Search

This article discusses some implications of working supportively with art and design students who manage mental health conditions in a postgraduate environment in a New Zealand University. The paper begins with a discussion of contesting research that considers relationships between highly creative thinkers and certain mental health conditions. It then proposes that, irrespective of arguments around correlations, supervisors are able to make a significant contribution to supporting candidates who combine autobiographically sourced knowledge with artistic inquiries into the experience of living with a mental health condition. In considering this proposition, the paper employs two case studies that illustrate certain strategies that proved useful when seeking to maximise the chances of successful and productive thesis completions. Working in tandem with wider institutional and therapeutic support, these strategies functioned alongside each candidate's research journey. Eight of these approaches are discussed in relation to a pedagogically responsive, informed and creatively supportive environment in which the students were able to develop complex and insightful research projects.

Since the evolution of the internet in 1969 and the inception of the personal computer in the early 1970s, a significant body of research has emerged that highlights the impacts of digital technology on education, health and human development. This paper reviews research in this area and examines the physical, mental, and social health effects on children and adolescents (10- to 19-year-olds), as well as the impacts of digital technology on educational achievements. The aim of this literature review, to examine the psychological impact of digital technology, was prompted in part by the widespread use of digital technologies in schools including Bring Your Own Device (BYOD) policies. BYOD asks students to bring personal laptop or iPad/tablet computers to school. Outcomes of this study may be surprising in the quantity of research available that provides red flag alerts. This fact alone will be of interest to school leaders as policy makers. There is a need for trustworthy information on which to base reviews and revisions of school policy to reduce the risks from the use of digital technology.

This rapid systematic review examined the reported effects of large-scale online education on the behaviour and, ultimately, practice of health and social care professionals. Electronic databases of health and education literature were searched, 193 unique records were screened against inclusion and exclusion criteria, 31 papers were accessed for full text reading and six were included. Identified studies reported primarily qualitative results, which were synthesised according to outcomes. Factors that contributed to the results were also identified. All papers reported that participation in e-learning programmes resulted in changes in behaviour and practice, including: increased awareness, changes in attitudes, improved communication, increased confidence and the actual changes applied in a workplace. Observed benefits of these programmes ranged from gaining new insights into own practice, through feeling empowered to apply changes, to eventually being able to provide more person-centred services and willing to adopt and spread a more humane evidence-based practice. While the current study is an early indication of the potential of large-scale online education to effect practice change, further research is recommended as is further in-depth investigation into how these changes are achieved and what factors contribute to success.

Consumer collaboration in mental health research has demonstrated significant benefits and reflects both contemporary research practice and policy goals for the expected genuine involvement of consumers in all aspects of mental health service delivery. Notable barriers have been identified as impeding consumer researcher positions that must be better understood and ultimately addressed. The aim of this research was to better understand these barriers from the perspectives of non-consumer researchers who have worked collegially with consumer researchers. We developed a self-report survey, Consumers as Researchers in Mental Health (CaRiMH) and administered it to non-consumer mental health researchers in Australia and New Zealand. Findings suggest a lack of organizational structures to support both consumer research and capacity building of consumer researchers. Most consumer researchers were employed casually with no set hours. Although consumer researchers were typically remunerated, inadequate funding and inflexibility of employment were highlighted as major barriers. There was variation in opinion about token involvement of consumer researchers and some uncertainty about whether these roles, where they existed, were actively resisted. Despite the acknowledged barriers, participants were positive about collaborations with consumer researchers. Overall, findings suggest consumer research is unlikely to proliferate without greater attention to organizational structures. A systematic and strategic approach to advancing mental health consumer research is required, including extra-organizational policy factors., (© 2020 Australian College of Mental Health Nurses Inc.)

This review aims to address the major sources of stress experienced by international students, the role of individual differences, the chronology of their stress levels and wellbeing over time, and gaps in the existing literature. Two electronic databases (PubMed and Psych Info) were searched for English peer-reviewed articles using eight search terms. Thirty-eight studies were included in this paper and divided into themes and sub-themes including sources of stress, individual differences and mental health including stress, depression and wellbeing. The findings highlight major stressors and show mixed results in some areas due to the lack of homogenous samples based on country of origin or ethnicity and sometimes context differences concerning the country or university social dynamics. Limitations were identified in the methodology, and several recommendations for future research are included.

Introduction Through a unique, inter-sectoral and interprofessional initiative, practitioners from education, health and social service sectors were invited to participate in communities of practice, facilitated online. The focus was on building workforce capacity to address the mental health needs of children and youth. Aim This paper explores interprofessional workforce development by translating knowledge from a mental health promotion initiative developed overseas into the Aotearoa New Zealand context. Methods Over a 6-month period, practitioners engaged in an iterative, capacity-building process, where they had access to the initiative materials and resources, shared practice stories, networked, and discussed barriers and facilitators for implementation. Qualitative thematic analysis was used to interpret data. Results Members of the communities of practice engaged in storytelling and made sense of the initiative in relation to their previous knowledge and experiences: practice and thinking were validated. Mental health promotion was positioned as the responsibility of all sectors and the need for effective interprofessional collaboration was deemed essential. Furthermore, translation of the initiative into the bicultural context of Aotearoa New Zealand demanded and deserved sustained attention. Discussion This study contributes interprofessional and inter-sectoral evidence for building workforce capacity to address the mental health needs of children and youth. Further research is warranted to investigate the outcomes for the children and youth served. Interprofessional communities of practice were shown to provide a sustainable mechanism by which knowledge can be received, transformed and translated into practice.

