Health: Theses and Dissertations
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Item Open Access Muramura ana te ahi | A pedagogy of fire : ways to reconnect.(2023) Berning, HannahFires are an integral part of human history and have provided safety, cooking, warmth and a centre for social gatherings. However, fires are also linked to death, loss of biodiversity and habitat as well as massive carbon dioxide emissions. Many national and international reports highlight such environmental changes, that are interconnected to social inequity. They, at the same time, call for urgent actions and change. This thesis addresses fire. By looking at educational fire contexts, this research explores if fire can re-connect people and the environment, as well as connect Western and Indigenous Māori knowledges. In Aotearoa New Zealand, fire is linked to human arrival. Māori used to travel with fire which connects people to their homelands and other important places. Since colonisation, Indigenous views have been marginalised by Western approaches. Therefore, this research draws on He Awa Whiria (a braided river) methodological approach, which highlights the authority of both Western and Indigenous knowledge streams as they come together and interact. The research is theoretically grounded in whakapapa and critical theory. Additionally, He Awa Whiria is visible through two case studies: one shaped by predominantly Māori perspectives and one shaped by Western lenses. In the Western case study, participants were kaiako (teachers) and ākonga (students) from tertiary institutions, while in the other case study, the researcher went on a hikoi (journey) with a kaiako (Te Hurinui Karaka-Clarke) from Te Arawa (Māori tribe). The thesis uses reflexive thematic analysis for both data sets to interrogate and integrate the data. The stories identified in the data broaden Western understandings of fire, which are for example defined through the fire triangle (fuel, heat and oxygen); instead, the thesis argues that places with fire features and meanings should be included in outdoor education programmes. Further, fires reveal power dynamics that exist in places, fire regulations, pedagogical approaches and the teacher-student relationships. Importantly, findings show how fire enhances reflection, promotes inclusive conversations and develops feelings of belonging. Implications for sustainable (outdoor) education include a pedagogical framework considering learning around and through fire. This framework challenges oppressive, unsustainable practices and views. It argues that a pedagogy of fire in Aotearoa New Zealand should be place-responsive, skill-based, reflexive, engaged and bicultural.Item Open Access Positive video self-review of parent-infant interactions with adolescent mothers: exploring intervention feasibility and changes to interactive parenting behaviour, parenting self-efficacy, and mental health.(2023) van Gerwen, JenniferA long history of research indicates that adolescent mothers are more likely to enter motherhood experiencing risk factors that may negatively impact developmentally supportive interactions with their child. One effective intervention for promoting developmentally supportive interactions is the use of parent coaching from video recorded parent-child interactions (known as video feedback; VF). However, like many parenting interventions, this approach may be perceived by adolescent mothers as too intrusive. This study explored an adaptation of VF called Positive Video Self-review of Parent-infant Interactions (PVSR-PI). PVSR-PI is based upon the principles of Video Self Modeling (VSM) and is distinct from VF approaches as it employs autonomous video self-review of only positive parent-infant interactions. This study examined the feasibility of the PVSR-PI, changes in observed parenting behaviour, parenting self-efficacy, maternal mental health, and mothers’ reflections on experiences of personal and relationship change with their infant over the course of the intervention. A single-case research design was employed with four mother-infant dyads recruited from a local Young Parents Programme (YPP), with three assigned to the intervention condition and one to a treatment as usual condition. Intervention engagement was very good and discourse around the acceptability of PVSR-PI was largely positive, offering preliminary support for feasibility. Data attributes restricted the interpretation of intervention effects or meaningful change for observed parenting behaviour, and no replication was seen across participants. Parenting self-efficacy increased for all intervention participants from pre-intervention to post-intervention, but did not meet reliable change criteria, and one mother experienced a clinically meaningful improvement in emotional closeness to her infant. At baseline, participants reported symptoms of depression, anxiety, and stress within a normal range, and idiosyncratic changes were seen, but none met reliable change criteria. Qualitative findings indicated that all mothers perceived some effects of the intervention on their thoughts about, and interactions with their child. Study findings are discussed in relation to previous video feedback and video self-modeling research and theory, alongside implications and recommendations for future research.Item Open Access An investigation into the effectiveness of psychosocial sleep interventions for children with cystic fibrosis.(2023) Ballam, KimberlyCystic Fibrosis (CF) is an inherited and life-limiting chronic illness which affects multiple organs including the lungs and digestive system. CF can lead to many symptoms including chronic cough, poor weight gain and chest infections, which all vary in their intensity. Over the last two decades illness outcomes for those with CF have dramatically improved. Despite this, those with CF still experience significant challenges, including psychological, social and physiological difficulties, as well as a significant treatment burden. Sleep problems are a challenge commonly reported for children with CF at a higher rate than their healthy peers. Common sleep issues include sleep related breathing disorders, reduced total sleep time, lower sleep efficiency, increased frequency of arousals, and a longer duration of wakefulness after sleep onset. This is especially problematic as sleep problems are associated with increased severity of lung disease, low mood and decreased quality of life in those with CF. Research has found that children with CF can experience sleep problems resulting from non-respiratory factors, suggesting that their sleep difficulties may be amenable to psychosocial