policies. I conclude in Chapter Seven by comparing findings within this study to other empirical work. I explore how insights from this study help to deepen understanding of inconsistencies in previous empirical work. I propose multi-level, inter-sectoral approaches for future praxis-oriented mental health promotion initiatives focused on promoting a fuller realization of young people’s mental health. 14 Chapter Two: Review of Current Knowledge Introduction While the importance of socio-economic factors to child and youth mental health is incontrovertible, further research is needed to deepen understanding regarding relationships among young people, their mental health, and socio-economic factors in light of complex findings in previous research. Between 1990 and 2012, Reiss (2013) conducted a systematic review of 79 publications comprising 55 cross-sectional, longitudinal and cohort studies of children and adolescents between the ages of 4 and 18 years of age with samples that ranged from 88 to 40,592 participants (M=3974). Within this review of individual-level socio-economic factors, an “overall correlation between at least one marker of socio-economic status and mental health problems was proven in 52 studies from a total of 23 countries” (Reiss, pp. 25–26). Household income and low parental education were the strongest predictors of children and adolescents’ mental health problems compared to other socio-economic indicators such as parental unemployment or low occupational status (Reiss). Similar to previous studies (West, 1997), Reiss found that while socio-economic status was associated with mental health in all age groups, socio-economic disadvantage was more strongly associated with mental health problems in younger children than it was in those 12 years of age and older. Reiss’s finding regarding the decreased strength in association between socio-economic status and youth mental health (compared to children) supports a previous review by West (1997) who reported that several studies found no relationship between a young person’s socio-economic status and mental health and distress. In making sense of these inconsistencies West argued that there are unique dynamics inherent to adolescence, such as peer and school culture that “equalizes” class differences once seen in childhood and that re-emerge into adulthood. Researchers have hypothesized that use of parental indicators of socio-economic status may not adequately capture young people’s experiences of their socio-economic context (Goodman et al., 2001; Goodman et al., 2007; Hamilton et al., 2009). Subsequent studies thus explored young people’s perceptions of their socio-economic status (versus parental reports of socio-economic status) and found more consistent, albeit complex associations between perceived status and young people’s mental health and substance use patterns. I thus extended Reiss’s beginning  15 review of studies exploring youth’s perceived socio-economic status with studies that explicitly sought to examine the relationship between perceived socio-economic status and mental health, as well as the relationship between young people’s employment and unemployment status (versus their parents’ occupational status) and mental health outcomes. As Reiss’s review did not include group-based socio-economic factors, I also reviewed studies that explored young people’s neighbourhood contexts and levels of economic inequities in relation to mental health. In searching for relevant studies, I cross-referenced search terms for young people, socio-economic factors and mental health within CINAHL and Academic Search Complete databases. For young people, I inputted ‘youth/adolescent/young people’; for socio-economic factors, I inputted: ‘socio-economic’, ‘inequity’, ‘neighbourhood disadvantage’. In seeking studies that explored mental health in a positive sense, I used the search terms ‘mental health’ and related terms of ‘wellbeing’, ‘mental flourishing’, ‘mental fitness’. As most studies continue to focus on mental distress, I also included these studies in this review. Furthermore, I included studies involving young people between the ages of 13 and 24 years in acknowledgment of the complex developmental transitions that young people face (Hickie, 2011) and their extended time in post-secondary school, delays in leaving the parental home, and delays in marriage and childbearing (Furstenberg, 2008). Perceived Socio-Economic Status and Mental Health and Substance Use Young people’s perceived socio-economic status has a complex and not fully understood influence in relationship to mental health and substance use. In contrast to parental—or what some refer to as “objective” socio-economic indicators that include parental income, occupational, and educational status—perceived socio-economic status includes young people’s perception of either their own social and economic position compared with peers in their school context and/or their family’s social and economic position as compared to other community members in social life. Studies comparing perceived socio-economic status to objective indicators found perceived status to be a stronger predictor of mental health outcomes (Koivusilta et al., 2006; Piko & Fitzpatrick, 2001, 2007) with this relationship being unmediated by other socio-demographic variables. Hamilton et al.’s (2009) cross-sectional Canadian study using a student drug survey data of seventh to twelfth grade students (N=7726) found that  16 adolescents with lower perceived financial status8 were associated with greater emotional distress, while adjusting for age, gender, household characteristics and parental education. These associations between perceived socio-economic status and mental health are in tension, however, with unexpected findings in relation to substance use. Similar to Reiss’s (2013) review, which shows inconsistencies in associations between various socio-economic factors and internalizing and externalizing mental health symptoms,9 inconsistencies have been found in the relationship between perceived socio-economic status and substance use. Piko and Fitzpatrick (2007) found that young people evaluating themselves as lower and lower-middle class had a lower likelihood of reporting drinking and marijuana use. Hamilton et al. (2009) reported age effects in which hazardous and harmful drinking was lower in early adolescence among youth of higher perceived financial status. However, by mid-adolescence the harmful drinking of those with higher perceived financial status surpassed that of young people with average or below average perceived financial status. The likelihood of drug use among young people with above-average perceived financial status increased with age at a much faster rate than those with below-average perceived financial status. Using area-based measures of socio-economic status, Luthar and Latendresse (2005) also found this increased strength of association between higher socio-economic status and substance use, as well as emotional distress. They found higher substance use and higher emotional distress among higher income youth (living in the suburbs) compared to lower income youth (living in the inner city). Within the first of three cohort studies, they found that upper-class, suburban high-school students reported significantly higher anxiety, somewhat higher depression, and significantly higher use of cigarettes, alcohol, marijuana, and hard drugs than young people in the inner city; suburban youth’s substance use was also higher than national norms. Furthermore, girls in the suburbs were three times more likely to report clinically significant signs of depression in comparison to normative samples in the U.S. context. In their third cohort study,                                                 8 As an example of how perceived socio-economic status was evaluated, Hamilton et al.’s (2009) study assessed perceived financial status by asking young people: “ ‘How would you describe your family’s financial situation?’” Response options included: “Well above average average/somewhat above average/about average/somewhat below average/well below-average” (p. 1529). 9 For example, from Reiss’s (2013) review: a number of studies reported a stronger association between low SES and externalizing disorders than between low SES and internalizing disorders. In contrast, representative studies from the U.S. and the Netherlands reported a stronger association between low SES and internalizing compared to externalizing disorders. Two studies found no association between low SES and internalizating and externalizing disorders. One study from New Zealand found a significant association between family SES and anxiety but not depression.   17 popular suburban seventh grade youth had significantly higher levels of substance use. Finally, Luthar and Latendresse showed how “youth at the socio-economic extremes were more similar than different” (p. 51). On returning to their cohort I data to explore overt forms of rebellion, they found distinct sub-groups of young people among both lower- and upper- income youth who manifested multiple behaviour problems (e.g. substance use, delinquency, lack of interest in academics) and significantly lower than average grades. Further exploring the sub-group of suburban youth, they found that “twenty percent of these students showed persistently high substance use across time” and that “across all three assessments, [higher income youth] showed relatively high levels of depression and physiologically manifest anxiety (e.g. nausea, difficulty breathing), and poor grades and negative teacher ratings” (Luthar & Latendresse, p. 51). In their study of 445 adolescents (14-18 years of age), while Tur, Puig, Pons and Benito (2003) found that the mother’s educational level was negatively associated with alcohol consumption, they also found that “adolescents from occupational upper class parents were positively and significantly related to alcohol consumption” (p. 243). These unexpected findings are similar to other studies. Varga, Piko and Fitzpatrick (2014) found that subjective socio-economic status was the most influential indicator of youth mental health (compared to objective measures). However, middle-class youth had the highest risk of low mental wellbeing compared to lower and higher-class youth. Aslund, Peppert, Starrin and Nilsson (2009) found that if shaming experiences were present, participants who perceived their family’s wealth and social standing (compared to others in society) as both high and low were at increased risk for depression, whereas medium status seemed to have a protective function. In contrast, the lowest perceived status in comparison to one’s peers had the highest elevated risk for depression. The role of gender in mediating the relationship between both parental- and youth-perceived socio-economic factors and mental health is complex. Reiss’s (2013) review found “no consistent gender patterns” across studies reviewed (p. 27). Piko and Fitzpatrick (2001) found that while gender was significantly correlated with all psychosocial health variables, gender was not a confounder in the relationship between self-assessed socio-economic status and psychosocial health. Hamilton et al. (2009) reported that gender was not a significant moderator of the association between perceived financial status and emotional distress, nor was there a gendered effect for alcohol or drug use. In a cross-sectional study of two groups (11–13 years of  18 age; 14–16 years of age) of youth (n=830) Hutton, Nyholm, Nygren and Svedberg (2014) found that self-rated mental health was associated with the total Family Affluence Score (FAS) (material goods such as car ownership, taking holidays, number of computers) for boys only in both age groups, with no association between total FAS for girls and mental health. By contrast, girls’ mental health was only associated at the item level: not having one’s own bedroom was significantly protective of mental health and having none to one family holiday was significantly associated with worse mental health. Other studies have yielded unexpected findings regarding the influence of racial/ethnic background on the relationship between young people’s perceived socio-economic status and mental health. In their longitudinal study of 1179 non-Hispanic Black and White young people from their seventh to twelfth grade, Goodman, Huang, Schafer-Kalkhoff and Adler (2007) found that race and objective socio-economic measures (parental education and family household income before taxes) did not further affect how low perceived socio-economic status predicted self-rated health. Their cross-sectional and longitudinal analyses also indicated that Black teens from families with low parent education had higher perceived family socio-economic status than White teens from similarly (low) educated families, whereas White teens from highly educated families had higher perceived family socio-economic status than Black teens from highly educated families. Overall, several inconsistencies are found across these studies. While perceived socio-economic status was found to be a strong predictor (compared to objective measures) of youth mental health in ways unmediated by race and gender, complexities were found in relation to substance use patterns in which young people with upper socio-economic status had higher substance use. These studies coincide with other studies, which also found that upper-class young people experience higher levels of emotional distress and behavioural challenges (Luthar & Lattendresse, 2005). Complex findings include studies that found that while one’s middle income status was protective of mental health when faced with social shame (Aslund et al., 2009) it was also harmful to one’s mental health (Varga et al., 2014). These inconsistent findings suggest there may be additional experiences within young people’s socio-economic environments that may influence their mental health experiences. In context of growing economic inequities and challenging employment experiences faced by young people, as discussed previously, it is also important to consider the influence of young people’s direct  19 participation in the labour force along with group-based socio-economic measures that explore levels of economic inequities and neighbourhood social disadvantage on young people’s mental health.   Employment Status Studies exploring young people’s employment status and mental health outcomes draw further attention to the complex relationships among socio-economic factors and young people’s mental health. Previous research has explored the relationship between mental health and various dimensions of the work environment such as hours of work, level of decision-making power, skill building in relation to young people’s future career goals, and work stress. Mortimer, Harvey and Staff’s (2002) review of previous studies revealed mixed findings in relation to number of work hours and mental health. Some studies found associations between longer work hours and unhealthy lifestyles—such as less sleep and exercise, skipping breakfast and greater use of alcohol, cigarettes and illicit drugs, minor delinquency and school misconduct (Mortimer, Harvey, & Staff, 2002). Others found no relationship between work hours and self-esteem, efficacy and depressed affect (Mortimer et al.). Job stressors and early decision-making autonomy have been associated with increased distress for adolescent boys, with the acquisition of useful skills on the job decreasing male depressive affect (Mortimer et al.). Work stress and being held responsible for things beyond one’s control have been associated with increased depressed mood for females (Mortimer et al.). Skill building at work has been associated with greater quality relationships with parents and peers for boys, with positive experiences at the workplace appearing to support adolescent resilience when faced with strain in families and tensions between parents and adolescents (Mortimer et al.). Studies have also found that when work is relevant to young people’s futures, work intensity was less associated with negative mental health outcomes (Mortimer et al.). In their own longitudinal exploration of the relationship between work, school, and mental health among 7,700 young people, Mortimer et al. (2002) found that extrinsic rewards such as having enough money to spend time with friends were associated with wellbeing in the last year of high school, and that wage satisfaction or perceived good pay was predictive of increased wellbeing and reduced depressive affect. Employed students who believed work was compatible with school (i.e. work contributes to education and vice versa) experienced less  20 depressive affect in the twelfth grade. Early work stressors were found to have lasting effects on depressed affect with overly stressful/demanding work being associated with depressed affect four years after high school. Unexpectedly, and in contrast to a previous study that found that young people employed in jobs with which they were dissatisfied were as badly off as unemployed peers (Winefield, Tiggemann, Winefield & Goldney, 1993 cited in Fryer, 1997), Mortimer et al. found no association between intrinsic rewards (learning new things on job) and wellbeing or depressive affect in twelfth grade. Studies have reported both positive and negative mental health experiences in relation to situations of unemployment. Some studies have found associations between unemployment and psychological distress (Fryer, 1997; Hammarstrom, 1994). Reviews of empirical work report associations between unemployment and minor psychological disorders, increased physiological illness (particularly for girls), increased health care consumption, and increased tobacco consumption and illicit drug use (Hammarstrom, 1994) and depression, lower life satisfaction, increased alcohol consumption, civil unrest, and increased crime (Allen, 2014). Long-term unemployment has been associated with increased physical and psychological symptoms, smoking habits and use of cannabis for young people across gender, increased systolic blood pressure and increased crime rates among long-term unemployed boys (Hammarstrom, 1994), increased alcohol use for unemployed men (Hagquist & Starrin, 1996; Hammarstrom, 1994) and increased smoking for females (Hagquist & Starrin). In their study of the