Purpose: The aim of this paper is to report the process, findings and implications of a three-year evaluation of integrated health centres (IHCs) established in three secondary schools in Cornwall by the School-Based Integrated Health Centres (SBIHC) partnership. Design/methodology/approach: When the partners had completed the capital works, an evaluation strategy was designed for 2009-2012 to identify the extent to which each of the IHCs was meeting the aims set for the IHCs, and each IHC and school was contributing to the aims of the SBIHC project. Formative and summative evaluation used annual case studies to apply data progressively regarding: the use, users and operations of each IHC; students' perceptions of the user-friendliness of the IHCs; indicators of the general health and well-being of students and their sexual and mental health; students' exposure to crime, substance abuse and poverty; and students' academic achievement, attendances and exclusions. This process culminated in this paper which reports and discusses findings, suggests implications for practice, theory and research and proposes future directions for the partnership. Findings: All three schools engaged students closely in the design and decoration of their IHCs. Student ownership was extended into the selection of Coordinators and into centre management and governance. Budehaven Community School appointed a National Health Service (NHS)-trained Coordinator for their IHC, The Haven, a mental health worker funded for one year by the NHS. After 2009-2010, his responsibilities were shared by the NHS-trained Receptionist and the Manager, an Assistant Headteacher. During Year 3, Budehaven added a "co-location" building, Kevren. About 37 professionals are now located in or visit The Haven and Kevren. Student footfall doubled to about 4,000 in the second year and increased by another 25 per cent in the third year. The wide range of general, mental and sexual health services were highly valued by the students. The Crayon, the IHC in Hayle Community School, achieved a similar footfall over three years. It started with a Receptionist and the Pupil Welfare Officer. The Manager, a Deputy Headteacher, and the Headteacher moving most student support services into the IHC at the end of Year 1. From then on the Crayon had three full-time professionals. By the end of Year 3, the Crayon had reached the limits of its facilities. A solely positive association was found between IHC usage and measured improvements to mental health and academic progress. The IHC in Penair School, Bywva, developed a wide range of general, sexual and mental health services, attracted a similarly strong footfall, and also reached capacity in Year 3. Penair refined their IHC's line management by an Assistant Headteacher and coordination by a Lead. Originality/value: This paper offers a new conceptual model of the SBIHC model of health care centred on the reciprocity and integrity of relationships between students and professionals. (Contains 4 notes, 1 figure, and 4 tables.)

As the availability of new communication technologies increases, mental health professionals have incorporated these innovations into their practice and research. Up to now several studies have presented promising results in using the power and convenience of the Internet for clinical care. While multiple contributions focus on the potential and the advantages of therapies delivered through the Internet, mental health practitioners may take into account new technological opportunities to improve their practice. Mobile phone diffusion is expanding worldwide at breath-taking speed. In fewer than 20 years, mobile phones have gone from being rare and expensive pieces of equipment used primarily by the business elite, to a pervasive low-cost personal item. In many countries, mobile phones now outnumber land-line telephones, with most adults and many children now owning mobile phones. With high levels of mobile telephone penetration, a mobile culture has evolved, where the phone becomes a key social and cultural tool. The purpose of this paper is to explore the potentialities that mobile phones may offer in clinical care. The paper will investigate in which areas of clinical interventions mobile phones have already been successfully applied. Moreover, the paper will discuss these opportunities by presenting the results of two different studies based on the use of the mobile phone for anxiety management. (Contains 2 tables and 4 figures.)

This paper discusses the need for multi-cultural methodologies that develop knowledge about the maternity experience of migrant women and that are attuned to womens maternity-related requirements under multi-cultural conditions. Little is known about the transition to parenthood for mothers in a new country, particularly when the country is New Zealand. This paper will challenge the positivist hegemony of previously completed research on migrant women by reflecting on my own experience as a researcher grounded in a broadly-based, pluralistic set of critical epistemologies that allowed me to uncover the issues and contexts that impacted on the experience of migrant women. It concludes by proposing that, where research occurs with minority groups, multiple research strategies are incorporated in order to prevent the reproduction of deficiency discourses. (Contains 1 footnote.)

This paper examines the perspectives of secondary school students and staff about the extent to which young people's health rights are catered for at school. The United Nations Convention on the Rights of the Child and the concept of Health-Promoting Schools encourage the provision of healthy school environments. A postal survey of secondary schools in New Zealand elicited responses from 821 Year 11 (15-16 year olds) students and 438 staff in 107 schools. Most students and staff reported that sources of health advice were available at their schools, but only a minority of students saw these sources as accessible or trustworthy. In every area of health promotion, students saw information and advice as less accessible than staff did. Most staff and students identified mental health problems such as depression as a source of concern in schools, but only a quarter of students (compared to half of staff) thought that this topic was covered during classtime. Students in lower-income schools reported the school environment as slightly less healthy than did students in high-income schools. The paper concludes that schools and policy makers should seek the voices and opinions of young people in order to improve effectiveness in catering for health rights. (Contains 4 tables and 1 figure.)

This review aimed to inform a deeper understanding of the varied experiences of ageing in place for older adults in Australia and New Zealand. Ageing in place involves older adults remaining in their own home or community as they age rather than moving into residential care. Our focus was on how ageing in place relates to older adults' mental health, life satisfaction, wellbeing, and overall ability to adapt well to ageing. This paper followed PRISMA‐ScR guidelines. Of the initial 210 papers identified, 20 met inclusion criteria and were retained. Four key themes related to experiences of ageing in place and the skills and strategies utilised to age in place were extracted from these studies. Themes encompassed older adults' individual characteristics and strategies, their connections to community, their home environment, and the appropriateness of support and services. We conclude that ageing in place should not be considered a "one size fits all" approach to ageing. Policymakers, researchers, and governments should acknowledge that older adults are a diverse group. Future ageing policy should strive to accommodate all older adults regardless of their circumstances or ageing preferences and researchers should include older adults from diverse populations and circumstances. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement. [ABSTRACT FROM AUTHOR]

Introduction Body image dissatisfaction and its associated challenges have been related to poorer health outcomes among adolescents worldwide, including disordered eating behaviour, depression, and anxiety. However, current prevalence estimates of these issues in Aotearoa New Zealand or, relatedly, the estimates of positive attitudes and behaviours, such as intuitive eating and body appreciation are dated. Aim The primary aim of this paper was to provide updated estimates for a variety of constructs related to eating behaviours and body image, sourced from a diverse range of early adolescent participants. Methods For this report, a brief online survey was advertised to adolescents throughout Aotearoa New Zealand (n  = 893) via school and community noticeboards. Results Approximately one-in-three male participants and one-in-two female participants reported body image dissatisfaction. One in four participants reported clinically significant symptoms of depression and anxiety. Discussion Given such issues, there is clearly still much progress to be made in advancing positive health among early adolescents. Identifying potentially protective constructs such as intuitive eating and body appreciation may offer guidance into the best targets for prevention and early intervention.