sleep interventions. Psychosocial sleep interventions are a category of interventions that focus on the underlying psychological or behavioural factors that impact sleep. These interventions can include cognitive behavioural techniques, sleep hygiene modifications, stimulus control techniques, sleep restriction, extinction procedures and relaxation strategies. Psychosocial sleep interventions have been found to be effective in improving sleep among typically developing children and children with neurodevelopmental disabilities, however, no research has explored the use of these interventions among children with CF. This thesis aims to investigate the use of psychosocial sleep interventions for children with CF and sleep problems through two studies. Study one involved a systematic review of the effectiveness and acceptability of psychosocial sleep interventions among children with various Chronic Health Condition(s) (CHC), including children with respiratory conditions, diabetes and epilepsy. The review identified 13 studies which investigated the use of behavioural strategies, cognitive behavioural therapy for insomnia and motivational based interviewing techniques. The overall findings from the review were promising, with 12/13 studies reporting at least some improvement in sleep outcomes across participants. Additionally, improvements were seen in daytime behaviours, quality of life and symptoms of depression and anxiety following sleep treatment. While promising, the findings of the review are limited due to the small number of studies focused on each CHC condition, as well as methodological limitations (e.g., limited experimental control). Despite these limitations, the use of psychosocial sleep interventions emerged as a promising avenue for future research. The findings of study one were used to inform study two. The aims of study two were to investigate the effectiveness of a psychosocial sleep intervention for a child with CF. Study two also aimed to investigate if any change in sleep would result in secondary improvements in the child and parent’s wellbeing, and if the intervention would be considered acceptable to the parents. Within this study a multi-component psychosocial sleep intervention was implemented with a five-year-old boy with CF who was experiencing problematic night waking (NW) and unwanted co-sleeping. The intervention involved three sequential phases, beginning with sleep/wake rescheduling, followed by the use of reinforcement and a social story, and finally modification to parental responses to NW. Following intervention, the frequency and duration of NW decreased significantly, which was maintained at six weeks follow up. Additionally small improvements were reported in his quality of life and daytime behaviour as measured using the Pediatric Quality of Life Inventory and Child Behavior Checklist administered pre- and post-intervention. Some improvements were also reported in parental sleep, however, few changes were observed in regard to parental emotional wellbeing and parental relationship quality using the Depression Anxiety and Stress Scales –21 and the Relationship Quality Index. The intervention was reported be highly effective and acceptable. Despite these promising findings, further replication is needed which builds upon the limitations in existing research, including this study.Item Open Access Parents of children with hyperactivity, impulsivity, and inattention: what do parenting programs contribute to parental wellbeing?(2023) Taylor, SamanthaHyperactivity, impulsivity, and inattention are patterns of behaviour that are interrelated, multidetermined, and characteristics of attention deficit hyperactivity disorder (ADHD), yet HII are not limited to people with ADHD. Parenting a child with hyperactivity, impulsivity, and inattention has been described by parents as a “stress-generating experience” as the associated behaviours can be difficult for parents to manage (Johnston & Chronis-Tuscano, 2014, p. 193). Parenting is a modifiable component of the child’s ecological context and central to the management of hyperactivity, impulsivity, and inattention in childhood. Parenting programs aim to promote positive parent-child relationships and developmental outcomes for children and are a recommended intervention for children with ADHD. The aim of this systematic review of randomized control trials was to establish what secondary benefits parenting programs have for the wellbeing of parents of children with elevated levels of hyperactivity, impulsivity, and inattention. A systematic search strategy was implemented in accordance with PRISMA guidelines. A total of 16,027 records were identified from six databases, trial registries and citation searches. After screening, 21 studies were included in the review. A total of nine parenting programs involving 1,323 parent participants were evaluated. While most parenting programs were likely to improve at least one-dimension parental wellbeing, either by reducing stress, depression, or anxiety, or by increase parents’ sense of competence or self-compassion, these effects were highly variable. The largest and most consistent effect found on any measure of parental wellbeing was a reduction in stress after completing Parent Child Interaction Therapy, Mindful Parenting, Triple P, Helping the Non-compliant Child or 1-2-3 Magic. The majority (85%) of between group findings were not significant. Thirteen constructs of parental wellbeing were measured by 16 different psychometric assessments. Implications and limitations are discussed, and recommendations made for future research.Item Open Access Student Experiences of E Tū Tāngata at School : a collaborative evaluation and pilot test of effects on school climate and student outcomes.