mental health effects of unemployment, Hagquist and Starrin found that out of 81 unemployed young people under the age of 25, every fourth unemployed male and every second unemployed female’s mental health worsened when they became unemployed. Unemployed youth have described their experience of unemployment as “boring and marked by idleness and inactivity” evoking fear and nervousness about the future (Hagquist & Starrin, p. 219; Kieselbach, 2003); challenging to one’s self-esteem and confidence and evoking restlessness, anxiety and a sense of social isolation (Hagquist & Starrin); including loneliness, and feelings of depression (Kieselbach). Conversely, some young people have experienced unemployment situations positively. In contrast to their finding that unemployment was associated with mental distress, Hagquist and Starrin (1996) also found that for 10% of the unemployed participants, unemployment was experienced positively and another 10% associated unemployment with both positive and negative experiences. Positive experiences included: opening up new possibilities and  21 opportunities that otherwise would not have been considered and enabling more time for friends and family, walking and cycling, volunteering in community, and having time for one’s children (Hagquist & Starrin). Research has shown that unemployment is mediated by several factors, such as level of social support from friends, family and one’s community, varying attitudes and beliefs regarding work and one’s level of external locus of control (Hammarstrom, 1994), and income supports such as unemployment benefits and access to employment training programs. Hammer’s (2000) comparison of the effects of unemployment on young people’s mental health across five Nordic countries (N=8000) found that social exclusion was not necessarily an outcome for unemployed youth. Social integration, levels of unemployment benefits, and economic deprivation were more strongly associated with mental health symptoms than one’s unemployment status (Hammer). Previous studies have shown how social support from family, friends and community, including less ‘victim blaming’ attitudes, is associated with diminishing the negative effects of unemployment (Hammarstrom, 1994). Kieselbach’s (2003) research with unemployed youth across three Northern European countries found that factors that decreased risk for social exclusion included youth with higher qualifications, relative financial security, and youth who were supported by their social environment while seeking work (i.e. financial, social, and institutional supports). Benefits from governmental institutions and supports from family and friends were associated with higher self-esteem (Kiesebach). Employment training programs have been associated with promoting self-confidence, giving young people somewhere to go, learning new things, and enabling work experience that young people associated with being good for the future and fun (Hagquist & Starrin, 1996). Comparing unemployed youth to those in youth employment training programs, Hagquiest and Starrin found that nervousness and anxiety were five times higher among unemployed women compared to female trainees and that 50% of unemployed men experienced higher anxiety than trainees. They also found that restlessness was more than twice as prevalent for women, and almost twice as prevalent for males who were unemployed as compared to female and male youth trainees. They reported improved states of health and mental health when unemployed youth transitioned to training programs. However, Hagquist and Starrin also reported that some youth trainees expressed negative experiences of youth training programs such as being exposed to real work situations and feeling like they were  22 observers, and feeling exploited and used with their engagement in free labour (Hagquist & Starrin).  Overall, these studies offer contrasting perspectives in relation to the benefits and challenges of both employment and unemployment situations for young people’s mental health. Unemployment has been associated with both positive and negative experiences that are mediated by levels of social integration and income supports. While earlier studies have indicated potentially beneficial aspects of employment to young people’s mental health, these studies are limited in number and findings are inconsistent. There are significant gaps in this body of research. Despite Mortimer et al.’s (2002) finding regarding the long-term impact of stressful and demanding work on young people’s depressive affect for up to four years after high school, there has been no more in-depth follow-up research exploring young people’s experiences of their employment situations in relation to their mental health. Furthermore, there has not been explicit attention given to exploring the meaning of employment and employment experiences in relation to young people’s mental health in context of current educational and labour market trends.10 This is particularly important considering the challenging socio-economic trends for young people discussed previously.  Neighbourhood socio-economic disadvantage, which in some studies includes the rates of unemployment at the community level, is another socio-economic dimension that has been explored in relation to young people’s mental health. Neighborhood-level Socio-Economic Disadvantage A central question addressed in studies exploring group-based socio-economic indicators has been whether neighbourhood social disadvantage (NSD) has a direct relationship with young people’s mental health, or an indirect relationship, being mediated by other risk and protective factors. Some studies have found a direct relationship, uninfluenced by confounding variables,                                                 10 For example, in context of challenging socio-economic trends, there is a lack of attention to exploring meaningful employment in relation to mental health outcomes in previous research exploring the relationship between dimensions of employment and health and mental health outcomes. This is evident within previous reviews of this literature for the World Health Organization Commission on the Social Determinants of Health (Employment Conditions Knowledge Network, 2007) and in relation to informing policies oriented to supporting young people who are “not in employment, education or training (NEET)” in the UK (Allen, 2014).   23 while others have not. Dupere, Leventhal and Lacourse’s (2009) longitudinal study, which followed 2776 children from the age of 8 to 18 years of age through six cycles of data collection found that living in a poor neighbourhood was directly associated with both suicidal thoughts and suicide attempts for adolescents. The odds of reporting suicidal thoughts was two times higher among those who lived in poor neighbourhoods compared to those who did not, and the odds of attempting suicide was four times higher in poor compared to non-poor neighbourhoods while controlling for other risk factors. Neighbourhood poverty had a significant independent effect on youth suicidal thoughts in which its association with suicidal thoughts was not attributable to individual and family vulnerabilities and youth risk factors (Dupere et al.). Aneshensel and Sucoff (1996) studied a community sample of 807 adolescents in Los Angeles. Using regression analysis, they found that of the structural aspects of neighbourhood contexts (median household income, percentage of population below poverty line, percentage of labour force in professional or executive or management level occupations) and youth’s subjective experience of their neighbourhood (the presence of ambient hazards such as graffiti, crime, violence, drug use and dealing; and social cohesion which was seen as essential to controlling the impact of ambient hazards), ambient hazards was the sole factor related to all dimensions of mental health evaluated. The more threatening the neighbourhood was, the more common were the symptoms of depression, anxiety, oppositional defiant disorder, and conduct disorder symptoms. Among the structural neighbourhood factors, conduct disorder was common among the low socio-economic status cluster and oppositional defiant disorder symptoms were common among the middle and affluent clusters. This bears some similarity to previous studies on perceived socio-economic status and substance use and Luthar and Lattendesse’s (2005) unexpected finding that more challenging behaviours were found among higher income youth. In contrast, Brenner, Bauermeister and Zimmerman’s (2011) study of 711 urban high school youth via multilevel modelling found that NSD was not directly associated with adolescent alcohol use (while accounting for risk and protective factors such as peer and parental substance use, and social support and prosocial activities). This lack of support for the neighbourhood disorganization theory or a direct relationship between NSD and health outcomes was also the case in earlier studies exploring the effects of NSD on health outcomes such as violence and delinquency (Brenner et al. 2011). More recently, Drukker et al.’s (2006) longitudinal study of 475 youth living in 36 neighbourhoods through a baseline and a follow-up  24 survey 2–3 years later found that neighbourhood factors did not predict changes in general health or mental health in the period of transition from late childhood to early adolescence. Studies of NSD have also produced unexpected (opposing) results. For example, Drukker et al. (2006) found a positive association between NSD and self-esteem in youth of lower educated parents and a negative association between NSD and self-esteem in youth of higher educated parents (which wasn’t statistically significant). This contrary finding was also shown in Snedker, Hertin and Walton’s (2009) study, which drew from previous survey data and drug use prevention intervention studies for 2,006 youth. They found that youth living in economically disadvantaged areas had lower rates of alcohol and marijuana use and, furthermore, NSD was associated with reduced effects of deviant peers on adolescent substance use. In support of West’s (1997) equalization hypothesis, Drukker et el.’s (2006) baseline measurement (at 11 years of age) showed associations between neighbourhood factors and general health and mental health, but not at follow-up 2-3 years later. The researchers hypothesized that this likely was due to children spending most of their time in their neighbourhoods, compared to youth who may have greater freedom to go outside their neighbourhood to a different school and/or neighbourhood context. Studies have also explored whether factors such as social cohesion mediate the relationship between NSD and young people’s mental health, and conversely, whether NSD mediates the relationship between inter-personal factors and youth mental health outcomes. Exploring the role that inter-personal factors play in mediating the relationship between NSD and mental health outcomes, Drukker et al’s (2006) study further found that the positive association between NSD and self-esteem in youth of lower educated parents and a negative association between NSD and self-esteem in youth of higher educated parents was stronger in neighbourhoods low in social cohesion and trust. In contrast, other studies did not find interactive effects of social processes such as social support mediating the relationship between NSD and mental health. McMahon, Felix and Nagarajan’s (2011) longitudinal cross-sectional study of 85 students who completed a pre- and post- survey in grades 6 and 8 from two Chicago public schools explored the stress-buffering effects of social support. They used hierarchical regression to test main effects and stress-buffering models of social support on neighbourhood stressors in relation to global self-worth in context of NSD. They found no evidence for the stress-buffering hypothesis of social support;  25 that is, social support did not buffer the effects of NSD on youths’ sense of self-worth. Similarly, Brenner, Zimmerman, Bauermesiter and Caldwell (2013) did not find a buffering effect of social support in relation to NSD and young people’s cortisol levels. In contrast to studies that explored whether inter-personal factors mediate the relationship between NSD and young people’s mental health outcomes, studies have explored whether NSD influences the relationship between individual and inter-personal factors and young people’s mental health outcomes. Brenner et al. (2013) used a subsample (N=163) of young people from the sixth wave in a longitudinal study of 850 youth to explore whether NSD influences the relationship between perceived stress and type of coping on young people’s cortisol levels. They found that “both high effort coping and perceived stress were dependent on the level of NSD in their effect on cortisol reactivity” (p. 801). Put another way, the relationship between coping and perceived stress and cortisol were moderated by the degree of NSD. Other studies have drawn attention to the influence of the discrepancy between a young person’s family socio-economic status and that of their neighbourhood as influential on mental health outcomes. Within Drukker et al.’s (2006) study, while they found that none of the indicators of NSD were associated with change in general health or mental health over a two-year period, they did find that exposure to greater disparity between individual level socio-economic status and NSD (i.e. high socio-economic status youth living in deprived neighborhoods) negatively impacted young people’s self-esteem and satisfaction. This finding points to the final dimension I considered in this review, that of economic inequities.Economic Inequities School and national levels of economic inequities have been associated with young people’s mental health outcomes. A study by Goodman, Huang, Wade and Kahn (2003) explored the relationship between the socio-economic context of the school environment and adolescent depressive symptoms independent of household income. Their cross-sectional, multivariate linear/multilevel regression analysis of 13,235 young people in grades 7 through to 12 from 132 schools found that lower household income, lower average school income and greater (within) school-level income inequality were significantly associated with depressive symptoms. At the national level across 34 countries in Europe and North America, Elgar, Roberts, Parry-Langdon and Boyce (2005) conducted a cross-sectional study of 162,305 adolescents (aged 11, 13, 15) from 5,998 schools using the international Health Behavior in School-Aged  26 children data. Elgar et al. (2005) explored the relationship between country-level income inequality (UN Development program) and young people’s health (including mental health indicators) and found that countries with high-level inequality reported greater drinking for 11 and 13-year-olds, but not 15-year-olds while controlling for sex, family affluence and country wealth. The 11-year-olds were found to report greater levels of drunkenness for highly unequal countries compared to low national inequality. Due et al. (2009)11 used the same dataset as Elgar et al. (2005) and found (in support of previous research) that adolescents of greater socio-economic disadvantage are at higher risk of being victims of bullying. They also found that: international differences in prevalence of exposure to bullying were not associated with the economic level of the country (gross national income) or the school, but wide disparities in affluence at a school and large economic inequalities (as measured by the Gini coefficient) at the national level were associated with an increased prevalence of exposure to bullying. (p. 907) Overall, this review of studies exploring various individual and group level socio-economic factors in relation to young people’s mental health has shown that perceived socio-economic status measures tend to be more consistent than objective (parental) indicators in measuring the association between socio-economic status and young people’s mental health. Findings from studies that have explored the relationship between perceived socio-economic status and young people’s mental health outcome are complex, however. Two studies produced contrasting results with one showing that, in the context of shaming experiences, middle perceived socio-economic status had a protective effect compared to lower and upper perceived socio-economic status groups; whereas another study found that youth who rated themselves as middle perceived socio-economic status were at greater risk of poorer mental health outcomes compared to lower and upper perceived socio-economic status youth. Findings are also unexpected in relation to substance use, in which young people with higher perceived socio-economic status have reported greater levels of substance use. This finding is similar to some studies that have shown that young people of upper socio-economic status backgrounds are also vulnerable to greater levels of distress and behavioural challenges and experience vulnerabilities as has been found in previous studies showing vulnerabilities for lower income young people.                                                 11 Due et al. (2009) did not explore inequities in relation to young people’s mental health per se. This study is included in this review, however, due to the strong associations between bullying and young people’s mental health for both victims and perpetrators of bullying (see Kim & Leventhal, 2008).  