The article comments on the primary papers from Te Rau Hinengaro, the New Zealand mental health survey. It states that there are more useful myths than scientific facts based on the eleven reports related to mental health survey and research. It mentions that mental illness is associated with much more over-reporting than under-reporting of treatment.

Background: The Unmind Index is a 26-item, 7-subscale measure of mental health and wellbeing designed for use on the Unmind digital workplace mental health platform. The Unmind Index was developed and validated in the UK but is used internationally. This paper reports further psychometric validation of this measure for use in USA, Australia, and New Zealand (ANZ)., Methods: Participants in four countries completed the Unmind Index and a battery of existing measures. In Study 1 (N = 770), we validated the Unmind Index separately in USA and in ANZ. In Study 2 (N = 600), we used multiple group confirmatory factor analysis to test the measurement invariance of the Unmind Index across the UK, USA, and ANZ., Results: Study 1 establishes the factor structure, reliability, convergent and discriminant validity, and measurement invariance by age and gender of the Unmind Index separately for USA and for ANZ. Study 2 further demonstrates measurement invariance across locations, and establishes benchmark scores by location, age, and gender., Conclusions: We conclude that the Unmind Index is valid and reliable as a measure of mental health and wellbeing in these locations., Competing Interests: Authors ET and HB are employees of and hold stock options in Unmind Ltd. Authors LS and BSL are employees of the University of Cambridge Psychometrics Centre, which received payment from Unmind Ltd for consultancy services delivered by the authors. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Travers et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This paper aims to examine the influence of Maori culture upon psychiatric service provision in Aotearoa/New Zealand and the implications of this for career counselling of people with experience of mental illness in Aotearoa/New Zealand. The research explored the experiences of a group of women in Aotearoa/New Zealand who have been diagnosed with a psychiatric illness, with the aim of gaining some understanding about how they negotiate issues around diagnosis, recovery and resilience development and employment. The women interviewed for the study ranged in age from 17 to late 60s. They displayed academic ability ranging from literacy issues to postdoctoral experience. Their psychiatric illnesses ranged from single episodes to chronic lifetime conditions and from depression to psychotic bi-polar disorder. Their occupations ranged from unemployed status to an acting CEO. All but one of the women identified as Pakeha/tauiwi. One woman had Maori heritage but had been adopted at birth by Pakeha adoptive parents and had no knowledge of her Maori whakapapa [genealogy; descent lines; ancestry] until later in her adult life. The key idea that emerged was the importance of mentors in vocational settings, and the helpfulness of Maori-focused group and family wellness models for renegotiating vocational identity when suffering from a psychiatric illness. Implications for career practitioners are discussed. (Contains 7 notes.)

The impact of Maori identification on alcohol behaviour and mental health and has been neglected in the psychological literature. This paper consists of a review of literature on the history of alcohol use in New Zealand and its impact on indigenous Maori, on their cultural identity and on their mental health. Previous research has been primarily concerned with the benefits of strengthening Maori cultural identification when treating alcohol abuse. Prevalence rates of alcohol consumption, behaviour and attitudes amongst Maori have also been well established. However, none of these studies have addressed the relationship of Maori identification to alcohol behaviour. Research on the relationship between Maori identification and mental health is also scarce. Because there is little research on the associations among Maori identification, non-abusive alcohol behaviour and mental health, further research in this area would therefore contribute to an understanding of how Maori identification could impact on alcohol behaviour and mental health.

Access to, and delivery of, safe and culturally appropriate health services is increasingly important in New Zealand. This paper will focus on counting the costs of health advocacy through the experience of a small non government charitable organisation, the Health Advocates Trust, (HAT) which aimed to provide advocacy services for a wide range of different population groups, each with distinct but also similar health needs in the Auckland and Northland regions of New Zealand. The costs of advocating for a fair share of funding for the provision of health advocacy services for approximately a third of New Zealand's population and the legal journey and involved is discussed as well as the lessons those involved have learnt along the way. A focus is made on the importance of health advocacy to address the health needs of Maori, especially those in mental health services, specialist forensic services and those who are need of mental health care in prison.

Background: Indigenous children living in high income countries have a consistently high prevalence of mental health problems. We aimed to identify psychosocial risk and protective factors for mental health in this setting. Methods: A systematic review of studies published between 1996 and 2016 that quantitatively evaluated the association between psychosocial variables and mental health among Indigenous children living in high income countries was conducted. Psychosocial variables were grouped into commonly occurring domains. Individual studies were judged to provide evidence for an association between a domain and either good mental health, poor mental health, or a negligible or inconsistent association. The overall quality of evidence across all studies for each domain was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) guidelines. Results: Forty-seven papers were eligible (mainland US 30 [64%], Canada 8 [17%], Australia 7 [15%], Hawaii 4 [9%]), including 58,218 participants aged 4-20 years. Most papers were cross-sectional (39, 83%) and measured negative mental health outcomes (41, 87%). Children's negative cohesion with their families and the presence of adverse events appeared the most reliable predictors of increased negative mental health outcomes. Children's substance use, experiences of discrimination, comorbid internalising symptoms, and negative parental behaviour also provided evidence of associations with negative mental health outcomes. Positive family and peer relationships, high self-esteem and optimism were associated with increased positive mental health outcomes. Conclusions: Quantitative research investigating Indigenous children's mental health is largely cross-sectional and focused upon negative outcomes. Indigenous children living in high income countries share many of the same risk and protective factors associated with mental health. The evidence linking children's familial environment, psychological traits, substance use and experiences of discrimination with mental health outcomes highlights key targets for more concerted efforts to develop initiatives to improve the mental health of Indigenous children. [ABSTRACT FROM AUTHOR]