(2023) Fraser, ChloeSchools are complicated developmental contexts, and many different aspects of the school environment can influence how students experience school life, interact with others, and generally feel within that environment. E Tū Tāngata is a new initiative within Aotearoa New Zealand that aims to address the country’s alarming mental health challenges, at a cultural level, by addressing the social norms and values associated with Tall Poppy Syndrome. Within schools, E Tū Tāngata aims to improve the school’s climate by shifting how students communicate and interact with one another through the promotion of three key mindsets – You Have Value, We Succeed Together, and Others Matter. This mixed-methods pilot study is one of the first attempts to evaluate the implementation and efficacy of E Tū Tāngata in a target school in Canterbury. This study had three aims: (a) to examine the psychometric properties of a retrospective survey of student experiences with E Tū Tāngata and hypothesised outcomes; (b) to examine how the school’s integration of the E Tū Tāngata mindsets is associated with students’ sense of belonging to the school, positive risk-taking behaviours, and response to failure; and (c) to investigate how students reflect on the changes they have experienced personally and seen within their classroom and school. Sixty-six students from years 6, 7, and 8 completed the survey. Psychometric testing found acceptable reliability for over half of the survey subscales and preliminary evidence for convergent validity, alongside a considerable need for redevelopment of other aspects of the survey. The vast majority of students evaluated the initiative positively and those who perceived better integration of the E Tū Tāngata mindsets also reported a greater sense of school belonging and connection to their peers. The results of this pilot test remain relatively consistent with the current literature on school climate and school belonging and provide preliminary support for E Tū Tāngata’s theory of change model. In light of the strengths and limitations of this pilot test, suggestions are made for future investigations into E Tū Tāngata, including opportunities for further survey development and evaluation strategies which should facilitate a better understanding of E Tū Tāngata’s effect on students and schools.Item Open Access You get better with age : wellbeing and health status assessment in older people.(2022) Johnston, Robyn MarjoriePeople aged 65 years and older are the fastest growing age group in New Zealand. By the mid-2070s, there are predictions that this age group is likely to comprise approximately one third of the population. Older people are encouraged to stay in their own homes within their community for as long as possible with support to encourage the extension of ageing in place. Currently around 14% of those aged 75 years or older, make the move into retirement villages. This is expected to increase. Little is known by retirement villages about the wellbeing and health of those who decide to live independently in these facilities. Predicting the need for a continuum of care is challenging. This research measured the wellbeing and health of older adults. It was situated in a critical realist paradigm, overlaid with an empathetic axiology. A focused literature review considered the impact on wellbeing from the aspects of living place, age, gender, health status and the 2010/2011 Canterbury earthquakes. Longitudinal studies used the Enlightenment Scale and the interRAI Community Health Assessment (CHA) to measure the wellbeing and health of one group of residents (n=120) living independently in one retirement village in Canterbury, New Zealand. The research was extended to incorporate two cross-section studies when initial results for wellbeing were found to be higher than anticipated. These additional studies included participants living independently from other retirement villages (n=115) and those living independently within the community (n=354). A total of 589 participants, aged 65 – 97 years old, completed the Enlightenment Scale across the four studies. Across the living places, wellbeing continued to significantly improve with age. The Enlightenment Scale was a useful measure of wellbeing with older adults. Participants in the longitudinal studies largely maintained a relatively good health status, showing little change over the study period of 15 months. Predictions for the need for a move to supportive care were not able to be made using the CHA. The health status of participants did not influence their level of wellbeing. The key finding of note is that the wellbeing score of older adults increases by 1.27 points per year, using the Enlightenment Scale, irrespective of where they live.Item Open Access The health benefits of trampolining.(2022) Clement, TāneTrampolining is a common recreational activity, that is especially popular amongst children. The body of evidence investigating the health effects of trampolining on human physiology is very limited compared to other common modalities, such as running, rowing or biking. Therefore, the purpose of this series of studies was to expand the amount of literature using trampolining as the modality of choice. This thesis first comprehensively reviews the literature relating to physiology and trampolining. General methods used in the studies are then discussed. The next five chapters consist of the five studies that were published as a part of completing this thesis. Finally, the findings from each of the studies are summarised in the last chapter. In the first study, a model was developed which allows energy expenditure, on an app- equipped trampoline, to be calculated using only the input of the user’s mass. Participants were required to bounce on a trampoline while wearing a breath by breath analyser. This allowed the model to be validated by comparing the model’s estimated energy expenditure to the participant’s oxygen consumption, as measured by breath by breath analysis. This allows the intensity of bouncing on a trampoline to be easily calculated and measured. This method was used in every subsequent study, as it was a significant improvement to the quality of life, for the collection of data, for exercise on a trampoline. In the second study, energy consumption while bouncing on a trampoline was compared to energy consumption while running on a treadmill. Participants wore a breath by breath analyser and blood lactate was collected, while bouncing on a trampoline. Then in a second session, a week later, participants wore a breath by breath analyser and blood lactate was collected while running on a treadmill. This was to build on the findings of a previous study to see if they remained consistent. It was confirmed that trampolining and running had similar exercise profiles and the findings of the previous study were validated. In the third study, energy expenditure while bouncing on a trampoline was measured while altering the bouncing action. A variety of different bouncing actions were measured and it was discovered that altering the bouncing action did increase the energy expenditure. The model produced in the first study was then updated. This allowed a more accurate estimation of energy expenditure, while using the bouncing actions measured in the study. In the fourth study, a novel exercise protocol on a trampoline was investigated to assess whether it produced a positive change to various health markers. The novel protocol was designed to be very time efficient. Participants regularly exercised on a trampoline for 8 weeks. The novel protocol appeared to improve the participant’s fitness and vertical jump with as little as ten minutes of exercise per week. The fifth study investigated whether trampolining could be used as a novel treatment to improve body composition, cardiovascular fitness, bone density and stress urinary incontinence amongst parous women. Participants regularly exercised on a trampoline for 12 weeks. The treatment appeared to improve the participant’s pelvic floor strength and reduce the impact stress urinary incontinence had on their quality of life.Item Open Access Student reflections on school transitions and their experience of E Tū Tāngata in promoting school belonging.