27 In relation to young people’s employment experiences, studies have begun to explore various dimensions of employment in relation to young people’s mental health, but they are limited. Studies exploring the impact of unemployment on young people’s mental health outcomes have found both positive and negative experiences associated with unemployment. Studies have also found that mental health outcomes in relation to unemployment experiences depend on the level of social integration and income supports or level of economic deprivation. In relation to studies exploring associations between neighbourhood disadvantage and young people’s mental health, studies have shown that in some cases NSD is directly associated with mental health outcomes whereas others have not found a direct association. Opposing findings have also been found whereby young people from NSD have better mental health outcomes such as higher self-esteem and lower rates of alcohol and marijuana use and reduced effects of deviant peers on adolescent behavior. Studies have also shown that in some cases social factors mediate the relationship between NSD and mental health outcomes and others have not found this interactive effect. One study found that NSD mediates the relationship between perceived stress and coping style and cortisol levels. Finally, studies have found positive associations between greater levels of economic inequities and poorer mental health outcomes. Overall, these studies affirm the important, albeit complex relationship between socio-economic factors and young people’s mental health. A central limitation of quantitative methods is their inability to explore complex relational dynamics between young people and socio-economic processes. Quantitative studies are also limited in terms of pre-selecting socio-economic factors that lack attention to young people’s lived experiences. Young people’s experiences offer insights into relevant dimensions of current and evolving socio-economic dynamics for young people’s mental health that have been neglected in previous quantitative studies. Qualitative studies exploring the meaning and determinants of mental health from young people’s perspectives have identified several socio-economic factors not explored in quantitative studies examining the relationship between socio-economic factors and young people’s mental health outcomes. In these youth views studies, young people have expressed concerns about environmental pollution (Harden et al. 2001; Oliver et al. 2008), the built environment, and green space, as well as concerns regarding their access to key resources such as public transportation, grocery stores,  28 and safe physical environments, neighbourhood and school amenities and health care (Ott et al., 2011)12 which has included the need for a stable home (Oliver et al.). Young people have suggested that a lack of material resources that prevents them from getting on with daily tasks of life and engaging in leisure activities is a barrier to mental health (Oliver et al. 2008). Young people have identified their schooling experiences including school performance and an ability to attend college or vocational school as influential to their mental health (Gampetro et al., 2012). Young people have expressed difficulties with studying, coping with academic pressure, and in particular, fears about academic failure (Gallagher & Miller, 1996). They have identified the stress of exams and having too heavy a workload in school that eats into free and leisure time (Harden et al., 2001; Oliver et al., 2008) and challenges associated with finding balance in life into late adolescent years (White & Wyn, 2008) as threats to their mental health. Furthermore, young people have identified having enough funds for post-secondary schooling as influential. Young people in state care transitioning into adulthood have identified worries associated with not having enough money to pay bills and to finish high school or to pay for post-secondary schooling (Leadbeater et al., 2008).13 Young people in state care have explained that once leaving care, “all of [one’s] time and earnings [go] towards rent, food and bills” leaving little left for costs associated with school (Leadbeater et al., p. 13). Young people have also expressed their need for financial security. Within their experiences as consumers who participate in paying for food and clothing to offset family expenses, young people have expressed worries about financial independence (Gampetro et al., 2012). Young people have explained that they need to work to contribute to family income and to support oneself and thus have identified family finances as a factor that affects their health (Ott et al., 2011). Young people have explained that having to work to support family finances has contributed to young people’s stress with balancing time to make healthy meals and meet their needs (Ott et al.). Young people who were nearing completion of high school have expressed worries about long-term future goals and the ability to make a living (Gampetro et al.                                                 12 Note that this focus group study explored young people’s views of the meaning of health generally. 13 Note that both Leadbeater et al. (2008) and White and Wyn’s (2008) work discuss young people’s wellbeing more broadly. Furthermore, Leadbeater et al.’s study focused more broadly on what factors shape young people’s experiences as they transition into adulthood.    29 2012) and making decisions about employment (Gallagher & Miller, 1996; Oliver et al., 2008). Young people have expressed concerns about choosing and finding a job and worries about finances and money (Gallagher & Miller) and they have expressed worries about the ways that certain social locations are discriminated against by future employers (Harden et al., 2001; Leadbeater et al., 2008; Oliver et al., 2008). Young people have expressed concerns about their social location as youth where young people have “described their experiences of watching adults watch them in public places . . . [seeing this] gaze as a specter of apathy, condemnation and anger” which have evoked feelings of fear, being unwanted and invisible in community life (Leadbeater et al., p. 14). More broadly, young people have identified restrictions on young people’s freedom due to societal attitudes, structure and police, and their powerlessness when adults make decisions for them as barriers to mental health (Harden et al., 2001; Oliver et al., 2008). Young people have expressed a need to be heard on all levels of decision-making from state policies to local programs and inter-personal interactions (Ott et al., 2011). Young people have also identified not feeling in control as a barrier to mental health (Oliver et al.). In other work, young people have associated their wellbeing with the ways that they relate to valued consumer goods, which are shaped by peer pressure and peer hierarchies (Morrow, 2001). More generally, international young people’s activists have expressed concerns about the ways that the “socialization of children in affluent countries by corporations and the media [encourage young people] to evaluate their self-worth in terms of clothing labels and electronic toys” (Stasiulis, 2002, pp. 290–291). These qualitative studies offer important insights into socio-economic factors that are relevant to young people’s mental health that have not been addressed in previous quantitative studies. Because these factors were identified in studies looking generally at what aspects of young people’s lives affect their mental health, a more in depth exploration of how these aspects of socio-economic life affect young people’s mental health and implications for mental health promotion programming is needed. Importantly, further work is needed to identify implications for youth mental health promotion initiatives that are oriented to addressing the ways that socio-economic dynamics constrain young people’s mental health. Previous work has shown discrepancies between youth  30 views studies that highlight the importance of broader structural factors and mental health promotion intervention research and policy that lacks an attention to addressing structural factors. A previous comparison of youth views studies to youth mental health promotion intervention research (between 1990 and 2000) shows a discrepancy between the attention that young people have brought to the importance of structural factors14 in relation to their mental health and the lack of attention to addressing structural factors in intervention studies (Harden et al., 2001; Oliver et al., 2008). Harden et al. compared mental health promotion intervention studies to youth views studies. They found that socio-economic determinants of mental health were identified by youth in 10 (of 12) qualitative studies exploring young people’s views of the determinants of mental health.15 However, of the high quality systematic reviews (N=7) and outcome evaluations (N=47) that were included in their in depth review, no evaluated interventions addressed the concerns identified by young people regarding the material and physical circumstances of young people’s day-to-day lives (Harden et al.; Oliver et al.). More broadly, in Harden et al.’s exploration of trends across 345 studies that included a mixture of outcome and process evaluations, non-intervention research, and systematic reviews, they found that only 32% of these studies addressed broader societal (socio-economic and socio-cultural) factors. This tendency to develop individual and inter-personal level health promotion interventions is also reflected within Canadian health programming. Within the Canadian health policy context, MacNeil (2012) conducted a cross-jurisdictional scan of all Canadian health region websites exploring interventions addressing social determinants of health, equity and structural-level interventions16. Based on his review of 2200 interventions, MacNeil found that 25% of interventions addressed equity and of these, 16% were structural in nature. Most interventions relied on direct interventions at the 1:1 level (e.g. bringing health services to                                                 14 Harden et al. 2001 use the notion of structural factors to refer to material (e.g. access to resources, built and natural environments) dimensions of young people’s lives. Examples of structural interventions include: “increasing access to resources or services, environmental modification and legislation or regulation” (Oliver et al., 2008, p. 777). 15 For their more rigorous review, Harden et al. (2001) selected qualitative studies that sought to explore young people’s views regarding the meaning and determinants of mental health as a central focus of the study (as opposed to situating young people’s views within a particular theoretical or analytic framework or use of survey methods with pre-selected questions) 16 MacNeil (2012) defines structural interventions as including: “those which address health outcomes not on a case by case basis, but across larger populations” (p. vi)  31 underserved communities). Interventions providing fiscal support for citizens or through formalized policies addressing environmental factors such as regulation were less common than individual level supports. As mentioned previously, this primary focus on promoting health at the individual and inter-personal level is also reflected within B.C. mental health policy. Furthermore, similar to the tendency to develop health promotion programming in individualistic ways, recommendations made within previous quantitative studies tend to be individualistic in nature despite their focus on exploring the relationship between socio-economic factors and young people’s mental health. For example, based on research exploring the relationship between perceived SES and young people’s mental health, Frojd et al. (2006) and Hamilton et al. (2009) highlighted the psychological meaning attached to young people’s life situations. Frojd et al. suggested that while adolescent perception of financial difficulties is probably associated with the objective financial situation of the family, it may also be an indicator of the psychological meaning attached to the situation and should thus be considered a possible risk factor for adolescent maladjustment in clinical practice (Frojd et al., 2006). Frojd et al. suggested that: social and healthcare professionals working with families should consider the financial difficulties in the family as a possible risk factor for maladjustment in the offspring. Possible ways of preventing maladjustment are discussions of the psychological meaning of economic hardship (helping the adolescent to see his/her situation in a new way, reducing feelings of inferiority or shame) and giving the adolescent tools to cope with situations arising as a consequence of financial difficulties (conflicts with parents, conflicts between parents and difficulties in socializing with peers). (p. 547) These recommendations lack attention to balancing care at the individual and interpersonal level with attention to addressing socio-economic factors that influence young people’s mental health. Furthermore, while several recommendations have been made within the broader social determinants of health literature regarding ways to address various social determinants of health (including that of employment, income and economic inequities, for example), and while there is an abundance of evidence regarding interventions (Marmot & Allen, 2014), understanding what interventions are relevant to young people with attention to current and evolving socio-economic dynamics requires more in depth exploration of young people’s views.  32 Gaps in Previous Research and Objectives Guiding this Study Overall, across the studies reviewed the nature of the relationship among aspects of socio-economic life in relation to young people’s mental health remains unclear. Specifically, there is little understanding of relational dynamics among young people’s mental health and various aspects of socio-economic life. This includes a lack of understanding regarding how to translate more nuanced understandings of these complex relationships into mental health promotion initiatives oriented to addressing aspects of socio-economic life that constrain young people’s mental health. Qualitative work has drawn attention to concerns raised by young people about structural determinants of mental health. Empirical findings affirm the important albeit complex role that socio-economic factors play in young people’s mental health. Together these bodies of literature suggest the importance of exploring the relationships among young people’s mental health and socio-economic factors from a broader relational perspective. The dominance of individual and inter-personal approaches to CYMH prevention/promotion programming and their incongruence with young people’s attention to structural factors (Oliver et al., 2008) suggests the importance of exploring opportunities for addressing constraining socio-economic determinants of young people’s mental health in health promotion initiatives from the perspective of young people. More specifically, this lack of attention to addressing socio-economic factors in young people’s mental health promotion programming is likely due to several factors, including the lack of a broader relational understanding of socio-economic life and young people’s mental health. Quantitative studies are limited in their ability to deepen understanding regarding the complex and dynamic interrelationship of diverse aspects of socio-economic life in relation to young people’s mental health. Qualitative studies exploring youth views have begun to identify additional socio-economic factors, but have not explored how aspects of socio-economic life affect young people’s mental health and implications for mental health promotion initiatives. Causal models underpinning theories of the relationships among socio-economic factors and health have several limitations for giving clear directions regarding health promotion initiatives. A causal model is reflected in debates regarding which factors are most salient, with neo-materialists putting material and structural conditions of people’s lives at the centre of explanations of health inequities in contrast to others putting psychosocial mechanisms and  33 specifically the negative emotional impact of living in an unequal society at the centre of explanations of health inequities (Crinson & Yuill, 2008). A causal model is also reflected in polarizing debates regarding the direction of the causal relationship between health and wealth. Some argue that people who are ill drift into situations of poverty and thus ill health is the cause of health inequities. Others argue that income inequality is either directly causal or indirectly causal (in being a marker of broader social inequalities) of poor health (Marmot, Allen, & Goldblatt, 2010). This “linear model of causality” in which cause-and-effect relationships are assumed, lacks attention to “emergence and contingency . . . and the complexity of human agency and social structural interaction within an open society” (Crinson & Yuill, p. 467). This causal-linear perspective is constraining in that it results in ideological stalemates in theoretical and empirical explorations of the nature of relationships among social determinants of health and health outcomes and proposed solutions. Furthermore, quantitative studies underpinned by realist and idealist ontologies are limited in that they assume the possibility of developing truth claims regarding ‘socio-economic factors’ and ‘mental health.’ This perspective is problematic in that it does not consider the dynamic, interrelated, co-evolving nature of aspects of socio-economic life and young people’s mental health. This perspective does not address how conceptions of mental health and socio-economic factors are rooted in social and cultural values and shaped by dominant and evolving assumptions regarding human nature and social change. These concepts are contested and political in nature. Their definitions are shaped by evolving power relations and shape how young people’s mental health is promoted in community life (Bambra et al., 2005). The contestation of these terms is reflected in analytic work that has questioned taken-for-granted assumptions underpinning notions of mental health and mental health promotion within the health promotion and mental health policy and practice literature. Based on a review of critical perspectives in mental health, Coppock and Hopton (2000) draw attention to the lack of “a universally accepted theory of mental health and distress” (p. 176) and argue that there is a “hierarchy of ideologies, which seems to privilege discourses which incorporate biological psychiatry over all competing discourses” (p. 165). In the case of theorizing mental health, the majority of works construct mental health as being an ability to cope or adapt to environmental stressors at the individual level and the ability to be productive in the larger economic environment (For example, McDougall, 2006; Mohr, 2006; Townsend, 2006; World Health  34 Organization, 2004). Analyses have variously shown the dominance of Western cultural, patriarchal, individualistic, bio-medical/psychiatric, middle-class, and liberal/neoliberal discourses inherent to notions of mental health and distress in mental health practice (Coppock & Hopton, 2000; Crowe, 2000a, 2000b; Ferguson, 2007; Rose, 1999; Stavropoulos, 2008; Teghtsoonian, 2009; Timimi, 2005, 2010). Barriers to addressing social determinants of health in policy and practice has been attributed to the continued dominance of quantitative and individualistic approaches to researching health and determinants of health that are depoliticized and the dominance of liberal ideological values such as individualism in Western culture (Raphael, Curry-Stevens, & Bryant, 2008). As argued by Bambra et al. (2005), health is a political concept “because its social determinants are amenable to political interventions and thereby dependent on political action” and “because power is exercised over [health] as part of a wider social and political system. Changing this system requires political awareness and political struggle” (pp. 187–188). It is thus important to build on previous work in making transparent the underlying assumptions and values that are operating within notions of health/mental health. This includes addressing the attention that young people have brought to the importance of addressing structural factors in relation to mental health and calls that have been made within nursing and interdisciplinary health disciplines for addressing the socio-environmental determinants of health (E.g. Baum, 2007; Hawe, 2009; Marmot, Friel, Bell, Houweling, & Taylor, 2008; Raphael, 2010; Reutter & Kushner, 2010). I thus drew on a praxis-oriented approach to inquiry, underpinned by a Hegelian-Marxist historical-dialectical perspective that enabled an exploration of socio-economic life in relation to young people’s mental health and implications for mental health promotion initiatives. In order to ensure that insights and recommendations were responsive to young people’s needs and experiences, this approach to inquiry was grounded within young people’s lived experiences. It was also reflexive in nature, attending explicitly to the political and co-evolving, contested nature of the notions of mental health and socio-economic factors. In this study I viewed both mental health and socio-economic environment as political concepts (Bambra et al., 2005). I explored young people’s views and experiences on how their socio-economic environments affected their mental health in relation to dominant ways of understanding and addressing socio-economic determinants of mental health within mental health policy. This helped to inform  35 insights regarding ways to build on existing health promotion work in ways that address constraining aspects of socio-economic life for young people’s mental health.  This study was guided by the following objectives: 1. To deepen understanding regarding ways that young people’s current socio-economic environments are influencing their mental health and young people’s processes of realizing their mental health.  2. Identify opportunities for developing mental health promotion initiatives in ways that address current socio-economic dynamics that are constraining young people’s mental health. 36 Chapter Three: Research Design and Implementation Critical qualitative research methods are a means of exploring relationships among broader social, political and economic dynamics and the day-to-day life and health experiences of people (Cook, 2005; Raphael et al., 2001). Political-economic and dialectical perspectives are important to deepening understanding about these relationships in ways that prevent “ideological dichotomies” (Robertson & Minkler, 1994, p. 298) between macro- versus micro- level factors that affect health (Raphael & Bryant, 2006; Raphael et al., 2001; Robertson & Minkler). Labonte, Polanyi, Muhajarine, McIntosh, & Williams (2005) argue for the importance of research specifically focused on understanding the relationships among aspects of socio-economic life and health in order to guide diverse political and social actors—such as health workers, community-based organizations, employers, government policy makers, and politicians—in developing policies that transform the socio-economic conditions that lead to ill health. Furthermore, better understanding of these relationships will support the selection and development of theories of society and social change that can be taken up in critical health promotion research, policy and practice (Labonte et al., 2005). I thus used a praxis-oriented approach to inquiry, underpinned by a Hegelian-Marxist dialectical and historical perspective (Bologh, 1979; Choat, 2010; Harvey, 1996; Hill, 2009; Lather, 1986; Lefebvre, 1969; Marcuse, 1960; Ollman, 1976, 2003) to address the objectives guiding this study. Bologh (1979) describes Marx’s research method as a form of “dialectical phenomenology” that supports a relational analysis of mental states, political and economic systems, language and knowledge. This relational approach to inquiry assumes that aspects of socio-economic life are dynamic, co-evolving, historical in nature, and not always self-evident within evolving language and conceptual systems. A central goal of this approach to inquiry is to deepen understanding regarding relational and ideational dynamics to identify opportunities for ethical and socially just socio-economic change (Bonefeld, 2012; Harvey, 1996; Lather, 1986; Ollman, 2003) that, in the case of this research, is supportive of young people’s mental health. I start by providing an overview of the historical-dialectical ontology that supported my relational approach to inquiry in this study. I then provide an overview of the process of social  37 praxis that informed my approach to data collection and analysis and, more specifically, the research process. Historical-Dialectical Ontology In support of my relational approach to inquiry within this study, I drew upon insights from the field of Western Marxism (Choat, 2010; Feenberg, 2014; Kellner, 2005), and more specifically Hegelian-Marxist scholarship (Hill, 2009) that has interpreted Marx’s approach to inquiry from a historical–dialectical perspective (Bologh, 1979; Feenberg, 2014; Feenberg & Leiss, 2007; Harvey, 1996; Hill, 2009; Lefebvre, 1969; Marcuse, 1960; Ollman, 2003). This approach to inquiry is focused on exploring relations as a fundamental unit of analysis (Harvey, 1996; Ollman, 1976, 2003) and offers a “fundamentally non-reductive way of viewing the world” (Hill, 2009, p. 609). Put another way: a historical dialectical approach to inquiry is relational inquiry. I have thus used the terms dialectical (encompassing historical) and relational interchangeably in this report. Two overarching sets of assumptions supported my approach to relational inquiry within this study. The first set of assumptions within this historical–dialectical perspective centre around the notion that aspects of socio-economic life are inter-related with, and co-constitutive of, each other and with the whole system of which they are a part. Parts of a system are assumed to encompass relations that contain within themselves the very interactions to which they belong (Bologh, 1979; Hill, 2009; Ollman, 1976, 2003). Furthermore, a dialectical view holds that while autonomous in nature, parts and wholes also co-constitute each other within socio-economic life (Bologh; Harvey, 1996; Hill, 2009; Ollman, 1976, 2003). This means that parts of a system are both internally autonomous and “identical” in that each part is a necessary condition for the other and thus is conceived as a part of the other (Ollman, 2003). For example, while people are free and function as independent autonomous agents within a market economy, they are also fundamentally dependent on the market in realizing income and resources from exchange relations (Harvey, 2010, 2014). Attention is thus brought simultaneously to the “part” (e.g. an entrepreneur) and the process of which it is a part (e.g. exchange relations within markets) (Bologh; Hill; Harvey; Ollman, 2003). In moving beyond tendencies in social research to stop at exploring similarities and differences between parts (e.g. thematic analysis), a central focus of dialectical inquiry is to explore not only the ways that parts are similar and different to each  38 other, but also to explore the ways that their identities include the relationships with other parts of the system of which they are a part (Ollman, 2003). This perspective helped me to explore young people’s lived experiences of their socio-economic environments while maintaining a simultaneous attention to socio-economic processes in which young people participate. This perspective also helped me to resist dominant, linear, and taken-for-granted ways of conceiving notions of mental health and socio-economics within this inquiry process. For example, instead of dividing research participants into income levels or socio-economic positions (e.g. capital and labor) and explaining their mental health experiences and needs within those categories, I sought to explore inter-relations among young people, their mental health experiences, needs, response patterns, and socio-economic processes and level of access to resources, while keeping an open mind to additional ways of understanding their experiences. I sought to understand the relationship between young people and the socio-economic processes of which they are an inter-related part. From this perspective, I further explored how young people are both influenced by and influencing socio-economic processes that they are part of within their day-to-day lives. This was important to deepen understanding regarding how relational dynamics among young people and socio-economic processes were influencing young people’s attempts to realize their mental health and specifically, their level of influence and control in meeting their mental health needs. Drawing on both Marx and Adorno’s work, Bonefeld (2012) argues that “agency” and “structure” and “subject” and “object” are not separate, but connected through social practice. This social practice includes evolving language and meaning systems oriented to understanding and coordinating social practice with other people to meet needs and goals within the broader world of which practice is an inter-related part (Lefebvre, 1969). For example, as new needs and goals arise out of evolving production systems (and the new technologies and commodities that are produced), new ideas and language are needed to coordinate social relations in meeting evolving needs and goals. Both Marx’s dialectics (Ollman, 2003) and Adorno’s negative dialectics “hold that however much the objective world has autonomized itself from the acting individuals, it remains a form of human practice” (Marx quoted in Bonefeld, 2012, p. 129). With this focus on practice, there is no “essence” of subjects and objects; “essence is ‘society as the unity of object and subject,’ however much the subject is degraded to a foundational means of the object that it forms” (Bonefeld, p. 128). With this in mind, I paid attention to research  39 participants’ descriptions of how, for example, commodities such as name-brand clothing and IPhones shaped and influenced their mental health and, in turn, how they sought to meet their mental health needs within this material context. I also explored how young people were being positioned and positioning themselves within socio-economic processes in relation to their processes of seeking to realize their mental health needs. More broadly, I explored young people’s experiences in relation to mental health policies and assumed that while social structures (and processes) such as a mental health system, and the economic system with which it is inter-related, may appear as separate structures and permanences, they are inter-related with, and extensions of, the co-evolving social processes and practices that constitute them. This understanding set the stage for examining the positioning of mental health policies and programs in relation to young people and broad socio-economic processes. This understanding of the nature of socio-economic life formed part of the lens through which I analyzed possible opportunities for developing future mental health promotion initiatives. The other lens was that of contradictions. The second set of assumptions within this historical–dialectical perspective centre around the notion that contradictions are important sites for analyzing opportunities for social change. From this perspective, moments of socio-economic life are considered to be heterogeneous in nature through their dynamic inter-relation with other moments of socio-economic life over time (Harvey, 1996).17 A moment within socio-economic processes can be internally contradictory within itself as well as in contradictory relationship with other moments in socio-economic life. Contradictions can arise when internally related aspects of a moment (through its relations with other moments) or relational dynamics between moments hold oppositional needs, goals, interests, values, positions, ideas, desires and/or directions. For example, conflicts and tensions emerge within relationships among different social positions and respective needs, goals, values, and interests. With our embeddedness within this complex and contested social terrain of ideas and relational dynamics, we too can experience contradictory internal experiences. An example from this study entailed how young people both resisted what they referred to as “capitalist brainwashing” at the same time as they sought the very products being advertised to meet their                                                 17 Harvey uses the notion of “moments” to reflect this relational perspective on aspects of socio-economic life that are assumed to be temporal and historical in nature, as well as inter-related with other moments of socio-economic life in dynamic ways. The notion of moments signals the impermanent and dynamic nature of socio-economic life such that there are endless possibilities for change that occurs at various points in time and contexts (Harvey, 1996).  40 need for social inclusion. These contradictory dynamics are considered to be the most important relations for dialectical analysis in that it is assumed that they are key sites for transformative social change (Harvey, 1996; Ollman, 2003). Understanding these contradictory dynamics from a dialectical perspective is important to enable insights into relational power dynamics and opportunities for systemic change that, in the case of this research, is supportive of young people’s mental health. Importantly, contradictions include direct conflictual dynamics, as well as a mutual dependency between moments of socio-economic life (Bologh, 1979). A contradiction is a divergent “tense form [or relation] because the side that is repressed is in conflict with its other side and there is a suppression of one side to allow the other side to realize itself” (Bologh, p. 69). A contradiction also includes an alliance and mutual dependency between conflictual moments in that each part is a necessary condition for the other’s existence. Put another way, contradiction “refers to the incompatible development of different [moments] within the same relation [i.e.] between [moments] that are also dependent on each other” (Ollman, 2003, p. 17). From this dialectical view (as opposed to the Aristotelian view in which two statements are held to be completely at odds so that one cannot be true) a contradiction is assumed to “arise when two seemingly opposed forces are simultaneously present within a particular situation, an entity, a process or event” (Harvey, 2014, p. 1) and thus are mutually dependent upon one another. Analysis of the conflictual and interdependent nature of contradictory relations in socio-economic life offers a lens for identifying opportunities for systemic change. Within my analysis of contradictory dynamics faced by young people within this study, this awareness of the mutual and divergent aspects of a contradictory dynamic enabled me to consider solutions that are oriented to enabling the realization of both sides of a contradictory dynamic in ways that attend to “different sides of [the] contradiction . . . at the same time, and [to] grasp the ways that processes actually interpenetrate . . . as their mutual dependence evolves” (Ollman, 2003, p. 18). This was important to avoid mutual interactions from being mistaken for causality (with the tendency to focus on one side of the contradiction to a greater degree than the other) (Ollman, 2003) and, in turn, one-sided solutions that do not address the inter-dependent elements of a contradictory dynamic. An example of this kind of analysis can be applied to a living wage policy, which has been identified as a key strategy for ensuring access to income as a determinant of health within  41 the field of public health (e.g. Public Health Association of British Columbia, 2014). While a living wage can alleviate the struggle for labourers to meet their needs for a period of time by increasing access to money and thus needed resources or commodities, this solution contradicts the drive for profits within private production processes. As increased wages result in loss to profit margins, the price of commodities must increase, which then contradicts the solution of increasing wages in the first place. Conversely, the increased focus on maximizing profit margins inherent to neoliberal economic policies and practices results in increasing precarious and low-wage work followed by the challenge in realizing profits in markets where there is no longer an effective demand (Harvey, 2005, 2014). Analysis of this contradictory dynamic shows the mutual dependency of capital and labour. Labour is dependent on production to access money to meet needs, and capital is dependent on labour in production and, in free markets, as consumers to actualize profits. Solutions thus need to be developed from an understanding of both the root conflict and mutual dependency between, in the case of this example, labor and capital in production and distribution processes. These insights apply to youth mental health promotion in that promoting young people’s socio-economic wellbeing cannot be achieved