The relationship between shift-work, sleep and mental health among Paramedics in Australia and Saudi Arabia A thesis submitted in fulfillment of the degree of Doctor of Philosophy Wahaj Anwar A. Khan BSc, (Medical Sciences, Umm Al-Qura University) MSc, (Occupational and Environmental Health, Monash University) School of Health and Biomedical Sciences College of Science, Engineering and Health RMIT University July 2020 Declaration I certify that except where due acknowledgement has been made, the work is that of the author alone; the work has not been submitted previously, in whole or in part, to qualify for any other academic award; the content of the thesis is the result of work which has been carried out since the official commencement date of the approved research program; any editorial work, paid or unpaid, carried out by a third party is acknowledged; and, ethics procedures and guidelines have been followed. _________________________ Wahaj Anwar A. Khan 10/07/2020 ii Publications/Manuscripts that have arisen as a direct result of this thesis: (1) Khan, Conduit, Kennedy, & Jackson. (2020). The Relationship Between Shift- work, Sleep and Mental Health Among Paramedics in Australia. Sleep Health, Journal of The National Sleep Foundation. https://www.sciencedirect.com/science/article/abs/pii/S2352721819302645?cas a_token=5doYlmAgDO4AAAAA:XAHQcCtUowSTw1-F7gfaKxxd1- EMjSw3oSdedIGly5N-OfTmpyyzeeLqBELbqTE4MFV1fvv4D8NX (2) Khan, W.A.A.; Conduit, R.; Kennedy, G.A.; Abdullah Alslamah, A.; Ahmad Alsuwayeh, M.; Jackson, M.L. Sleep and Mental Health among Paramedics from Australia and Saudi Arabia: A Comparison Study. Clocks & Sleep 2020, 2, 246-257. https://dx.doi.org/10.3390/clockssleep2020019 Manuscripts accepted pending minor revisions: (3) Khan, W., Conduit, R., Kennedy, G. A., & Jackson, M. L. The effect of rotating shift schedules on sleep, mental health and physical activity of Australian paramedics: a field study. Submitted in April 2020, Scientific Reports – Nature. iii Conference abstracts that have arisen as a direct result of this thesis: (1) Khan, W., Jackson, M., Conduit, R., & Kennedy, G. The effect of rotating shift schedules on sleep, mood, and stress of Australian paramedics: A field study. Abstract presented as an oral presentation in Australasian Chronobiology Society Annual Meeting, Sydney, 2019. (2) Khan, W., Jackson, M., Conduit, R., & Kennedy, G. The effect of rotating shift on sleep, mood, and stress of Australian paramedics: A field study. Journal of Sleep Research, 28: e133_12913. doi:10.1111/jsr.133_12913 Abstract published and presented as a poster discussion in Australasian Sleep Association Sleep DownUnder, Sydney, 2019. (Travel award). (3) Khan, W., Jackson, M., Conduit, R., & Kennedy, G. The effect of rotating shift schedules on sleep, mood, stress, energy expenditure and physical activity of Australian paramedics: a field study. Abstract presented as a poster in World Sleep Conference, Vancouver, 2019. (4) Khan, W., Jackson, M., Conduit, R., Kennedy, G. The effect of shift-work and sleep disorders on the mental health of Victorian paramedics. Abstract presented as an oral presentation in Sleep and Brain Health Symposium, RMIT University, Melbourne, 2018. (5) Khan, W., Jackson, M., Conduit, R., &Kennedy, G. The relationship between Chronotype and sleep, mental health, and well-being in paramedics. Abstract iv presented as an oral presentation in Australasian Chronobiology Society Annual Meeting, Brisbane, 2018. (Travel award). (6) Khan, W, Jackson, M., Conduit, R., & Kennedy, G. The effect of shift-work and sleep disorders on the mental health of Victorian paramedics. Journal of Sleep Research, 27: e63_12766. doi:10.1111/jsr.63_12766 Abstract published and presented as poster in Australasian Sleep Association Sleep DownUnder, Brisbane, 2018. v Acknowledgements This work could not be completed without the guidance, support, and encouragement of many. A very special and big thanks to my supervisors, Melinda Jackson, Russell Conduit and Gerard Kennedy for their extraordinary support and guidance inside and outside the academic life. I greatly appreciate their understanding, handling and patience to me as an international student, especially during the first few months of my candidature. Also, their amazing support and help throughout my candidature, and during final months leading to submission. Together, they played a crucial role in the development of my research skills and I will be forever grateful for that and for everything they taught me. I also could not have completed my study without the love and the support of my family. To my mother, wife, kids, brothers and sister, thank you very much for your endless support throughout my study. It was a very long journey, and I am really grateful for everything you have done for me. To my father, a great and wise man, thank you for everything. A very special thanks to my friends Prerna, Hailey, Ridwan, Hasan, Bader, Baraa, Adib, Ahmad, M. Shah, M. Refae, and Rakan; your help, understanding and support throughout my study were very important to me and helped me to keep going. To RMIT, especially the discipline of psychology, thank you for your enthusiasm and cooperation throughout the duration of my candidature. Also, a very special thanks to Ambulance Employee Victoria Australia (AEVA) and Saudi Red Crescent Authority (SRCA) for allowing me to conduct my research and to collect data from their paramedics and for their amazing cooperation. vi Finally, to my great country Saudi Arabia, to my employer Umm Al-Qura University and to the Saudi Arabia Cultural Mission in Australia, thank you very much for your support, help and for giving me this opportunity to pursue my dreams. vii Table of contents Declaration .............................................................................................................. ii Publications/Manuscripts that have arisen as a direct result of this thesis: ............. iii Conference abstracts that have arisen as a direct result of this thesis: ................. iv Acknowledgements ................................................................................................ vi Table of contents ................................................................................................... viii List of Tables .......................................................................................................... xi List of figures .......................................................................................................... xii Glossary of Abbreviations ...................................................................................... xiii Abstract ................................................................................................................. 15 Chapter One : Literature review ............................................................................. 17 1.1 Paramedics ...................................................................................................... 17 1.2 Impact of night-shift and rotating shift on health and safety ............................ 18 1.3 Sleep and circadian rhythm ............................................................................. 20 1.4 Rotating shift work and recovery ..................................................................... 21 1.5 Mental health and sleep in paramedics ........................................................... 22 1.6 Mental health ................................................................................................... 23 1.6.1 Stress .................................................................................................................... 23 1.6.2 Anxiety .......................................................................................................... 27 1.6.3 Depression ............................................................................................................ 27 1.6.4 Post-traumatic stress disorder ............................................................................... 28 1.7 Occupational Suicide ....................................................................................... 28 1.8 Shift work and sleep disorders ........................................................................ 30 1.8.1 Shift work disorder (SWD) ..................................................................................... 31 1.8.2 Insomnia ................................................................................................................ 32 1.8.3 Obstructive sleep apnoea (OSA) ........................................................................... 33 1.8.4 Parasomnia ........................................................................................................... 34 1.8.5 Narcolepsy ............................................................................................................ 34 1.9 Chronotype ...................................................................................................... 35 1.10 Objective sleep measures ............................................................................. 36 1.11 Sleep and mental health ................................................................................ 37 1.12 Paramedics from Saudi Arabia ...................................................................... 38 1.13 Accidents and work-related injuries ............................................................... 40 1.14 The hierarchy of controls ..............................................................................