(2023) Parkes, ConstanceYoung people spend nearly half of their waking hours at school, and this complex context has the potential to support or undermine children’s development. A new initiative in Aotearoa New Zealand called E Tū Tāngata (ETT; Stand Together) is being implemented in a variety of schools to help address the concerning rates of young people experiencing mental health difficulties and the cultural practice of tall poppy syndrome, in addition to promoting students’ sense of belonging to their school, self-worth, and positive relationships with peers and school staff. ETT promotes three key mindsets – You Have Value, We Succeed Together, and Others Matter. In this retrospective, qualitative evaluation of ETT at a single target school, six students new to the school participated in semi-structured interviews exploring their recent school transition, their experience of this new school climate, sense of school belonging, and relationships with peers and teachers. Across all participants, their school transition experience was consistently described in the context of peer relationships, rather than other elements of school climate. Five participants reflected positively about their school transition, the positive and socially inclusive climate at the target school, and sense of school belonging; whereas the sixth participant’s experience of peer exclusion and difficulty adjusting to the target school provided a sharp contrast. These new students had difficulty in distinguishing between the ETT mindsets and the school values, which may be due to insufficient exposure or could also reflect issues with implementation. The findings were broadly consistent with the literature on school transitions, school climate and belonging, and are generally supportive of the ETT theory of change model. In light of the strengths and limitations of this study, additional opportunities to further examine the hypotheses of the ETT theory of change in future research are discussed.Item Open Access An evaluation of the effectiveness of a telehealth-delivered behavioural intervention for toilet training takiwātanga/autistic tamariki/children.(2023) Aldersley, Hannah KateToileting is a critical life skill that is needed for all individuals to be able to live independently. Toileting difficulties are highly prevalent among takiwātanga/autistic tamariki/children and are thought to result from a range of biological, psychological, and behavioural factors. If left untreated, toileting difficulties can results in a range of challenges for both tamariki and their whānau including social, emotional, educational, and financial difficulties. Many studies have investigated the effectiveness of behavioural interventions for toileting difficulties in takiwātanga tamariki. This research suggests that behavioural interventions such as rapid toilet training, and behavioural methods such as graduated guidance, reinforcement, scheduled sittings, elimination schedule, hydration, manipulation of stimulus control, and priming, are among the most successful approaches for improving toileting behaviour in takiwātanga tamariki. However, there is limited research looking at the effectiveness of such interventions delivered via telehealth and its secondary effects on quality of life, child behaviour, and parent well-being. The present study aimed to: (a) investigate the effectiveness of telehealth-delivered behavioural interventions for toileting in 2-5 year old takiwātanga tamariki, (b) identify the level of therapist assistance required for an effective telehealth intervention for toilet training, (c) assess the collateral benefit of improvement in toileting behaviour on a child's daytime behaviour, adaptive functioning, quality of life, and parental well-being, and (d) identify whether the telehealth approach is perceived by parents to be culturally responsive, acceptable, and beneficial. Seven, 2-5-yearold takiwātanga tamariki and their parents participated in this study. The effectiveness of a telehealth-delivered toileting intervention was evaluated using a single-case multiple baseline across participants design study. The effectiveness of the intervention was measured using toileting diaries and the Profile of Toileting Issues. Secondary effects were assessed using a combination of psychometrics including the Child Behaviour Checklist (CBCL), Pediatric Quality of Life Inventory (PedsQL), and Depression, Anxiety and Stress Scale-21 (DASS-21) which were administered pre-and post-intervention. The intervention consisted of three subphases: parent psychoeducation, parent group coaching, and individualised parent support which lasted for four weeks each. Results indicated that the intervention was effective at improving toileting behaviours including in-toilet urination and toileting independence across all seven participants, as measured through daily toileting diaries. This improvement was maintained or further improved at the 12-week follow-up for all five tamariki with available follow-up data. Through evaluation of toileting diaries, the intervention was also found to be effective at increasing in-toilet defecation for six out of seven participants. This was maintained or improved on at follow-up for two out of three tamariki with available followup data. Toileting behaviour steadily improved for most tamariki across intervention phases. However, the most significant change was seen during phase three indicating individualised specialist support to be necessary for the successful implementation of a toileting intervention for takiwātanga tamariki. The study did not find consistent improvements in quality of life, child behaviour, and parental well-being across all participants. However, improvement was seen for 7/7 tamariki in behaviour when using the CBCL, and 12/14 parents in well-being when using the DASS21, with some to a clinically significant degree. In general, parents who completed the telehealth intervention found it to be reasonable, of low cost, and effective in improving their child’s toileting behaviours. The present findings add to the limited literature examining the effectiveness of telehealth-delivered behavioural toileting intervention for takiwātanga tamariki. Further research is needed to investigate the maintenance of positive impacts long term, and to enhance our understanding of the role of participant specific variables in intervention outcomes.Item Open Access Development of a fidelity rating scale for the real-world delivery of media smart, a universal eating disorder prevention program.