through simple, one-sided solutions. In addition to the contradictory dynamics that can arise within material life, Marx and subsequent Hegelian-Marxist scholars drew attention to the contradictory dynamics that can arise between material reality and evolving conceptions of this reality (Adorno & Horkheimer cited in Crotty, 1998; Feenberg, 2014; Feenberg & Leiss, 2007; Hill, 2009; Kellner, 2005; Levebvre, 1969; Marcuse, 1960). They variously critiqued the ways that capitalist logic and scientific knowledge and subsequent concepts, theories and abstractions present seemingly static truths about the world that contradict the dynamic and co-evolving, relational nature of life and how these “truths” can strengthen existing power dynamics and limit opportunities for change. A central and dual aspect of Marx’s analytic work included analyzing not only relational dynamics within actual existing socio-economic life, but also analyzing the ways that concepts and constructs are taken up in limiting and constricted ways that mask broader social relations that are operating in social life (Bologh; Hill; Harvey; Ollman, 2003). For example, Marx showed the ways that wage labour presents a façade of mutual exchange when in reality the wages exchanged for labour power and surplus profits are not equivalent in private production processes (Ollman, 1976). Marx “devoted significant critical energies to an intensive re- 42 examination of the way in which economic abstractions distort the internal relations that actually exist between human beings” (Hill, p. 613). The notion of reification is used to draw attention to how certain ways of conceptualizing aspects of socio-economic life (e.g. subjectivity, social and material relations) can distort a more expansive understanding of actual existing and complex relational dynamics (Feenberg). Further, Marx and subsequent thinkers drew attention to how reified notions limit the potential of human beings and their capacity for critical thought, imagination and action in relation to actualizing evolving goals and needs (Hill). These reified forms of rationality negate the dialectical view of human nature, which Hegelian-Marxist scholars assumed was historical in nature (Hill; Lefebvre). This means that we, as human beings, are continually seeking to understand (and conceptualize, abstract) the world and address needs in relation to a world that we both change, are changed by, and respond to in a co-evolving way (Feenberg & Leiss; Hill; Lefebvre; Ollman, 1976). This contradictory dynamic between reality and conceptions of reality can occur within daily social and cultural practices, as well as within knowledge development processes. These concerns regarding reified reality emerged from Marx’s critique of how philosophy (and modern rationality) had evolved to be disconnected from reality and his argument for the importance of starting with day-to-day life experiences and using our senses as theoreticians in praxis-oriented inquiry (Hill, 2009; Lefebvre, 1969). The philosophy of praxis that informed my approach to inquiry was enlightened by these critiques of the reifying practices inherent in dominant forms of rationality, and the historical-dialectical ontological perspective that emerged from these critiques. Research Methodology: Social Praxis I drew upon a Hegelian-Marxist philosophy of praxis to inform my approach to data collection and analysis in this study in which I explored young people’s mental health needs within the context of their day-to-day life experiences. I examined participants’ experiences and perspectives regarding the ways that aspects of socio-economic life affected their mental health and their approaches in seeking to realize their mental health needs in relation to dominant conceptions of mental health and approaches to promoting mental health. This philosophy of praxis also supported my reflexive approach to inquiry.  43 Referred to as “meta-critical” in nature by Feenberg (2014),18 Marx’s approach to praxis-oriented inquiry includes an iterative two-step process of first, analyzing relational dynamics and second, identifying solutions that have potential for resolving contradictory dynamics within material and social life (Feenberg). The first step of relational analysis entails exploring lived experience and relational dynamics within socio-economic life. This includes analyzing language and conceptions of reality in relation to actual existing socio-economic life both in terms of a) the ways that dominant understanding of, in the case of this research “mental health/promotion” and “socio-economic determinants of youth mental health” contradict reality and in turn limit possibilities for meeting young people’s mental health needs; and b) the potential ways that dominant understandings and assumptions in socio-economic life may hinder insights gained within the research process itself.  In relation to the potential influence of dominant ideas within the research process, Hegel, Marx and subsequent Marxist scholars acknowledged the necessity and challenge of critique (inquiry) from within the conceptual systems of thought that mediate our knowledge of reality. Hegel’s critique of Kant’s ahistorical categories of understanding and Hegel’s marrying of “epistemology with ontology” within his arguments that “thought could never exist as a stand- alone entity from the subject from whom it emanated” brought a “historical-dialectical vantage point” to philosophy (Hill, p. 607). From this perspective, pre-existing suppositions are rigorously critiqued (Hill). Furthermore “given that the only knowledge we can ever have of the external world is mediated by what Hegel calls ‘formations of consciousness’, which constitute mere interpolations of reality, reality is always only ‘known’ through a fixative process of ‘abstraction’” (cited in Hill, p. 608). From this view, Hill argues that: We are only ever able to gain a semblance of reality, this being a mere representation or a mediated impression of what lies beyond our human and historically situated field of vision. Knowledge can only ever be knowledge of                                                 18 Feenberg (2014) uses the notion “meta-critical” to distinguish Marx’s “non-reductive social theory of knowledge” (p.12) based on his critique of the metaphysical and idealist-normative aspects of previous philosophy.  Feenberg  argues that Marx’s approach to inquiry is meta-critical in nature in that a dual attention is brought to analyzing two domains of contradictions that are resolved through social practice: First, the contradictions that occur in existing material-social reality and second, the contradictions that occur between ideas-abstractions and material-social life. Attention is brought to abstractions as “relative states” and to comparing these abstractions to concrete reality. Concepts are held as relative and evolving states of understanding the world, which may contradict the realities of that world. By increasing awareness of the contradictions between ideas and reality, opportunities open for new ways of being and becoming through social practice.   44 ‘appearances’ by this view. Far from our reasoning therefore being braced by timeless and eternal truths, it becomes a very human and historical entity as a result. (Hill, p. 608) For Marx, this necessitated a “skeptical self-comprehension” (Hill, p. 608) resulting in the need for a continual questioning of knowledge claims and their influence on relational dynamics and social practices that then shape human thought, experiences, needs, and evolving understandings and knowledge claims in an iterative way (Hill; Ollman, 2003). For Adorno, this required a form of “immanent critique,” a form of phenomenological critique from within the complex relational and ideational dynamics that are at play within evolving socio-economic dynamics (Adorno cited in Crotty, 1998). A central feature of this approach to inquiry is thus the simultaneous exploration of relations among moments of actual existing socio-economic dynamics and the relation between conceptions of reality and actual existing socio-economic dynamics (Ollman, 1976, 2003) both as the object of inquiry and within the inquiry process itself. I thus attended to material and ideational dynamics that were influencing young people’s mental health and their attempts to realize their mental health, as well as my own assumptions shaping my approach to inquiry. Hill (2009) describes this praxis-based approach to inquiry as an audit of dominant ideas and normative accounts of reality with real life experience. This is based on the assumption that ideas are in dialectical relationship with social relations over time in ways that both reveal and conceal aspects of reality, social relations and power dynamics (Bologh, 1979; Lefebvre, 1969; Marcuse 1960; Ollman, 2003). A central focus of relational analysis is to explore the ways that dominant ideas and ways of making sense of reality may present seeming truths and permanences in social relations and institutional forms in order to show how these ideas obscure oppressive and unjust relations and limit potential (Harvey, 1996) of, in the case of this research, young people’s mental health and wellbeing. Abstractions are analyzed in relation to how they contradict the dynamic and co-evolving, relational nature of life and thus possibilities for change (Harvey). Marcuse (1960) argued that dialectical thinking is negative thinking in that it must negate the established social “facts” so that their emancipatory potential may be realized. An example of this contradictory dynamic from this research includes the ways that research participants expressed yearning to engage in meaningful work that contributed to their communities, at the same time that many of them held dominant assumptions that people would not be “incentivized” to work if they were not paid.  45 From this new approach to rationality in which concepts (and human nature) are not read normatively, but dialectically and historically (Hill, 2009), the second step of this approach to relational inquiry is that of solution building in ways that are informed by a deeper understanding of relational dynamics. From this perspective, relational dynamics are explored and concepts are deconstructed in order to enable potential openings for new ways of understanding and being in the world. From this historical view of human nature and social change, Marx argued that the forms of human being’s powers and capacities are endless and “have as many possibilities as there are ages and classes in human history” (Ollman, 1976, pp. 87–88) and thus there are open possibilities and solutions for meeting evolving needs. This is partly based on Marx’s critique of the ways that history was depicted as an external force operating upon people and to which people must passively submit and forfeit their autonomy in determining their future (Hill). Instead, he projected a meta-view, or “onto-formative” (Hill, p. 606) view of human nature with a central focus on people’s abilities to reflect, create, set goals, and act in a world that people change and in turn are changed by and “a thoroughly humanized and dialectical view of history that advances human purposive activity as the motor force of cultural evolution and progress” (Hill, p. 609). I applied this process of solution building within this study by a) engaging young people in critical reflections on the research objectives guiding this study while being attentive to their mental health needs, and b) analyzing contradictory dynamics between dominant ways of understanding mental health/promotion and participant’s lived experiences. Importantly, I recognized that within this process of immanent or reflexive inquiry, a central goal is to build ethical and moral choices within a contested terrain of constructed knowledges (Harvey, 1996). The goal of analysis is to “find a plausible and adequate basis for the foundational beliefs that make interpretation and political action meaningful, creative and possible” (Harvey, 1996, p. 2). According to Harvey (1996), “the exploration of potentialities for change, for self-realization, for the construction of new collective identities and social orders, new totalities (e.g. social ecosystems) and the like is a fundamental motif in Marxian dialectical thinking” (p. 56). Knowing what ideas and actions to prioritize in the context of complex and contradictory dynamics within co-evolving material and ideational moments of socio-economic life is a fundamental challenge in praxis-oriented inquiry. My analysis of solutions thus focused both on addressing socio-economic dynamics that were constraining young people’s ability to realize  46 mental health in their day-to-day lives and, more broadly, opportunities for developing mental health promotion initiatives in ways that address contradictory dynamics that constrain young people’s mental health needs in this contemporary socio-economic context. Importantly, instead of producing normative truth claims, this approach to inquiry is oriented to producing a “constellation” of ideas and calls to action (Adorno cited in Crotty, p. 135) that are open to ongoing praxis that is, in the case of this research, oriented to meeting young people’s evolving needs and goals (Levebvre, 1969). I thus sought to identify multi-level opportunities for future praxis-oriented youth mental health promotion initiatives that are responsive to current relational dynamics that constrain young people’s mental health. Overall, I applied this praxis-based approach to inquiry across two phases within this study. First, I engaged 30 diverse young people between the ages of 15 and 28 years from an urban context. Within two series of dialogue sessions and the use of participatory documentary photography, I explored participants’ experiences and perspectives regarding the ways that their socio-economic environments were influencing both their own and fellow young people’s mental health. This included exploring the ways that participants were seeking to meet their mental health needs in their day-to-day lives. Furthermore, in agreement with Marx’s recognition of the creative and imaginative powers of people (Hill), and the central importance of goals and aims in processes of praxis, whereby praxis “involves tactics and strategy . . . [and] no activity without an aim in view, no act without a program” (Lefebvre, 1969, pp. 54–55), I engaged young people to share their recommendations for socio-economic change oriented to supporting young people’s mental health. I also explored their critical reflections on barriers and supports to change. Based on the assumption that mental health policy reflects dominant and privileged ways of understanding and promoting mental health and to identify implications for mental health promotion initiatives, I compared insights gained from dialogue sessions with young people to the ways that mental health and socio-economic determinants of mental health are discursively taken up within two sets of provincial mental health policy documents within the second phase of this study. More specifically, I compared the ways that notions of mental health and socio-economic determinants of mental health are taken up within these policy documents to the lived experiences of participants in this study. I analyzed the ways that mental health/promotion and socio-economic determinants of mental health are understood within current mental health policy  47 and how mental health policy is positioned in relation to young people and broader socio-economic processes. I explored how common sense notions of mental health and socio-economic determinants of mental health within these policy documents both support and/or gloss over, or deny potentialities for promoting mental health in young people’s day-to-day lives. This analysis was important to understand the relational context of young people’s lives and to deconstruct taken-for-granted assumptions regarding mental health/promotion and social determinants of mental health. It was also important to explore the responsiveness of mental health policies and proposed programs in addressing socio-economic dynamics that constrain young people’s mental health and to identify implications for future mental health promotion initiatives. In essence, I applied this reflexive, relational-dialectical (meta-critical), and solution-oriented approach to inquiry by examining the meaning of “mental health” and “socio-economic determinants of mental health” (Bologh, 1979) as taken up in two sets of provincial mental health policy documents by subjecting these notions to the “scrutiny and rigorous audit based on real world experience” (Hill, 2009, p. 608) of young people. In context of previous arguments that this critical approach to praxis is best taken up within settings, by those most affected (Kemmis, 2010) and within iterative spirals of critical reflection, learning, action and evaluation (Kemmis, 2010; Stringer & Genat, 2004), I considered this to be a process of social praxis. I assumed that the setting of focus is the broader, contemporary socio-economic environment of diverse young people, their allies, and mental health programs. I sought to develop insights regarding the relational terrain of young people’s lives and possibilities for promoting mental health that can be the source of further dialogue and action within the broader community. Within this research, while I recognized the benefits of engaging research participants within group dialogue, I also recognized the importance of ensuring that these diverse young people felt safe in sharing their views and experiences and thus gave them the option of how they wanted to meet with me. This resulted in a mixture of mostly individual meetings and some dyadic and small group dialogue sessions with 30 diverse young people. This necessitated my engagement in analyzing patterns across dialogue sessions. The Research Process Within the first phase of this study, I used methods of data collection from the fields of critical pedagogy (Friere, 1970; McLaren, 2001; Tones, 2005) and photovoice (Wallerstein,  48 1987; Wang, 1999; Wang & Burris, 1997; Wang, Kun Yi, Wen Tao, & Carovano, 1998) to explore young people’s lived experiences of their socio-economic environments and their recommendations for change oriented to supporting young people’s mental health. In the second phase of this study, I engaged in a meta-critical analysis of all data collected, including retrieved policy documents, to address the research objectives guiding this study. Phase I: Critical dialogue sessions and participatory documentary photography The first phase occurred over a period of 17 months and involved recruiting young people from diverse social locations to participate in two sets of dialogue sessions and participatory documentary photography. Recruitment for engagement in first dialogue session Informed by standpoint theory19 (Swigonski, 1994), I sought to engage diverse research participants to ensure that varied experiences of socio-economic processes were represented. Guided by previous empirical and analytic work exploring the nature of socio-economic status/class and social stratification (Berkman & Macintyre, 1997; Crompton & Scott, 2005; Devine & Savage, 2005; Liberatos, Link, & Kelsey, 1988; Lynch & Kaplan, 2000; Raphael et al., 2005) I sought diversity in level of income and perceived socio-economic status, employment status, levels of education, housing situation, as well as positioning in relation to ownership of capital/production systems and level of political voice/activism ranging from non-participation through to engagement in youth-led activist/advocacy organizations. Engagement of research participants and data collection occurred from July 2012 to December 2013. I utilized four approaches to invite young people between the ages of 13 and 30 to participate (Appendix A). First, I posted recruitment posters and brochures, which included links to Facebook and Twitter pages, along central city street bulletin boards (Appendix B).                                                 