Background: Primary healthcare services have principal responsibility for providing child and youth wellbeing and mental health services, but have lacked appropriate measurement instruments to assess the wellbeing of Indigenous children and youth or to evaluate the effectiveness of programs and services designed to meet their needs. This review assesses the availability and characteristics of measurement instruments that have been applied in primary healthcare services in Canada, Australia, New Zealand and the United States (CANZUS countries) to assess the wellbeing of Indigenous children and youth. Methods: Fifteen databases and 12 websites were searched in December 2017 and again in October 2021. Pre-defined search terms pertained to Indigenous children and youth, CANZUS country names, and wellbeing or mental health measures. PRISMA guidelines were followed, with eligibility criteria guiding screening of titles and abstracts, and selected full-text papers. Results are presented based on the characteristics of documented measurement instruments assessed according to five desirability criteria: development for Indigenous youth populations, adherence to relational strength-based constructs, administration by child and or youth self-report, reliability and validity, and usefulness for identifying wellbeing or risk levels. Results: Twenty-one publications were found that described the development and or use by primary healthcare services of 14 measurement instruments, employed across 30 applications. Four of the 14 measurement instruments were developed specifically for Indigenous youth populations, four focused solely on strength-based wellbeing concepts but none included all Indigenous wellbeing domains. Conclusion: There is a diversity of measurement instruments available, but few fit our desirability criteria. Although it is possible that we missed relevant papers and reports, this review clearly supports the need for further research to develop, refine or adapt instruments cross-culturally to measure the wellbeing of Indigenous children and youth. [ABSTRACT FROM AUTHOR]

This paper reports findings from the first stage of an anticipated four-stage research project investigating the effectiveness of teacher education in health education. Prior to receiving any teacher education in health education, pre-service teachers (student teachers) were surveyed for their experiences of secondary school health education, and their beliefs about and attitudes towards the subject. Data were collected from questionnaire surveys (n = 295) and focus group interviews (n = 61). Results showed that student teachers had more exposure to school health education than had been assumed and had more positive attitudes towards the subject area than indicated by other studies into school health education. Many reported having had sexuality education and drug and alcohol programmes, but these were commonly described in contexts of safety rules and risk avoidance behaviours. Participants had greater understanding of and more exposure to mental health education than had been predicted. Those aged 20 years and younger reported significantly greater exposure to a range of school health education topics than did those aged 21-30 years or 30+ years. This difference is attributed to the younger participants receiving health education based on the "Health and Physical Education in the New Zealand Curriculum", introduced into schools in 1999. (Contains 2 tables and 1 figure.)

In New Zealand, people receiving care from specialist mental health and addiction services experience poorer health outcomes compared to the general population. Māori (Indigenous) specialist mental health and addiction service users experience disproportionate inequities. This study aims to: (1) Describe and understand mental health staff perspectives on the quality of care delivered to specialist mental health and addiction service users in their service - including specifically for Māori; and (2) Identify areas staff report as opportunities for quality improvement. In 2020, Southern District Health Board (now Te Whatu Ora - Southern) mental health staff were invited to participate in a cross-sectional study assessing their perceptions of a range of service aspects. This paper presents quantitative and qualitative analyses about quality of care. Among the 319 staff who completed the questionnaire; 272 provided quality-of-care responses. Among these, 78% reported the quality of care delivered to service users as 'good' or 'excellent'; only 60% reported this for Māori service users. Participants identified individual, service and broader system level factors influencing the quality of care delivered to service users, including factors specific for Māori. This study has identified, for what appears to be the first time, empirical and concerning differences in staff ratings of the quality of care delivered to Māori and SMHAS users overall. Findings highlight the need for institutional and managerial prioritization of hauora Māori, and incorporating tikanga Māori and Te Tiriti into practice., (© 2023 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

Background: Mental health conditions often arise during adolescence, are multifaceted in aetiology, and may be related to the type of environment in which young people reside. This study used nationwide population-level data to investigate whether the environment a young person grows up in is associated with their mental health., Method: Data were extracted from the Integrated Data Infrastructure (IDI), a large nationwide research repository, for 917,211 young people (aged 10-24 years) including sociodemographic and mental health data (i.e. emotional, behavioural, substance problems, and self-harm). Environmental data were sourced from the nationwide area-based Healthy Location Index (HLI), which has comprehensive data on the location of several health-constraining (i.e. fast-food outlets) and health-promoting features (i.e. physical activity facilities). Environments were classified as: i) health-promoting, ii) health-constraining, or iii) neither. Associations between the HLI and mental health were investigated using multi-level mixed effects logistic regression modelling., Results: Overall, there was evidence of an association between the environment a young person resided in and their mental health. Young people residing in health-constraining environments had higher odds of any mental health condition (Adjusted Odds Ratio (AOR) = 1.020 [1.001, 1.040]) and any emotional condition (AOR = 1.037 [1.012, 1.062]). Young people residing in health-promoting environments had lower odds of substance problems (AOR = 0.950 [0.905, 0.997]). There were no significant effects of the environment on behavioural conditions., Conclusion: Our study utilises a large national sample of almost one million young people to confirm the importance of environmental determinants for mental health. It is possible that leverage points for improving the mental health of young people, and reducing the burden to the health system of mental health, can be sought in upstream environmental based interventions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: This paper seeks to extend research into the adult sequelae of childhood conduct problems by investigating the associations between conduct problems in middle childhood and psychosocial outcomes in adulthood. Method: Data were gathered during the course of a 25-year longitudinal study of a birth cohort of New Zealand young people. Information was collected on: a) parent and teacher reports of child conduct problems at ages 7, 8 and 9 years; b) measures of crime, substance use, mental health, sexual/partner relationships, education/employment; c) confounding factors, including childhood, family and educational characteristics. Results: There were statistically significant associations between childhood conduct problems from 7-9 years and risks of adverse outcomes across all domains of functioning. After control for confounding factors the associations between conduct problems and education/employment outcomes became statistically non-significant. Associations persisted for other outcomes (crime, substance dependence, mental health and sexual/partner relationships). Children in the most disturbed 5% of the cohort had rates of these outcomes that were between 1.5 and 19 times higher than rates for the least disturbed 50% of the cohort. The associations between conduct problems and adult outcomes were similar for males and females. Conclusions: Childhood conduct problems were associated with a wide range of adverse psychosocial outcomes (crime, substance use, mental health, sexual/partner relationships) even after control for confounding factors. The results reinforce the need for greater investment into interventions to address these problems.