(2023) Winters, Elizabeth MayIntervention fidelity, the extent to which an intervention is delivered, as intended, is rarely examined in “real-world” settings. This project aimed to establish whether Media Smart, a media literacy program intended to help prevent eating disorders, is delivered as intended by its developers, by developing a psychometrically valid and reliable rating scale to assess this. Media Smart-NZ was delivered in five New Zealand schools to 11–12-year-olds, by a range of facilitators with no background in eating disorders. These lessons were audio recorded and adherence to the key principles of Media Smart, and competence in delivery of the program were rated using a randomly selected sample of these recordings. The psychometric properties of the rating scale, Media Smart-NZ Assessment of Facilitator Competence (MS-FidelityNZ), were examined and the overall fidelity of the Media Smart NZ intervention delivery was evaluated. The MS-FidelityNZ was found to have good internal consistency (Cronbach’s alpha 0.89) and good inter rater reliability scores. ICC was between 0.76 and 0.84 (0.559 – 0.93), depending on the inclusion or omission of the one dichotomous choice item. An exploratory factor analysis revealed two underlying constructs; 1. effective delivery of the key principles of Media Smart and 2. the facilitator not delivering proscribed content. Overall fidelity to the program was moderate to high, with a mean total score of 40 (SD 9.16), with total scores ranging from 23 - 55. Comparisons between facilitators revealed a spread of mean scores from 24 (SD = 0.78) to 52 (SD = 4.32), indicating a between facilitator difference in adherence to and competence in delivery of the key Media Smart principles. This is the first rating scale of its kind, developed to evaluate fidelity to the Media Smart program and its results indicate that it may be a useful tool to help ensure that the real-world delivery of Media Smart is monitored, with the resulting information used to adequately train a range of facilitators.Item Open Access “You just end up feeling quite rejected by the entire healthcare system” A mixed methods study of perceived barriers to healthcare access in New Zealand LGBTQ+ teens, and their impact on sexual risk behaviour.(2022) Ferrara, AdiBackground In recent years, research on lesbian, gay, bisexual, trans*, queer/questioning (LGBTQ+) youth has shifted from risk-based to resilience research. Research suggests that three factors contribute to resilience: environmental support (e.g. school, family), positive interpersonal relationships (e.g. LGBTQ+ peers), and intrapersonal aspects (e.g. self efficacy, ability to define one's own gender). Unfortunately, even in settings that could contribute to building LGBTQ+ youths' resilience, this population often encounters rejection, bullying, and even violence in the everyday spaces they inhabit. As a result, adolescent sexual and gender minorities (SGM) are at heightened risk for adverse mental and physical health events, compared with their heterosexual, cis-gendered peers. Yet little information exists on the experiences of older (15-19 years) LGBTQ+ teens in the New Zealand healthcare system. International research indicates that LGBTQ+ people encounter barriers to healthcare access that arise from stigma and discrimination. A recent New Zealand study (Veale et al., 2019) of trans* teens and adults showed they, too, encounter difficulties accessing and receiving gender-affirming care. This study aimed to examine whether a sample of LGBTQ+ teens in New Zealand perceive interpersonal barriers to health care services. In addition, the study aimed to explore whether perceptions of health care barriers influence sexual risk behaviours, and uptake of preventive behaviours. This specific relationship has not been examined in earlier studies either. Methods Adopting a mixed methods, sequential explanatory study design, this research comprised an online anonymous survey with 310 respondents and in-depth, semi-structured qualitative interviews with a convenience sample of 15 LGBTQ+ teens. The survey included multiple choice and open-ended questions. Descriptive statistics and regression analysis were used to analyse the multiple choice questions. Content analysis was done on the open ended questions. The qualitative interviews were analysed using reflexive thematic analysis (Braun & Clarke, 2006). Results By combining quantitative and qualitative data, I was able to generate a more complete picture of the answers to my research questions. Building on the quantitative survey data to develop interview questions, which in turn expanded on and illustrated the quantitative findings. This study found that participating LGBTQ+ teens perceive interpersonal barriers to healthcare services, and these barriers have potentially serious consequences not only in the sexual health arena but also in terms of the participants' emotional wellbeing. The impact of these barriers seemed most pronounced in the gender diverse population. The participants predominantly attributed these barriers to lack of knowledge and training on the providers' side. Such perceptions caused participants to feel dismissed or misunderstood, and at times reluctant to continue seeking care. The perception of barriers also stems from the participants' own experiences of being LGBTQ+, driving their fear of coming out to providers lest they suffer discrimination and judgement, which may be a common occurrence in other areas of their lives. Participants' experience of a widespread heteronormative attitude in healthcare allows them to continue receiving care without having to come out. However, this attitude adds a layer of complexity and additional barriers to gender diverse individuals who require, at minimum, gender-affirming care in the form of respectful language. These above barriers, and the perceived lack of adequate sexuality education resources elsewhere, create a knowledge gap in the study population. No direct connection was found between