19 Having initially been informed by Marxist analysis of the conditions of the working classes, this term, “standpoint” is used within Feminist standpoint theory to enable analysis of the inter-relation of social locations and positions in society (Swigonski, 1994). Standpoint has been defined as “a position in society” (Swigonski, p. 390). I have used this term standpoint interchangeably with “position/positioning” to refer to one’s participation within socio-economic processes and the perspective that comes from this positioning.    49 Second, I emailed 24 community centres and six neighbourhood houses within the Vancouver catchment area requesting permission to post posters and brochures on their community bulletin boards and to be connected to their youth coordinators; I also offered to present the research project to youth groups. This resulted in presentations to two youth employment preparation programs for two neighbourhood houses and posters distributed to five community centres and one neighbourhood house, with one neighbourhood house distributing the brochures to their youth group. Third, I emailed, phoned and presented the project to various youth-serving non-profit organizations and left brochures to distribute to their members. This included: representatives of an agency offering supports to youth who were homeless; the youth engagement coordinator of provincially based child and youth mental health services located within Vancouver; two youth advisors for a provincially based child and youth mental health advocacy group who referred me to a university-based peer support group; a provincially based youth-led advocacy group focused on addressing social and environmental issues facing youth; the B.C. First Call Child and Youth Advocacy Coalition; and the Director of Clubs for the Boys and Girls Clubs of South Coast B.C. The contact from the service for youth who were homeless arranged for me to come and present on the project to their interested youth.20 Finally, at the end of each dialogue session, I gave brochures to research participants and offered them the option of inviting their friends or other young people whom they thought might be interested in participating. I also distributed brochures to a few young people I encountered on local transit and among my professional network of faculty and nursing students. This led me to offer presentations to two groups of young people at different community centres: an immigrant youth group and a youth leadership group. In determining inclusion criteria, I had initially extended the traditional upper age limit of 18 from previous definitions of youth/adolescence to 24 years of age. This decision was informed by the “widespread recognition as early as the 1970s that the timetable for growing up was slowing” (Furstenberg, 2008, p. 2). This has arisen from the extension of time in post-                                                20 I further discuss the steps I took to address the vulnerability that this group of youth face in the ethics section of this report.  50 secondary school, delays in leaving the parental home and delays in marriage and childbearing (Furstenburg) and with how the “developmental period from 12–25 years is characterized by multiple biological, neurodevelopmental, education and social transitions” (Hickie, 2011, p. 65). With feedback from the first group of young people to whom I had presented, and a couple of youth leaders and a member from the youth-led advocacy group, I learned that this upper limit of 24 years of age was too low. I learned that several Vancouver-based youth programs extended the upper age limit to 30 years of age, which for one program aligned with federal youth employment program guidelines offered through Service Canada. I followed their guidance and sought to recruit young people between the ages of 13 and 30. This enabled exploration of young people’s experiences within secondary and post-secondary educational programs and employment situations.  To optimize diversity, I invited young people to fill out an adapted demographic survey form from the National Longitudinal Survey of Children and Youth (Statistics Canada, 2009) at the start of their first dialogue session (Appendix C). After 12 young people had been recruited, two 4th-year Bachelor of Science in Nursing (B.Sc.N.) health promotion practicum students from Vancouver Community College joined me as research assistants. We collated the demographic profile of this initial sample and noted a lack of representation of young people who perceived their socio-economic status as being “somewhat above average” and “well above average” and those whose families owned their own homes. The research assistants thus distributed approximately 35 brochures to young people at cafes and convenience stores near private and public schools in the West side and South-West Vancouver to increase the likelihood of recruiting participants with greater economic resources. Introduction to research participants This recruitment process resulted in a sample of 30 diverse research participants between the ages of 15 and 28 years. Their self-identified gender included: 15 males, 14 females, one non-response.21 Participants reported various socio-economic experiences. I highlight some of                                                 21 Note that one non-response was due to my neglect to bring the demographic form to the dialogue session with one participant. I thus followed up via email to arrange to have the form filled out but this participant did not respond to my email.   51 these experiences here and refer the reader to Appendix D for information regarding participants’ level of personal and parental education, type of home ownership and length of residency. Participants also reported varying health- and wellness-related experiences and diverse self-identified ethnic backgrounds. Participants reported their family’s financial situation, as shown in Table 3.1. Table 3.1 Participants’ self-reported financial situation  Description  Number of responses Well above average 0 Somewhat above average 7 About average 13 Somewhat below average 4 Well below average 4 Response missing  2 Total 30 Your family has a hard time getting enough money for food, clothing, and basic living costs 4 Your family has just enough money for food, clothing and basic living costs 13 Your family has few problems buying what your family needs 4 Your family has no problem buying what your family needs and is able to buy special things 8 Response missing 1 Total 30 In relation to employment status, at the time of their participation 12 were employed and 17 were not, with one non-response. Within the previous 12 months there were 20 who had worked for pay, 8 had not with two non-responses. Three reported that they had run their own business in the past 12 months, 1 had indicated that they had “sold stuff on E-bay,” 1 indicated that they had “sort of” run their own business in the previous 12 months; 23 had not; and there were two non-responses. Among the 24 who identified when they had started working for pay the range was 10–25 years of age, with six working for pay at age 14 and under; 8 between the ages of 14 and 15; and the remaining 10 at age 16 or over. In relation to political participation, participants were asked if they had ever voted in an election. Eighteen had voted in school-related elections; of the 16 who were eligible to vote, two had voted municipally, 3 provincially, and five federally. When asked if they had ever  52 participated in a community-based decision-making process that influenced the participants’ life and that of other members in their neighbourhood/community, 13 indicated that they had, 15 indicated that they had not, and two made no response. Participants’ reported overall health status and wellbeing are shown in tables 3.2 and 3.3. Table 3.2 Participants’ self-reported health status Descriptor Number of responses Excellent 3 Very good 12 Good 8 Fair 5 Poor 1 Non-response  1 Total 30  Table 3.3 Participants’ overall wellbeing  Descriptor Number of responses Happy and interested in life 13 Somewhat happy 11 Somewhat unhappy 6 Unhappy with little interest in life 2 So unhappy that life is not worthwhile 0 Non-response 2 Total 30  Importantly, of those who indicated that they were “happy and interested in life”, two participants also indicated being “somewhat unhappy.” Of those indicating feeling “somewhat happy”, two indicated also being “somewhat unhappy.” More specifically, three participants indicated experiencing more than one category. One participant indicated experiencing: “happy and interested in life,” “somewhat happy” and “somewhat unhappy”; one participant indicated experiencing both “happy and interested in life” and “somewhat unhappy.” One participant selected both “somewhat happy” and “somewhat unhappy.” Overall, 17 indicated being somewhat happy, somewhat unhappy, or unhappy and 11 indicated being happy and interested in life with two nonresponses.  53 When asked if research participants had ever been formally diagnosed with a physical or mental health challenge, 11 indicated yes, 17 indicated no, 1 indicated that they did not know, and one did not respond. Of those who indicated that they had been diagnosed with a health challenge, they reported the following diagnoses: four reported that they had been diagnosed with depression; one reported a diagnosis of anxiety; one was diagnosed with dyslexia; and four participants indicated that they had been diagnosed with multiple health challenges. As listed by each participant, these multiple health challenges included: "scoliosis, chronic pain, depression and social anxiety"; “obsessive compulsive disorder, anxiety, attention deficit disorder-attention deficit hyperactivity disorder"; “dissociation, low blood pressure"; "attention deficit hyperactivity disorder, psychosis." Recruitment of participants within second dialogue session and participatory documentary photography I used the contact information provided by research participants in their informed consent forms to invite them to participate in a second dialogue session to provide feedback on my initial thematic analysis of the qualitative data. Of these 30 young people, 29 indicated an interest in meeting for a second dialogue session to provide feedback on the preliminary findings and to share more specific recommendations. Twenty-six young people (and one “maybe” depending on time) indicated interest in participating in the use of documentary photography to further explore young people’s experiences after the second dialogue sessions. After conducting an initial thematic analysis of the data, I followed up via email, text and phone calls (depending on participant’s preference) to invite the interested 29 young people to a second dialogue session. Of these, 14 young people engaged in the second dialogue sessions across 9 follow-up meetings. Two members responded to the email indicating their interest in learning about the findings via the use of Dropbox and suggested that they would like to share their feedback via email. I thus shared the findings via a Power Point presentation and narration of the preliminary themes via Dropbox with them and they participated that way. This resulted in a total of 16 young people who shared feedback on the initial findings across 9 interviews and two sets of email exchanges. For the remaining 13 young people who did not participate in the second dialogue sessions: 8 did not respond to my emails or phone calls and one person’s phone  54 number was out of service for a total of nine nonresponses. Three participants requested the preliminary findings via email/Dropbox, but did not respond to my email; 1 had moved and had also expressed interest to share feedback via email, but did not respond to my email. Finally, of the young people who participated in the second dialogue sessions, 11 expressed interest in the documentary photography process and ten joined individual or group training sessions in the use of photography as a data collection method (depending on their preference). One young person expressed interest but her family had moved to an outlying area of Vancouver and she did not feel comfortable commuting. Of the ten who participated in the training, 3 did not respond to follow-up texts/emails; 7 followed through with the documentary photography process. Consequently, 6 participants engaged in 5 dialogue sessions and one shared photos and feedback via email. Young people were given the choice of where to meet and I met them in coffee shops, community centres, neighbourhood houses, and their homes. I also gave young people the choice to meet individually or with peers in dialogue sessions in order to create safety in exploring diverse, and at times politically incorrect perspectives that might not be shared in a group context (Thorne, 2008). Collecting data to explore young people’s views and experiences: Dialogue sessions and participatory documentary photography In keeping with my methodology, I used a participatory approach to engage participants in sharing their reflections within the first phase of the data collection process. Within the first dialogue session, I asked seven open-ended questions (Fontana & Frey, 2005) (see Table 3.4) and used “generative words” (Freire cited in Crotty, 1998, p. 148), problem posing questions (Friere, 1970) and circular difference questions (from the field of family therapy) (Brown, 1997) to engage participants in reflecting on their experiences and to explore possibilities for promoting mental health from young people’s perspectives. According to Ollman (2003), Marx’s dialectical approach to inquiry entails starting with the whole, the system, or as much of it as one understands, and then proceeds to an examination of the part to see where it fits and how it functions, leading eventually to a fuller understanding of the whole. (p. 14)  55 I started by asking participants how they saw the world today and how the world as it is today affected them so that I could facilitate reflections upon their broader environments.22 This was important for being responsive to participants’ experiences, current needs and goals (Lather, 1986). I took the participants’ lead in this process. If there was an aspect of their socio-economic environment that was of central concern for them, I stayed focused on exploring that and only moved to the next questions if the participant felt that they had shared what they had wanted to in relation to that issue. With the use of generative words (Freire cited in Crotty, 1998), I then explored more specifically participants’ first thoughts and experiences associated with the notions of “mental health” and “socio-economics”, “socio-economic system” (or “money” if they did not know what socio-economics meant) in order to explore their meanings of these aspects of their lives, and their experiences of the relationship between their socio-economic environment and their mental health and wellbeing. Table 3.4 First dialogue questions As a lead into the dialogue, I asked: “Why are you interested in this project ‘Money and Young Minds’?” 1. How would you describe the world as it is today? 2. How does the world as it is today affect you? Your relationships with your friends/family/community? 3. What is “mental health”? 4. What is “socio-economics/socio-economic factors” “money”? 5. Do you think that there a relationship between “money”/“socio-economics” and youth mental health? If so, what is the relationship? How would you describe this relationship from your own experience? 6. How might we change the world/socio-economic environment to make it more supportive of young minds? 7. What recommendations do you have for mental health programs/supports in our community to address your concerns?   