Background: Early career medical professionals experience stress and burnout at higher levels than the wider community. Burnout can arise with competing demands of life and career, which is evident in early career development, where family planning can coincide with specialty training. General practice may be seen as a family friendly career option; however, few studies examine the experience of general practice trainees with stress and burnout and the impact that parenting has on their experience. This study aims to explore the experience of stress and burnout in general practice registrars and the exacerbating and protective factors, with a focus on the experiences of two groups of registrars, those that have children, and those that do not. Methods: A qualitative study was conducted with 14 participants, who were interviewed with questions exploring experiences of stress and burnout. Participants were grouped into those with children and those without children. The transcripts were thematically analysed. Results: Themes were identified as those that contributed to stress and burnout (such as time, financial concerns and isolation) and those factors that reduced stress and burnout (such as support from others and being respected and valued within the workplace). Parenting was identified as both a factor that could contribute to and reduce stress and burnout. Conclusions: Stress and burnout are important foci for future research and policy to ensure the sustainability of general practice. System based and individual focused policies, including individualising training to support parenting, are required to ensure that registrars are supported through their training years and beyond. General practice needs to work to increase recruitment of doctors, reduce early career burnout and to retain GPs in the long term. Early career medical professionals experience stress and burnout at higher levels than the wider community. General practice may have traditionally been seen as a family friendly career option, however, unfortunately it may be no longer. This paper examines the experience of GP trainees with stress and burnout and the impact that parenting has on their experience and looks at solutions to improve conditions for early to mid career GPs, and hopefully make general practice more attractive for future doctors. [ABSTRACT FROM AUTHOR]

Objectives: This paper synthesises critique from Māori patients with Bipolar Disorder (BD) and their whānau to identify barriers and propose changes to improve the structure and function of the New Zealand mental health system., Design: A qualitative Kaupapa Māori Research methodology was used. Twenty-four semi-structured interviews were completed with Māori patients with BD and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data., Results: Three key themes identified the impact of structural features of the New Zealand mental health system on health equity for Māori with BD. Themes involved the accessibility, delivery and scope of the current health system, and described how structural features influenced the quality, utility and availability of BD services for Māori patients and whānau. Structural barriers in the existing design, and potential changes to improve the accessibility, delivery and scope of BD services for Māori, were proposed including a redesign of operational, environmental, staffing, and navigation points (information, transition, fatigue) to better meet the needs of Māori with BD., Conclusion: A commitment to equity when implementing structural change is needed, including ongoing evaluation and refinement. This paper provides specific recommendations that should be considered in health service redesign to ensure the New Zealand mental health system meets the needs of Māori patients with BD and their whānau.

This article discusses some implications of working supportively with art and design students who manage mental health conditions in a postgraduate environment in a New Zealand University. The paper begins with a discussion of contesting research that considers relationships between highly creative thinkers and certain mental health conditions. It then proposes that, irrespective of arguments around correlations, supervisors are able to make a significant contribution to supporting candidates who combine autobiographically sourced knowledge with artistic inquiries into the experience of living with a mental health condition. In considering this proposition, the paper employs two case studies that illustrate certain strategies that proved useful when seeking to maximise the chances of successful and productive thesis completions. Working in tandem with wider institutional and therapeutic support, these strategies functioned alongside each candidate's research journey. Eight of these approaches are discussed in relation to a pedagogically responsive, informed and creatively supportive environment in which the students were able to develop complex and insightful research projects. [ABSTRACT FROM AUTHOR]

This article presents a description of a specific Indigenous research methodology, Kaupapa Māori Research (KMR), followed by a discussion of the potential contribution that KMR and other Indigenous frameworks make toward understanding and addressing widespread mental health inequities affecting the world's Indigenous peoples. The contribution of existing qualitative KMR to the fields of health and mental health in New Zealand is discussed, and innovative approaches employed within these studies will be outlined. This paper describes the utility of KMR methodology which informed the development of qualitative interviews and the adaptation of an analytic framework used to explore the impact of systems on the experiences of Māori (the Indigenous peoples of New Zealand) with bipolar disorder (BD). This paper adds to others published in this journal that describe the value, inherent innovation, and transformative potential of KMR methodologies to inform future qualitative research with Indigenous peoples and to enact systemic change. Transformation is achieved by privileging the voices of Māori describing their experiences of mental health systems; presenting their expert critique to those responsible for the design and delivery of mental health services; and ensuring equal weight is given to exploring the clinical, structural and organizational changes required to achieve health equity. It is proposed that this approach to research praxis is required to ensure that studies do not perpetuate institutional racism, which requires close adherence to Indigenous research priorities and partnership with Indigenous peoples in all steps of the research process. [ABSTRACT FROM AUTHOR]

As well as serving as a critic and conscience for societies, universities are elite sites of privilege which, at a surface level, are unlikely locations for health promotion interventions. This paper provides a critical review of the existing health promoting universities (HPU) approaches which is informed by health promotion values. It explores the silence in the global literature around issues of structural discrimination such as the sexism, homophobia and institutional racism that can thrive within university settings. The existing literature also reveals a very limited engagement about positive mental health or indigeneity. In response, this paper brings together these three factors—structural discrimination, mental health, and indigeneity—all of which the authors consider are criterial to health and its promotion. The authors introduce the New Zealand university landscape, in which there are eight Western universities and three whare wānanga (Māori universities), and, drawing on a survey of their Charters and other official statements, offer a moemoeā (vision or dream) of an HPU that addresses structural discrimination, is based on holistic conceptions of health, and is centred on indigenous worldviews and concerns. [ABSTRACT FROM AUTHOR]

The psychological wellbeing of Queer and Gender Diverse Young People (QGDYP) has received attention of late, and increasing research evidences much higher rates of psychological distress experienced by these groups, compared to their straight, cisgender counterparts. Far more limited is research exploring queer and gender diverse young people's own perspectives on their psychological wellbeing, an absence we address with the current study. We interviewed 21 queer or gender diverse 16–18-year-olds in Aotearoa New Zealand about their understandings of mental health and wellbeing. We took a critical realist thematic approach to analysis. This paper focuses on how participants made sense of their own distress. We explore and unpack three intersecting key themes around: 1) cisheterosexism, but not personally affected; 2) dismissal of QGDYP; and 3) validation and comfort in the biomedical model. We discuss the tensions of articulating these positions and (also) challenging cisheterosexism, and the implications for recognising and reducing the distress experienced by queer and gender diverse youth. We aim to inform policy and practice to support and ultimately improve psychological wellbeing for queer and gender diverse young people. [ABSTRACT FROM AUTHOR]