sexual risk behaviour and participants' ability to fully utilise healthcare services as LGBTQ+ individuals. However, the barriers found in this study contributed to lack of knowledge and lower uptake of preventive measures, which increase the risk of adverse outcomes (e.g. STI exposure) in this study population. Conclusions In a population already affected by marginalisation, participants' healthcare needs are not being met. This was especially true with regards to gender minority participants. Gender diversity was also associated with a lower health communication self-efficacy score, itself a barrier to healthcare utilisation. Mental health struggles were commonly reported in the interviews, and participants related those to being LGBTQ+ (the most cited factor) and New Zealand's inadequate mental health system. Long wait times for mental health appointments, as well as being told that "asking for help means you're well enough" raise the risk of exacerbating depression, anxiety, and suicidal ideation. These are conditions that already affect LGBTQ+ adolescents disproportionally. Participants' common concerns (e.g. confidentiality, denial of care, judgement and discrimination) around disclosing their sexual or gender identity, together with other research, indicate there are serious gaps in meeting the healthcare, including sexual health needs, of LGBTQ+ teens in New Zealand. These common concerns make the necessity of repeatedly coming out to new providers a daunting task for these participants. Inability to discuss their SGM status openly also creates a knowledge gap in sexual health knowledge, resulting in possible public health implications.Item Open Access Risk and protective factors of depression and their association to academic performance in Pacific children.(2022) Togiaso, VevesiDepression has become a growing mental health crisis around the world. In New Zealand, the Pacific population are overrepresented in mental health statistics in comparison to other ethnic groups. Pacific children and Pacific youth are recognised as a group that are of higher risk for depression. The effects of depression have also shown to have an impact on academic performance. Despite this, little is known about potential factors associated with Pacific children’s academic performance and furthermore, the relationship of depression and academic performance in this ethnic minority group. The main aim of this research was to examine the risk and protective factors of depression associated with teacher assessed academic performance in Pacific children aged 6, 9 and 11 years. Age-specific associations between the various factors and teacher assessed academic performance at 11 years was investigated to gain insight into potential mechanisms that lead to adverse academic performance. The examination of the population average trajectory of behavioural development and teacher assessment scores of Pacific children in New Zealand was also conducted. Data was extracted from the Pacific Islands Families (PIF) Study, a longitudinal birth cohort study that examines Pacific children and their families. This quantitative study focuses on Pacific children at ages 6, 9 and 11 years and the impact of various risk and protective factors on teacher assessed academic performance. This study includes 703 child participants with maternal reports for data collection measured at 6-weeks, 2 years, 6 years, 9 years and 11 years. In the PIF cohort, externalising behaviour, gang involvement and being a perpetrator of bullying were risk factors associated with lower teacher assessed academic performance at 11 years for Pacific children. Depression was found as a risk factor for lower teacher assessed academic performance at both 9 and 11 years. The protective factor of positive self-description at 9 and 11 years was associated with higher teacher assessed academic performance. Externalising behaviour over subsequent years of 6, 9 and 11 years indicated a decline in academic performance teacher assessment scores, whereas positive self-description in Pacific children indicated an increase in academic performance over the years. Post-secondary school qualifications of mothers, also increases teacher assessed academic performance in Pacific children. The findings of this study show that academic performance in Pacific children can be negatively influenced by externalising behaviour, gang involvement and bullying perpetration at ages 6, 9 and 11 years. Positive self-description is an important factor protecting against low academic performance in Pacific children. Externalising behaviour continued over the years leads to lower academic performance over time. Such findings highlight the need for targeting these particular risk and protective factors for future interventions and more importantly, how the onset of these factors can lead to detrimental mental health outcomes impacting on academic performance in later years.Item Open Access Adolescents and oral health service utilisation in Canterbury, New Zealand : a geospatial cross-sectional study.(2022) Lee, Joanne Jia Min; Schluter, Philip J.; Hodgett, Matthew; Deng, Ningyu; Hobbs, MatthewObjective: Non-utilisation of dental care during adolescence can result in poorer oral health and subsequently higher expenditures on dental services. This study examined the geospatial and epidemiological factors associated with the utilisation of the publicly funded Adolescent Oral Health Services (AOHS) in Canterbury, Aotearoa New Zealand (NZ). Methods: A secondary analysis of prospectively collected routine data from AOHS visits of adolescents in school Year 9 (13-14 years) for the financial year 2019-2020. Geographic Information Systems examined distance from home address to dental practices. Multilevel mixed- effects Poisson regression models investigated associations between geospatial, demographic and clinical factors and non-utilisation of dental services. Models were adjusted for sex, ethnicity, area- level deprivation, rural/urban classification, previous caries experience, and the distance from home address to dental practice referred. Results: Dental practices were concentrated in large urban areas and in the least deprived neighbourhoods, with several service area gaps identified. Rural areas and the most deprived areas of Christchurch City had the highest non-utilisation rates. After adjustment, adolescents residing in the most deprived areas had a higher risk of non-utilisation (adjusted risk ratio [aRR]=1.38 (95% CI 1.26-1.51) compared to adolescents in the least deprived areas. Adolescents in remote areas also had an increased risk of non-utilisation (aRR=1.36; 95% CI 1.20-1.54) compared