In order to explore participants’ recommendations for mental health promotion initiatives, I initially invited them to reflect on how they would change the world and socio-                                                22 I’d like to acknowledge that I learned about these open ended questions from a leadership training session that was lead by Deborah Littman, Lead Organizer from the Metro Vancouver Alliance in which they presented their approach to relational organizing based on Saul Alinsky’s work.   56 economic environment to make it more supportive of young minds. If they struggled, I asked them a miracle question, “if you had a magic wand and could change the world to make it more supportive of your mental health, how would you change it?” (Cited in Wright & Leahey, 2005). For those that struggled and in response to those that expressed fear that they would be “wrong” in their answers, I encouraged them to speak from their own personal experiences and perspectives and invited some of them to brainstorm ideas aloud. I later asked how the changes they recommended could be implemented. I then asked more specifically about how to promote young people’s mental health from both within and beyond our formal mental health system. If they struggled in answering this question, I shared my background as a children’s mental health nurse and previous research with young people that raised concerns for me about the influence of broader socio-economic factors such as income and poverty on young people’s mental health and wellbeing. I asked them to consider how mental health professionals and communities might work together in addressing these broader socio-economic factors and referred back to the concerns that each participant had identified in the earlier part of our meeting. For a guide to the small group dialogue sessions, which included a list of follow up (probing) questions that I prepared to support me in inviting research participants to reflect on aspects of their socio-economic environments in relation to their mental health, refer to Appendix E.23 After completing the first dialogue sessions, I conducted a preliminary qualitative analysis of participants’ critical reflections and presented these initial findings to 16 participants in the second dialogue sessions. I used power point to present the preliminary themes and read quotes that coincided with preliminary themes. This presentation included: young people’s reflections on aspects of socio-economic life that they described generally and in relation to their mental health; the initial themes pertaining to socio-economic needs for young people’s mental health; and participants’ recommendations for improving their “world” and socio-economic environment and promoting young people’s mental health and wellbeing. I then asked participants to reflect on what aspects of socio-economic life affected them most and to elaborate on how these aspects affected their mental health and wellbeing and whether they had any further recommendations. If they struggled to share ideas that addressed challenging socio-                                                23 I also used these probing questions for individual meetings with participants  57 economic dynamics, I engaged more interactively with them and shared recommendations that were made by fellow research participants and two examples of economic and labour policy options for their consideration.24 These policy options included a guaranteed annual income policy to address their expressed need to have their basic needs met (e.g. food, housing) and the example of cooperatively run businesses as an option in addressing their need for greater control over their work activities. Posing these examples evoked critical reflection and, at times, lively debate both within each dialogue session and across dialogue sessions as participants responded to the reflections of other participants that I had shared from the preliminary thematic analysis. I then engaged participants in analyzing “where the agency lies” (Harvey, 1996) to consider ways of fostering social change that could address their recommendations. This entailed exploring their views and experiences of barriers and supports to their own agency and broader change oriented to addressing their concerns and recommendations. Research participants looked at the PowerPoint slide of aspects of their socio-economic environment that were identified within the first dialogue sessions.25 They then reflected on what aspects of the system they thought would produce the greatest potential for systemic change and shared their thoughts on how to facilitate this change. I concluded by asking if they had any other general recommendations and then invited them to join a participatory documentary photography process to further explore their experiences in their day-to-day lives.  Within my use of documentary photography as a method of photo-elicitation, I applied methods from photovoice, which has been used to engage young people in participatory inquiry in previous studies. Photovoice is a participatory action research method developed by Carolyn Wang and colleagues in order to engage community members in visually documenting and analyzing assets and barriers to health with the aim of addressing determinants of health                                                 24 Note that an exception to this practice occurred for the young people who preferred to have the findings presented to them via Drop Box. For those participants I audio-recorded my presentation to them in which I read key quotes alongside the preliminary themes that were presented in the power point slides. I also mentioned the GAI and cooperative economic policy as examples of policies oriented to changing socio-economic processes.  25 Moments of socio-economic life that were presented in a series of thought bubbles in the power point slide included: social relationships including class/status (i.e. “rich” “poor” people); societal progress; neighborhood; community services (E.g. education, health, transportation); resources (food, housing); media and advertising; employment, jobs, income; economic system; impact of economic system on societal values; government and policies; pace of change; technology.   58 (Wallerstein, 1987; Wang, 1999; Wang & Burris, 1997; Wang et al., 1998). Photovoice extends Paulo Freire’s method of problem-posing education by inviting community members to use photography to document, interpret and present their surrounding environment (Strack, Magill, & McDonagh, 2004; Wang & Burris, 1997). I started by engaging participants in photovoice training sessions where I provided an overview of the consent process, basics of camera operation, and safety issues in taking photographs in the community setting.26 Within the photovoice training sessions I posed the open-ended questions from the first dialogue sessions and invited research participants to use cameras to take photos within their own day-to-day lives in order to further explore these questions and anything else they wanted to photograph.27 Participants were given note pads and offered the option of making notes of what they were aiming to depict in taking their photos and then engaged in a follow-up meeting to share their photos. I adapted the SHOWD tool from Wallerstein’s (1987) further development of this participatory data analysis tool for youth that was originally developed by Wang et al. (1998). When exploring photos with participants, I asked them to reflect on the following questions: • S=What do you SEE in your picture? (What is happening in this picture? What stands out the most for you in this photo?) • HO=HOW does this help us to understand young people’s mental health and what affects young people’s mental health? • W=WHY does this situation, concern or strength exist? (if appropriate) • D=What can we DO about it? Do you have further recommendations for supporting young people’s mental health in our community? I held five dialogue sessions with six young people, and one participant who shared photos and reflections via email for a total of seven responses. In sum, 22 initial dialogue sessions were held with 30 young people in a mixture of individual, dyadic and small group sessions. For the second dialogue sessions, 16 young people participated to further explore the initial findings from the first interviews and provided feedback across 9 follow-up meetings and two emails. I then engaged 7 of these young people to further                                                 26 I describe this process in more depth in the ethical considerations section of this report.  27 A more detailed description of this process is offered in the ethical considerations section of this report.  59 explore their experiences through the use of photovoice. All meetings were audio-recorded and professionally transcribed to support data analysis. I reviewed all transcripts alongside audio-recordings in order to ensure accuracy of transcription.         Figure 3.1 Dialogue sessions sequence. Data analysis Upon completion of the first dialogue sessions with 30 young people, I conducted a qualitative analysis of participants’ reflections. Drawing on Thorne’s (2008) overview of qualitative data analysis, I explored patterns within each individual transcript and across transcripts of dialogue sessions as a whole. I started by synthesizing the common and divergent patterns across dialogue session transcripts. This included developing a MSWord document and categorizing patterns and themes that were similar. I then conducted a second analysis with the use of HyperResearch software (Researchware) and specifically sought to explore contrasting and divergent themes compared to the initial themes I had identified. While doing so, I kept memos of potential themes, while also highlighting exemplar and contrasting perspectives. I also noted questions that came up for me in terms of understanding the relationships between the First Dialogues:  22 meetings with 30 young people Second Dialogues: 9 meetings and 2 emails with 16 young people Photo Dialogues:  5 meetings with 6 young people 1 email from one young Photovoice training with 10  60 ideas and experiences that young people were sharing in relation to the research objectives guiding this study. I presented themes from this initial qualitative analysis to research participants in the second dialogue sessions. Phase II: Meta-critical analysis of young people’s critical reflections in relation to mental health policy documents  In order to address the research objectives guiding this study, I compared insights gained from the first phase of this study to two sets of provincial mental health policy documents that were developed to guide mental health promotion across the full continuum of care in British Columbia. I assumed that these policy documents would reflect dominant (privileged) understandings and practices in addressing mental health. Data collection: Retrieval of B.C. Mental health policy documents The policy documents included first, the B.C. 10-Year Mental Health and Substance Use Plan and second, the Core Public Health Functions for B.C. Model Core Program Paper: Mental Health Promotion and Mental Disorders Prevention. In order to consider how socio-economic determinants of health were addressed within this goal of mental health promotion and mental disorders prevention, I also reviewed the main objectives and outcome indicators of inter-related core public health goals and programs within B.C.’s Guiding Framework for Public Health (BC Ministry of Health, 2013). The B.C. 10-Year Mental Health and Substance Use Plan policy was developed by the B.C. Ministry of Health Services and the B.C. Ministry of Children and Family Development to guide the development and implementation of mental health and substance use programs, services and initiatives in British Columbia (B.C. Ministry of Health Services (BCMHS) & B.C. Ministry of Children and Family Development (BCMCFD), 2010). One of the stated goals of this policy document is to expand the previously dominant focus on treatment of mental illness to include a focus on upstream approaches that focus on mental health promotion and prevention programs (BCMHS & BCMCFD, 2010). A previously developed 5-year child and youth mental health plan in 2003 (BCMCFD, 2003) has been integrated within and updated within this 10-Year plan.  61 Included within this plan is also guidance from the Core Public Health Functions for B.C. Model Core Program Paper: Mental Health Promotion and Mental Disorders Prevention. This core public health functions document was developed by the B.C. Health Authorities (BCHA) and (then) B.C. Healthy Living and Sport (BCMHLS) (now Ministry of Health) to guide the development of core public health functions focused on prevention of mental illness and promotion of mental health as part of the broader Core Public Health Functions process across the province (BCHA & BCMHLS, 2009). This document is framed as a vision for future mental health prevention and promotion based on current evidence. Within this document it is recognized that not all of the stated plans will have been implemented. The goal of the document is to guide development of a performance improvement process to “move the public health system in B.C. towards evidence-based best practice” in mental health promotion and prevention (BCHA & BCMHLS, 2009, preamble). This goal is part of seven core public health goals within the B.C. Framework for Public Health (B.C. Ministry of Health, 2013). There have been three follow-up reports on the 10-Year mental health and substance use plan, two in 2011 and one in 2012 reporting on the programs, services, and initiatives that have been implemented from proposed plans. The following B.C. mental health policy documents were thus retrieved for analysis: 1. Healthy Minds, Healthy People A Ten-Year Plan to Address Mental Health and  Substance Use in British Columbia (BCMHS & BCMCFD, 2010) and follow-up reports: • Healthy Minds, Healthy People A Ten-Year Plan to address Mental Health and Substance Use in British Columbia Monitoring Progress First Annual Report 2011 (BCMHS & BCMCFD, 2011a) • Healthy Minds, Healthy People A Ten-Year Plan to address Mental Health and Substance Use in British Columbia Monitoring Progress First Annual Report 2011 Supplementary Document (BCMHS & BCMCFD, 2011b) • Healthy Minds, Healthy People A Ten-Year Plan to address Mental Health and Substance Use in British Columbia Monitoring Progress 2012 Annual Report (BCMHS & BCMCFD, 2012)  62 2. Core Public Health Functions for B.C. Model Core Program Paper: Mental Health Promotion and Mental Disorders Prevention (BCHA & BCMHLS, 2009). This includes a report on school health promotion (Morrison & Kirby, 2010) and inter-related core public health program documents. I reviewed the core mental health promotion and mental disorders prevention document in depth pertaining to the data analysis plan. I reviewed inter-related public health functions documents specifically in relation to how social determinants of health were taken up within these documents:  • Promote, Protect, Prevent: Our Health Begins Here (B.C. Ministry of Health, 2013) • Model Core Program Paper: Healthy Communities (BCHA & B.C. Ministry of Health, 2007) • Model Core Program Paper: Food Security (B.C. Ministry of Health, 2014) Data analysis I analyzed the data in two stages. As mentioned previously, upon completion of the first dialogue sessions with 30 young people, I completed a qualitative analysis of participants’ reflections. In the second phase, I engaged in a meta-critical analysis of all data (demographic data, transcripts from first and second dialogue sessions, photo-elicitation data, and the two guiding B.C. mental health and substance use policy documents and the B.C. Framework for public health) with support of the ontological framework discussed earlier. In the first step of this second phase, I used thematic analysis and mind mapping to analyze transcripts from the first and second dialogue sessions and photo-elicitation meetings. In this process, I explored common and divergent patterns in the ways that participants described the relationship between “money/socio-economics” and “mental health.” I considered the ways that young people were being positioned, as well as positioning themselves, within socio-economic processes to meet their mental health needs. This attention to needs was important in identifying the ways that socio-economic dynamics faced by young people within their socio-economic environments contradicted their mental health needs (Lefebvre, 1969). During analysis of participants’ recommendations for change and their critical reflections on barriers and supports to change, I both recognized their capacity to identify needs and goals for informing future action and the importance of analyzing how dominant ideas may be  63 influencing their recommendations. For example, participants’ reflections on the relationship between their socio-economic environments and their mental health underscored several mental health needs such as the need for physical survival and the need for a secure future. One participant emphasized the importance of engaging young people in entrepreneurship as a way of promoting young people’s mental health. Analysis of how participants sought to meet their mental health needs showed, however, that private, individualistic production processes such as entrepreneurship contradicted participants’ needs in several core ways. For example, participants who pursued entrepreneurial activities in their attempts to seek income to access resources to enable their need for survival faced several barriers, such as the struggle to obtain start-up funds and the challenge of securing an ongoing income stream within free markets. More broadly, participants’ reflections showed how young people’s lives are situated within fundamentally insecure socio-economic processes that create several barriers not only to meeting their mental health needs, but also limiting their control over meeting their mental health needs in significant ways. This relational analysis enabled me to consider the influence of dominant ideas in relation to participants’ experiences and to develop insights into the potential role that nurses can play in supporting young people to address contradictory dynamics that constrain their mental health. To support this relational analysis of young people and their socio-economic environments and opportunities for change from young people’s perspectives I used the following analytic questions to guide my analysis of dialogue transcripts: • How do young people variously describe how socio-economic moments affect young people’s mental health? • How do young people variously describe how socio-economic moments constrain young people’s mental health? What dynamics within their socio-economic environments challenge their mental health needs? • How are young people positioned within the socio-economic processes that they have described? How are young people positioning themselves within these socio-economic processes in terms of enabling/promoting their own mental health and addressing their mental health needs?  