Globally, transgender people have been described as a highly marginalised population due to cisgenderism that delegitimises their gender identities and expressions. Despite robust evidence from many countries noting the association of discrimination and stigma for being transgender with heightened mental health risks, qualitative research that examines the nuances of mental health indicators using health equity frameworks has been scant both in Aotearoa/New Zealand and overseas. Using an inductive thematic approach, this paper analysed 222 open-text responses in the mental health section of the 2018 Counting Ourselves: Aotearoa New Zealand, Trans and Non-binary Health Survey. Our findings showed four overarching themes: gender-affirming healthcare, mental healthcare services and accessibility, gender minority stress, and self-affirmation and social support. Participants' narratives described pervasive gender minority stress experiences in gender-affirming and mental healthcare services, including unmet healthcare needs, lack of competency in healthcare delivery, and pathologisation of their genders. In social settings, our participants commonly reported discrimination and violence, although they also reported that self-affirmation strategies and social support offset the impacts of gender minority stress on their mental health. The current findings indicate the importance of exploring mental health outcomes for transgender people in relation to cisgenderism and resultant gender minority stress. [ABSTRACT FROM AUTHOR]

This paper describes development of a mobile e‐health application, Positively Pregnant, which provides tools to meet the psychological challenges of pregnancy and transition to parenthood. Positively Pregnant was developed with input from maternity carers and consumers, incorporating local cultures and contexts as well as international research on effective interventions for stress management and mental well‐being. The prototype app was piloted with 88 New Zealand women. Participants in the pilot used an average of 11.96 (SD = 7.44) components, and most were satisfied (45.1%) or neutral (40.3%) regarding the app. For 23 of the 26 interactive components, the majority of those who tried the component reported that they found it helpful. Participants reported a significant reduction in subjective stress (η2 =.088, p =.023). Feedback from pilot participants was incorporated in a version of the app that was publically launched as a free tool to support developing families. Mobile e‐health applications are a promising medium for providing preventative interventions and psychoeducation about the social and emotional challenges of pregnancy and early parenting; Positively Pregnant is an example of a tool, grounded in strength‐based, empirically supported strategies, to provide parents with support and information at this critical time. [ABSTRACT FROM AUTHOR]

Introduction and Aims: There is increasing interest and evidence for the use of cannabinoid medications in the treatment of cannabis use disorder, but little examination of the correlates of successful treatment. This paper is a secondary analysis of a randomised placebo-controlled trial of nabiximols for the treatment of cannabis use disorder (CUD), aiming to identify which client and treatment characteristics impact treatment engagement and outcomes.Method: Bayesian multiple regression models were used to examine the impact of age, gender, duration of regular cannabis use, daily quantity of cannabis, cannabis use problems, self-efficacy for quitting, sleep, mental health, pain measures, and treatment group upon treatment engagement (retention, medication dose, and counselling participation) and treatment outcomes (achieving end-of-study abstinence, and a 50% or greater reduction in cannabis use days) among the 128 clients participating in the 12-week trial.Results: Among the treatment factors, greater counselling attendance was associated with greater odds of abstinence and ≥ 50% reduction in cannabis use; nabiximols with greater odds of ≥ 50% reduction and attending counselling, and reduced hazard of treatment dropout; and higher dose with lower odds of ≥ 50% reduction. Among the client factors, longer duration of regular use was associated with higher odds of abstinence and 50% reduction, and lower hazard of treatment dropout; greater quantity of cannabis use with reduced hazard of dropout, greater odds of attending counselling, and higher average dose; greater pain at baseline with greater odds of ≥ 50% reduction and higher average dose; and more severe sleep issues with lower odds of ≥ 50% reduction. Males had lower odds of attending counselling.Discussions and Conclusions: These findings suggest that counselling combined with agonist pharmacotherapy may provide the optimal treatment for cannabis use disorder. Younger clients, male clients, and clients with sleep issues could benefit from extra support from treatment services to improve engagement and outcomes.Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12616000103460) https://www.anzctr.org.au. [ABSTRACT FROM AUTHOR]

Background: Primary care services have not generally been effective in meeting mental health care needs. There is evidence that collaboration between primary care and specialist mental health services can improve clinical and organisational outcomes. It is not clear however what factors enable or hinder effective collaboration. The objective of this study was to examine the factors that enable effective collaboration between specialist mental health services and primary mental health care. Methods: A narrative and thematic review of English language papers published between 1998 and 2009. An expert reference group helped formulate strategies for policy makers. Studies of descriptive and qualitative design from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted on factors reported as enablers or barriers to development of service linkages. These were tabulated by theme at clinical and organisational levels and the inter-relationship between themes was explored. Results: A thematic analysis of 30 papers found the most frequently cited group of factors was "partnership formation", specifically role clarity between health care workers. Other factor groups supporting clinical partnership formation were staff support, clinician attributes, clinic physical features and evaluation and feedback. At the organisational level a supportive institutional environment of leadership and change management was important. The expert reference group then proposed strategies for collaboration that would be seen as important, acceptable and feasible. Because of the variability of study types we did not exclude on quality and findings are weighted by the number of studies. Variability in local service contexts limits the generalisation of findings. Conclusion: The findings provide a framework for health planners to develop effective service linkages in primary mental health care. Our expert reference group proposed five areas of strategy for policy makers that address organisational level support, joint clinical problem solving, local joint care guidelines, staff training and supervision and feedback. [ABSTRACT FROM AUTHOR]

Purpose : Understanding the nature of wellbeing as multidimensional and complex provides a policy window to generate a strengths-based policy orientation to promote wellbeing in education settings. The purpose of this exploratory paper is to map how wellbeing is interpreted across public education policy documents in Aotearoa New Zealand. Method : To explore the narrative that this group of documents weave, we draw on models of holistic wellbeing, ecological systems and appreciative inquiry. Policy documents were analysed using text mining software to track notions of wellbeing; their occurrence and co-occurrence with related concepts. Results : Key findings include the predominance of wellbeing, the interrelatedness of wellbeing with relationships, and the predominance of student wellbeing over the wellbeing of other stakeholders, highlighting that current education policy does not interpret wellbeing as relational, complex or contextual. Conclusion : We argue that interpreting such documents through a wellbeing lens demonstrates the complexity and disparity of the conceptualization and contextualization. We assert that it is critical to explore possibilities for deliberate and ecological wellbeing connections within educational policy and practice for the good of all stakeholders.