to adolescents in urban core areas. Finally, Māori (aRR=1.37; 95% CI 1.29-1.46) and Pasifika (aRR=1.46; 95% CI 1.35-1.59) adolescents had significantly higher risks of non-utilisation compared to their NZ European counterparts. Conclusion: Inequitable access to publicly funded dental care exists among adolescents in Canterbury, NZ, which negatively impacts Māori, Pasifika, and those living in rural and most deprived areas. Adolescents at the greatest oral health risk are geographically underserved by current oral health services. The current health system could explore the possibility of partnering with Māori and Pasifika communities to provide services within culturally appropriate settings.Item Open Access Evaluating the effectiveness of function-based behavioural sleep interventions for the treatment of anxiety related sleep disturbance in autistic youth(2022) Edwards, JulianaThe prevalence of anxiety disorders, and sleep disturbance is elevated among autistic youth. However the ways in which anxiety, autism characteristics, and sleep disturbance interact with each other, in the context of an individual’s environment and family relationships is still unclear. The reciprocal influences between these variables is diverse, and multi-faceted. Despite the relatively common co-occurrence of sleep disturbance and anxiety in autistic and non-autistic individuals, these conditions continue to be treated separately, with minimal evidence of effective integrated treatment for anxiety related sleep disturbance. A greater understanding of the bi-directional relationship between anxiety and sleep in autistic individuals, and the development of minimally sufficient treatment of anxiety-related sleep disturbance is needed. This study evaluated the effectiveness of Functional Behavioural Assessment (FBA) - informed behavioural sleep interventions for the treatment of anxiety related sleep disturbance, utilising single-case-research design. Study One is presented as a case study with one 13-year-old participant. Study Two is a single-case multiple-baseline AB design involving three participants aged 13-16 years. The effects of sleep treatment on children’s anxiety, daytime behaviour, and quality of life, as well as parents’ sleep quality and well-being was examined. All four participants were adolescents, with a diagnosis of Autism, and parent or self-reported sleep-interfering anxiety. Participants’ interventions were informed by FBA, and individualised according to the needs of the child and their family. In Study One, treatment included relaxation strategies and faded parental presence procedures. Study Two included adjustment of participants’ sleep/wake cycle for all participants, with one participant also requiring sleep hygiene modifications. Results indicated substantial improvements in sleep for all participants who completed treatment, with improvements largely maintained up to 10 weeks following treatment. Findings related to anxiety were variable, with some indication of both reductions and increases in perceived anxiety following treatment. Positive changes were evident overall in participants’ daytime behaviour, quality of life, and parent well-being post-treatment, with mixed results relating to parents’ sleep quality. Parents and participants indicated that treatment was acceptable, cost effective, reasonable, and understandable. Families found treatment time-consuming, but worthwhile due to the benefits of effective treatment, and families felt well-supported by clinicians throughout the treatment process. Overall, this study provides evidence of the effectiveness of behavioural sleep interventions for treating sleep disturbance in anxious autistic youth, and highlights the utility of FBA informed interventions for providing individualised, responsive treatments, uniquely tailored to the needs of autistic individuals and their family.Item Open Access Examining parental predictors of young children’s problematic screen media use.(2022) Xue, XinyiThere is a rapid growth in children’s media use, which raise parents’ concern over time. Nowadays children can access to media at an early stage either actively or passively. Parenting practices behaviours start to intervene children’s screen time in early childhood. Therefore, parents play a critical role in guiding young children’s healthy media use habits. The present project aims to examine: a) to what extent parenting practices are related to parental media monitoring strategies and the reasons why parents allow children to use media, and b) to what extent parenting practice, parental monitoring strategies, and reasons why parents allow children to use media contribute to children’s problematic media use. Ninety-one parents (90.1% mothers; Mage = 34.7, SD = 5.8) with at least one child between the ages of two and five years of age completed a battery of questionnaires assessing the above constructs. Results indicated that authoritarian parenting behaviours were significantly related to using media to calm their child when upset. More restrictive mediation was negatively and significantly associated with using media to calm their child when upset. The results of a hierarchical regression analysis indicated that authoritative parenting practices and less use of media to calm children when upset contribute to fewer problematic media behaviours in young children. This study contributes to our understanding about how parents’ thoughts and behaviours are related to children’s media use at an early stage. This study also showed potential parental factors to prevent children’s problematic media use in early childhood. Therefore, this study can acknowledge and remind parents of certain parental behaviours to reduce children’s problematic media use in early childhood. However, future research is needed to investigate the consistency of these relationships. Future interventions are needed to guide parents through modelling and shaping children’s healthy media use.Item Open Access PolySaturated : illuminating the experiences of Polynesian athletes in professional rugby league.