64 • How does this positioning influence young people’s mental health? How does this positioning variously influence young people’s needs and their ability to meet their needs? • How do young people respond to their positioning? How do they seek to meet their mental health needs? • How are dominant ideas operating within young people’s reflections? What ways of understanding and promoting mental health are missing from participants’ reflections and my own attempt to capture patterns within their reflections? • What are participants’ recommendations for enabling young people’s mental health? What are their views regarding change that is supportive of young minds? What do these recommendations suggest about their needs and contradictory dynamics? • If there are contradictory dynamics operating, what are the opposing elements in these dynamics? What is the underlying common element and mutual dependency? How can this common element be used to inform change initiatives? • What are barriers/supports to young people’s action in meeting their mental health needs and change more broadly? • “Where’s the agency” (Harvey, 1996) in shifting contradictory dynamics in ways that could enable actualizing common needs across diverse social standpoints/positions? I then compared participants’ views to the ways that notions of mental health/promotion and socio-economic determinants of mental health were being taken up within the mental health policy documents. This subjecting of the notions of mental health/promotion and socio-economic determinants of mental health within the policy documents to the “scrutiny and rigorous audit based on real world experience” (Hill, 2009, p. 608) of study participants was important in revealing contradictory dynamics that exist between common sense truth claims and dominant ways of understanding mental health/promotion and young people’s mental health needs and experiences. Understanding these contradictory dynamics between dominant, common sense ideas and the realities of young people’s lives thus enabled deeper insights into the ways that mental health policies were being positioned in relation to recipients of mental health care and broader socio-economic processes and opportunities for change.  65 In order to support my close reading of the policy documents in relation to participants’ experiences, I drew guidance from elements of Gramscian rhetorical analysis (Zompetti, 1997, 2012) and critical rhetorical analysis (Winton, 2013) to explore discursive practices within the policy documents. Rhetorical analysis, as a form of critical policy analysis, provides a “method for identifying how arguments are constructed to persuade audiences to accept and support particular constructions of reality, truth and courses of action” (Winton, p. 161). Aligned with the philosophy of praxis presented earlier, rhetorical analysis assumes that “knowledge of [discursive] strategies can be used to understand why particular policy solutions are supported by groups with conflicting goals and values, to question the version of reality proposed by policy, to imagine other possibilities, and as grounds for political action” (Winton, p. 159). Exploration of discursive practices within these policies in relation to insights gained from the first phase of this study was important in showing the role and function of textual practices within these policies and, more broadly, how mental health policies and programs are positioned in relation to young people and young people’s socio-economic environments. The main focus of my close reading of the policy documents was to identify how dominant notions of mental health/promotion may limit possibilities for mental health promotion work oriented to enabling young people’s mental health needs within this current socio-economic environment. More specifically, in applying this process of auditing the dominant ideas within the policy documents in relation to insights gained from the first phase of this study, I extended the analysis of participants’ reflections with a close reading of the selected mental health policy documents. I started by drawing out key statements in relation to the definitions and conceptions of “mental health”, “socio-economic determinants of mental health”, and “mental health promotion” within goal statements and proposed programs and accountability criteria (performance targets and outcome indicators). I then thematized these statements to explore underlying assumptions. I compared insights gained from the first phase of this study and the analysis of all transcripts, to the ways notions of mental health/promotion and socio-economic determinants of mental health were being framed within the policy documents. I explored the ways that young people and these mental health policy documents were being positioned in relation to each other and to broader socio-economic processes. I explored how conceptions of mental health and approaches to addressing socio-economic determinants of mental health were being framed and normalized in  66 these documents and how discursive practices perpetuated dominant conceptions of mental health/promotion (Winton, 2013; Zompetti, 1997, 2012). In this process, I saw the mental health policy documents as potentially playing a role in perpetuating hegemony, which is defined as the process whereby consent is generated for dominant power relations through the use of images, representations and ideas that create a “common sense” that normalizes existing material and social relations (Zompetti, 2012). Key sites for these consent-building practices are socializing institutions such as education and mental health systems. To this end, I sought to analyze the commonsense and scientific ways that mental health/promotion is understood and abstracted within current policy in order to show the ways that mental health policy and practice both supports and/or glosses over and denies potentialities that exist for promoting mental health in young people’s day-to-day lives and broader socio-economic processes. I explored the ways that mental health promotion initiatives could build on insights gained about participants’ mental health needs and the contradictory dynamics they faced within their day-to-day lives. I also considered how mental health promotion initiatives could support young people in gaining greater control over the ways that moments of socio-economic life were challenging their mental health needs. I used the following analytic questions to guide this analysis: • What is the stated purpose of the mental health policy documents? • How is mental health defined? • How are outcomes evaluated? What are proposed accountability measures? • What is the positioning (function) of mental health policy in relation to socio-economic processes? • Within mental health policy: How are young people positioned within/in relation to mental health policy and programs? How are mental health policies positioned in relation to young people and their mental health? • What are proposed strategies for addressing socio-economic determinants of mental health? o How does mental health policy address young people’s socio-economic needs?  67 o How are constraints to young people’s mental health addressed within proposed strategies within the mental health policy documents? o How is mental health policy positioned in relation to these constraints to young people’s mental health and wellbeing? • If notions of mental health/promotion within the policy documents are limiting young people’s mental health needs, how are these notions maintained? How do discursive practices operate within mental health policies to maintain coherences/notions of mental health/maintain permanences that gloss over contradictions? • What are possible opportunities for mental health promotion initiatives to be developed in ways that: o support young people in gaining increased influence and control over aspects of their socio-economic environment that affect their mental health? o address aspects of socio-economic life that young people identified as constraining their mental health and wellbeing? o seize opportunities for shifting contradictory dynamics within young people’s socio-economic environments in ways that could enable actualizing young people’s socio-economic needs? With the use of these analytic questions, I used a mixture of a second-level thematic analysis with the use of HyperResearch software and mind mapping to explore themes and relational dynamics. I did not analyze the photos that young people took in the photovoice process and used them primarily as a way of engaging young people to reflect on their experiences. Conceptual terms used for presenting findings from phases I and II of data analysis In alignment with the historical-dialectical ontology within this praxis-oriented approach to inquiry and in order to support my presentation of the findings from this study, I use a few key terms to highlight relational dynamics explored in both phases of data analysis. I use the notion “material dynamics” to refer to the more structured social processes and practices, including the  68 material outcomes of these processes that participants described experiencing such as forms of production and distribution of resources, including technologies and commodities. I use the notion “social dynamics” to refer to the social positions and patterns of social relations that participants described experiencing, assuming, and observing within their communities; this included relational patterns such as socio-economic inequities, competition, individualism, and social distrust. This also included the ways that participants were being positioned (e.g. as students, consumers) and positioning themselves (e.g. as political consumers). At times, I use the notion “ideological” to bring an explicit focus and attention to dominant ideas, systems of meanings, and social norms that were reflected within participant reflections and the policy documents. Furthermore, I used the notion “dynamic” to refer to the social, ideological and/or material forms, as reflected in existing practices and processes, that were evident within participant descriptions of their experiences of the relationships among aspects of their socio-economic environments and their own and fellow young people’s mental health. Data quality: Validity criteria for judging the quality of agentic knowledge produced from this study As mentioned previously, this analysis and approach to inquiry was not intended to produce truth claims about a world that is assumed to be external to an observer. The intention was to identify a constellation of insights and potential actions that contribute to an ongoing social praxis that is oriented to co-creating healthy environments for young people’s mental health, with particular attention to the role of mental health promotion initiatives in this process. As I have argued previously, in light of the dominant approaches to promoting mental health at the individual and interpersonal levels and despite the attention that studies of the views of youth and other recent studies have brought to the importance of broader socio-economic factors, there were two central aims of this study. The first aim was to explore young people’s experiences of the ways that their socio-economic environments affect their mental health from a more open-ended perspective (compared to the dominance of quantitative methods used in previous studies). The second aim was to critically examine young people’s experiences in relation to the ways that notions of mental health/promotion and socio-economic determinants of mental health are taken up in two sets of provincial policy documents—as public statements that I assumed reflect dominant meanings of mental health and current accepted practices for promoting mental health.  69 My intention in doing so was to generate emancipatory knowledge in terms of liberating young people and their allies from “dependencies on myth, superstition, custom, tradition, ideology and irrationality” (Kemmis, 2010, p. 12) that could be operating within these current ways of understanding and living mental health/promotion. This included seeking to open up possibilities for addressing the ways that socio-economic dynamics are constraining young people’s mental health and wellbeing within mental health promotion initiatives. In recognition of the embeddedness of this research process within complex relational and ideational dynamics, and the impossibility of separating myself and the research participants from the public and common languaging systems of which we are an inter-related part (Habermas cited in Kemmis, 2010) and thus the necessity of immanent critique (Adorno cited in Crotty, 1998), I engaged in reflexivity within all stages of this research project. To enable judgment as to the relevance of theoretical insights from this study to young peoples’ lives and opportunities for youth mental health promotion initiatives, I applied process and outcome validity (Anderson & Herr, 1999; Oolbekkink-Marchand, van der Steen, & Nijveldt, 2014). This was important to enable future users of this research to deconstruct the process of knowledge production within this study and to judge the relevance of findings from this study for diverse contexts and settings. It was also important to enable future users of this research to take insights from this study to inform responsive praxis-oriented mental health promotion in other contexts. Reflexivity To address the ways that settling too quickly on potentially narrow abstractions could limit alternative understandings of social relations and possibilities for social change (Ollman, 2003), I sought to bring an ongoing reflexivity to the ways that prior concepts and categories could obscure my evolving understanding in this study. Reflexivity is an approach within the field of critical qualitative research that has been variously defined (Pillow, 2003). I have taken reflexivity to refer to “a deconstructive exercise for locating the intersections of author, other, text and world and for penetrating” the inquiry process itself (Macbeth, 2001 quoted in Pillow, p. 179). I have further taken representation to refer to the process of knowledge production in which new meaning and ways of understanding are rendered through the use of language (Cloyes, 2006).  70 Reflexive practices have been used to foster the validity and legitimacy of knowledge produced and to account for how researchers interact with and impact the research process (Pillow, 2003). Various methods have been used such as reflexive journaling or field notes, forms of textual reflexivity (e.g. questioning voice in text, using different writing and representational styles such as play, literary story or multivoiced text where no interpretations are privileged and the research text remains open-ended), and the use of participatory engagement of research participants within all stages of the research process (to validate the “truth” claims of researchers) (Pillow). In her review of previous approaches to the use of reflexivity in critical qualitative research, Pillow identifies two limitations. The first of these limitations relates to the complexity of the subject, including varying levels of conscious awareness of one’s assumptions, and in turn the challenges in gaining awareness of the researcher’s assumptions. Second, Pillow questions the ways that research participants are engaged in all phases of the research process to ensure adequate representation of research participants’ voices (as an attempt at ensuring validity). She argues that these forms of “member checking” practices can at times further entrench power dynamics where research participants in reality are used to legitimize, reassure, affirm and validate the researcher’s position and thereby solidify the power of the researcher and “truth claims” in the knowledge development process. Pillow (2003) advises against giving up on reflexivity altogether or allowing a kind of “paralyzed reflexivity” (cited p. 187) and recommends the importance of engaging in “reflexivities of discomfort” (p. 187). This formed a key way of positioning myself and this research in a politics of uncertainty to ensure that the constellation of ideas and proposed practices that have come from this study are accountable to “complexity and multiplicity, becoming and difference” (Lather, 2012, p. 1024). I engaged in reflexivity, or mindfulness awareness, intrapersonally and interpersonally (Hartrick-Doane & Varcoe, 2015) in the moments of my interactions with research participants and within the data analysis process. As I interacted with young people in the dialogue sessions, I strove to pay attention to my positioning as a child and youth mental health nurse, nurse educator, and researcher committed to social and environmental justice and equity. I sought to attend to my way of relating with participants. This included attending to my assumptions and first impressions in meeting participants and how my way of being was influencing their engagement in the dialogue sessions. I invited the participants to join me in this reflexive space. For example, I was transparent about my intention in wanting to understand their personal  71 experiences and perspectives. I shared this as my rationale for not sharing my views on the open-ended questions that I posed to them in the first dialogue sessions. When participants shared that they did not have “expertise” or know much about the questions I had asked them, I told them that from my perspective there was not a “right answer” and that my main curiosity was in learning more about their personal experiences in relation to the research questions.  When I was analyzing the research data, I engaged in mindfulness awareness and used reflexive notes to increase my awareness of what hypotheses and assumptions I was making.  While recognizing the impossibility of full awareness of all of my working assumptions, this was important in striving to guard against imposing prior theoretical assumptions on the data (Lather, 1986). Within my reflexive notes, I noted questions that arose for me, and noted aspects of the data that challenged my analysis to increase awareness of my evolving assumptions. I also used mind maps to explore the relationships within the data. I kept iterations of the drafts of my analysis to increase awareness of my evolving working assumptions and