WHAT IS KNOWN ON THE SUBJECT?: An important step towards improving mental health outcomes is the realignment of tertiary mental health education and research in a way which places strategic value on experience-driven involvement in mental health and addiction-related care. One of the most widely recognized ways of achieving this is by increasing representation of individuals with first-hand experience of mental health and addiction distress (also known or referred to as Experts by Experience or EBE) within the tertiary sector. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Benefits of tertiary EBE representation such as improving student's preparedness for practice and the empowerment of mental health consumers are consistently reported throughout the literature. In striving towards these outcomes, it is crucial we remain mindful of relevant and often-reported hurdles such as stigma and improper implementation. By using Aotearoa New Zealand as a case study, the need for approaches to increasing EBE representation which is conscious of diverse cultural contexts, perspectives and identities is highlighted. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This review draws together a broad range of factors associated with improving clinical practice. These include the potential for EBE representation to improve outcomes for trainee clinicians, and the incorporation of consumer-driven perspectives into evidence-based practice. This review further highlights the need for EBE representation to be implemented in a way which is responsive to the cultural needs and nuances of mental health education and practice in Aotearoa New Zealand, and, similarly in other countries. ABSTRACT: Introduction There is potential value in increasing representation of expert by experience (EBE) involvement in mental health education sectors. This approach to improving mental health outcomes is here explored in the context of Aotearoa New Zealand's tertiary education sector. Aim/Question This review sought to identify potential outcomes, benefits and barriers associated with EBE representation in tertiary institutions, whilst critically analysing these strategies in the context of Aotearoa New Zealand's mental health education sector. Method Data retrieved from electronic databases were subjected to critical appraisal and thematic analysis. The integrative review drew from a final data set of 113 articles. Results An integrative review of our search results indicated that moving towards a tertiary mental health model in which lived experience plays a central role has the potential to benefit both teaching and research in the tertiary sector. Discussion The interplay between contemporary perspectives on tertiary EBE representation and the cultural needs and nuances of Aotearoa New Zealand's tertiary sector highlights the need for critical and careful approaches to EBE representation. Implications for clinical practice Findings surrounding tertiary EBE representation have direct implications for the training of mental health practitioners and the evaluation and development of clinical practice outcomes and procedures., (© 2021 John Wiley & Sons Ltd.)

This paper engages with the notion of universality by critically exploring the concepts of trauma and post-traumatic growth from a cultural perspective. Drawing on the indigenous Māori model of wellbeing "Te Whare Tapa Whā", the inter-relationships between family relationships, physical wellbeing, mental and emotional health, and spirituality are examined as a holistic model. Spirituality is a key component of this holistic approach and arguably an inseparable aspect of holistic wellness and can be defined as "a broad universal construct associated with individuals' ways of making meaning of their lives and the acknowledgment of the presence of a higher being". Within the cultural context of Aotearoa New Zealand, we make a case for the value of holistic interventions to support people who have experienced trauma that prioritise spirituality alongside other aspects of wellbeing. [ABSTRACT FROM AUTHOR]

This paper draws together work on therapeutic assemblages, geographic assemblages, and therapeutic landscapes to develop the concept of "multi-sited therapeutic assemblages." Assemblage theory has been productively used in health research since it achieved prominence in the social sciences two decades ago. One facet that, however, remains as yet under-developed in the literature on "therapeutic assemblages" (as well as their close kin, "health assemblages," "ill-health assemblages," "care assemblages," etc.) is that of the multi-sited therapeutic assemblage. This paper demonstrates the significance of the multi-locality of therapeutic assemblages by mapping the mental health support activities of young New Zealanders. Grounded theory analysis of interviews with 150 New Zealand youth (which took place from 2015 to 2020) about their online and offline engagements in mental health support highlights the importance of the emplacement of therapeutic practices whilst also foregrounding their multi-sitedness. It enables opportunities to examine how therapeutically-meaningful places can be constituted both as independent sites and simultaneously re-made through their fluid, dynamic and temporal relations with one another. Through this analytic perspective, care and other elements of the therapeutic come to be understood as neither anchored to a single site nor constituted through the inter-relation of home and clinic, but defined via a shifting, dynamic, and multi-directional assemblage of multiple places, people, and resources. This has noteworthy implications for how we envisage relationships between a wide variety of therapeutic digital and real-life sites, as well as for examining scholarly and practical understandings of the emplacement of care., (Copyright © 2021 The Author. Published by Elsevier Ltd.. All rights reserved.)

Background: Significant progress has been made addressing adolescent health needs in New Zealand, but some areas, such as mental health issues remain, particularly for rangatahi Māori (indigenous Māori young people). Little is known about how contemporary Māori whānau (families) and communities influence health outcomes, health literacy and access to services. Previous nationally representative secondary school surveys were conducted in New Zealand in 2001, 2007 and 2012, as part of the Youth2000 survey series. This paper focuses on a fourth survey conducted in 2019 (https://www.youth19.ac.nz/). In 2019, the survey also included kura kaupapa Māori schools (Māori language immersion schools), and questions exploring the role of family connections in health and wellbeing. This paper presents the overall study methodology, and a weighting and calibration framework in order to provide estimates that reflect the national student population, and enable comparisons with the previous surveys to monitor trends., Methods: Youth19 was a cross sectional, self-administered health and wellbeing survey of New Zealand high school students. The target population was the adolescent population of New Zealand (school years 9-13). The study population was drawn from three education regions: Auckland, Tai Tokerau (Northland) and Waikato. These are the most ethnically diverse regions in New Zealand. The sampling design was two-stage clustered stratified, where schools were the clusters, and strata were defined by kura schools and educational regions. There were four strata, formed as follows: kura schools (Tai Tokerau, Auckland and Waikato regions combined), mainstream-Auckland, mainstream-Tai Tokerau and mainstream-Waikato. From each stratum, 50% of the schools were randomly sampled and then 30% of students from the selected schools were invited to participate. All students in the kura kaupapa schools were invited to participate. In order to make more precise estimates and adjust for differential non-response, as well as to make nationally relevant estimates and allow comparisons with the previous national surveys, we calibrated the sampling weights to reflect the national secondary school student population., Results: There were 45 mainstream and 4 kura schools included in the final sample, and 7,374 mainstream and 347 kura students participated in the survey. There were differences between the sampled population and the national secondary school student population, particularly in terms of sex and ethnicity, with a higher proportion of females and Asian students in the study sample than in the national student population. We calculated estimates of the totals and proportions for key variables that describe risk and protective factors or health and wellbeing factors. Rates of risk-taking behaviours were lower in the sampled population than what would be expected nationally, based on the demographic profile of the national student population. For the regional estimates, calibrated weights yield standard errors lower than those obtained with the unadjusted sampling weights. This leads to significantly narrower confidence intervals for all the variables in the analysis. The calibrated estimates of national quantities provide similar results. Additionally, the national estimates for 2019 serve as a tool to compare to previous surveys, where the sampling population was national., Conclusions: One of the main goals of this paper is to improve the estimates at the regional level using calibrated weights to adjust for oversampling of some groups, or non-response bias. Additionally, we also recommend the use of calibrated estimators as they provide nationally adjusted estimates, which allow inferences about the whole adolescent population of New Zealand. They also yield confidence intervals that are significantly narrower than those obtained using the original sampling weights., Competing Interests: The authors have declared that no competing interests exist.

Over recent decades, psychological health interventions have assumed a more prominent role in the conduct and regulation of daily life. Conceptualised in the critical social sciences as psychological governance, this development entails shaping the thoughts, feelings, and behaviours of individuals and populations to promote desired psychological states and conduct. In step with broader sociotechnical shifts, psychological governance is increasingly mobilised through digital technologies, such as smartphone apps. The COVID-19 pandemic marks a pivotal moment in the proliferation of digital mental wellbeing technologies. This paper examines the mental wellbeing app Mentemia, made available to the New Zealand public through government funding in the wake of COVID-19, exploring how Mentemia frames and addresses mental wellbeing in the context of the pandemic. Drawing from thematic analysis of within-app material and news media articles, we illustrate how Mentemia constructs mental wellbeing as a universal, everyday, and individual process and encourages users to engage with psychological intervention as a normalised component of daily life. We find that Mentemia's approach to framing and addressing mental wellbeing during COVID-19 aligns with prevailing discourses associated with the individualising and emancipatory values of contemporary neoliberalism which, in the context of psychological governance, presents as neuroliberalism. We highlight how Mentemia advances a particular understanding of psychological intervention to help remedy pandemic-related mental ill-health, illustrating the capacity for digital technologies to alter how mental wellbeing is experienced and acted on. [ABSTRACT FROM AUTHOR]

Within the National Rugby League (NRL), the elite competition body across Australia & New Zealand, clubs are mandated to report concerns to the NRL Integrity Unit for possible misconduct, on or off the field. This includes returning a positive illicit drug test leading to players needing to attend counseling that promotes behavioral change; ranging from alcohol and other drugs usage, mental health issues, anger management and family work. This paper strives to understand the purpose of psychological support and interventions as a reflective case study across professional rugby league settings, whilst looking at the role of counseling theories and practices. [ABSTRACT FROM AUTHOR]

Background: The literature regarding nurses' experiences of caring for chronically critically ill (CCI) patients is scant, however, there are subtleties within the literature, identifying nurses are often challenged providing care to this patient group. This can lead to feeling frustrated, lack of control, and distress. Aims and objectives: As part of a larger study, this paper reports nurses' experiences of caring for patients during a prolonged critical illness in the intensive care unit (ICU). Design A longitudinal, qualitative, instrumental, multi‐case study consisting of six cases from four New Zealand ICUs was conducted. Theoretical underpinnings were informed by the Chronic Illness Trajectory Framework. The principles of consolidated criteria for reporting qualitative research were applied in reporting the methods and findings. Methods: Patients, family members, nurses, and other health care professionals constituted the participant groups in the larger body of work. Data were collected from observations, conversations, interviews, and document review. Data were analysed by identifying themes, developing vignettes, and trajectory mapping. Results: Nurses' experiences of caring for CCI patients in the ICU can be framed by a prolonged critical illness trajectory that is unpredictable, problematic, and prolonged. Nurses experienced distress in one of the phases in the trajectory because of uncertainty about a positive outcome for the patient related to multiple complications, with anxiety, delirium, and the suffering they witnessed. Nurses were frustrated and challenged to meet all the patient's needs because of the many tasks they needed to complete over the shift. Conclusion: Understanding the trajectory of a prolonged critical illness from the perspective of nurses, allows for challenges to be identified and is the first step in improving practice through the education of nurses. Relevance to clinical practice: Understanding the challenges posed by caring for CCI patients will assist in improving their interactions and prioritizing their care for nurses. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this paper is to summarise the new psychiatry Fellowship programme and its rationale, highlighting the new inclusions, revised assessment structure, the benefits and structure of the programme.Conclusions: The 2012 Fellowship programme is based on the CanMEDs educational framework. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) underwent a comprehensive process, adapting the CanMEDs competencies to a psychiatric framework and mapping the curriculum to Fellowship competencies, learning outcomes and developmental descriptors of the various stages of training. The 2012 Fellowship programme introduced summative entrustable professional activities (EPAs), formative workplace-based assessments (WBAs) and revised external assessments. [ABSTRACT FROM AUTHOR]

Purpose: Self-direction–also known as participant direction, personalization and self-directed care–is a service delivery model that enables people to manage their personal budget and purchase services and supports tailored to their needs based on a person-centered plan. This paper, the outcome of an international learning exchange on self-direction, describes approaches across four countries' successful strategies, unresolved questions and recommendations to enhance self-direction globally. Design/methodology/approach: The findings are a product of discussions at the 2019 International Initiative for Mental Health Leadership and International Initiative for Disability Leadership Exchange on Advances in Self-Direction. Participants included people who are self-directing, providers and caregivers who support people who are self-directing, advocates, fiscal agents and public managers who administer self-direction from the United States, England, Australia and New Zealand. Findings: In all four countries, people who self-direct exercise high levels of choice and control and are able to individualize their services and supports to promote a good life in the community. The exchange also revealed challenges and possible solutions to improve and expand self-direction. Practical implications: The results of the meeting provide guidance for public managers, providers and advocates for initiating and expanding self-direction. Originality/value: This international meeting was a unique opportunity to compare self-direction across four different countries and across multiple perspectives, including people with disabilities, caregivers, providers and administrators. [ABSTRACT FROM AUTHOR]