(2022) Borell, Phillip JohnPolynesian athletes represent almost 50% of the Australian National Rugby League’s (NRL) top tier player contracts. The proportion of Polynesian professional rugby league players has trended upward from the mid-1990s and continues to grow with significant numbers of young Polynesian athletes coming through NRL pathways and junior systems. A spate of suicides of young Polynesian players in recent years highlight the difficulties faced by young men and particularly Polynesians in the NRL. With the increasing influence of Polynesian athletes in the NRL it is critical to draw from player experience in an effort to further understand the people and cultures that form such an integral part of contemporary professional rugby league. While there is a significant body of scholarly work in rugby league globally, there is limited literature that examines Polynesian contributions to the sport and the experiences of those Polynesian men. One aim of this doctoral thesis is to illuminate Polynesian experiences in professional rugby league to help better understand the complexities of being Polynesian in professional sport. Employing a qualitative research methodology, this research prioritises kaupapa Māori and pan-Pacific research methods. Pūrākau (oral tradition, stories and storytelling) and Talanoa (conversation and storytelling) are used alongside Narrative Inquiry to explore the experiences of 10 Polynesian men in professional rugby league. Participants were selected based on a Polynesian whakapapa (genealogy) and participation in professional rugby league or professional pathways (junior grades). Participants’ experience levels included: NRL pathways and under 20s teams; early stages of professional NRL and Super League Europe (SLE) careers and NRL and SLE first grade. Participants shared their pūrākau (stories) through talanoa (conversations) and revealed insights into the emergent themes. Findings suggest that while there is no ‘one model fits all’ for understanding Polynesian experiences in professional rugby league, there are notable commonalities: the role of the whānau/aiga (family), pressure, expectation and the need for culturally appropriate support initiatives, and the complexities of modern Polynesian masculinity. The familial unit emerges as a complex space with the potential to, both, support and undermine player experiences. Support initiatives exist in professional rugby league but participants felt they were not tailored to the cultural nuances that shape Polynesian worldviews. Masculine identity and the concept of a distinct Polynesian masculinity also influence young Polynesian men and their experiences in professional rugby league. These themes are complex and interrelated and can be employed to better support Polynesian experiences in professional rugby league. Using the metaphor of waka ama the ‘Te Waka Kōtihi’ model contains the takere (main hull), kiato (cross arms/braces) and ama (outrigger/flotation) as the fundamental elements of the waka ama. Each of these parts of the waka ama need to work cohesively together for the waka to navigate challenging waters: the takere represents professional rugby league as a vehicle capable of floating but with limited stability; the ama is the whanau/aiga and provides the necessary stability for turbulent waters; and the two kiato bind the takere and ama through identity and support. The Te Waka Kōtihi model is offered as a means of illustrating the functions and intersections of the research themes. The metaphor, as a visual representation of the findings, serves as a way of communicating the results in a way that demonstrates research by, for and with Polynesians. By using Polynesian research methods to listen to the narratives of Polynesian players and understanding their cultural heritage more deeply, this research can inform a more inclusive and supportive environment for Polynesians in the NRL and highlights the strengths of Indigenous research methods more generally.Item Open Access Successful ageing and trajectories of health among New Zealand older adults.(2022) Fasoro, Ayodeji AkinwandeBackground The goal of this thesis is to explain and examine successful ageing using disease conditions, functional capacity, life engagement, and health-related quality of life using longitudinal data, and to examine New Zealand older adults’ successful ageing trajectories. For an individual, successful ageing is defined in terms of having fewer diseases or no multimorbidity, high functional capacity, active life engagement, and good health-related quality of life. As successful ageing is on a continuum, it can be best assessed through data obtained from longitudinal studies. Methods A secondary analysis was conducted based on data from the ongoing New Zealand Health, Work and Retirement (NZHWR) Study. In the NZHWR study, 1,433 older adults recruited at the baseline in 2006 and followed up for 12 years through seven waves of data collection were included. A metric of successful ageing was constructed through the addition of the number of disease conditions, physical functioning, role emotional, life engagement, and physical and mental component summary scores. This gave a successful ageing score ranging from zero to six. Latent growth curve modelling (LGCM) was used to assess the growth factors (intercept and rate of change (slope)) of successful ageing trajectories of older adults. Multiple indicators, multiple causes (MIMIC) models were used within the LGCM to examine the effect of age, sex, and ethnicity on the growth factors. Results The majority of the participants were females (54.6%), New Zealand European (61.3%), and the mean age and standard deviation at the seventh wave were 72.8 years and 4.4 years. The mean successful ageing score was 3.53 in 2006 and decreased by 0.064 every year as a linear function. Those who had a higher successful ageing score at baseline had a slower decline. The mean successful ageing scores were significantly lower at baseline among females than males ( = -0.191, p = 0.013), among those in the older age group than the younger age group ( = -0.021, p = 0.017), and among M¯aori ( = -0.458, p < 0.001), Pacific Peoples ( = -1.490, p = 0.007) compared with New Zealand European. However, age was the only significant predictor in explaining the linear growth trend of successful ageing ( = -0.005, p < 0.001). The fit measures (RMSEA = 0.038, 95%CI: 0.031–0.045, CFI = 0.977, TLI/NNFI = 0.973, SRMR = 0.025) showed that the conditional model fit the data and was better than the null model. Conclusion Young older adults, males, and New Zealand Europeans were observed to experience successful ageing more. The ethnic differences suggest the possibility of inequalities in the factors that promote successful ageing among New Zealand European and non-European. Factors that promote successful ageing among the ethnic groups in New Zealand need to be identified and culturally appropriate models of successful ageing developed. Ageing is a life-long process, and it can best be explained by taking a life-course approach to the roles policies, early and midlife experiences, and the environment play.Item Open Access Exposure to particulate matter and lung cancer survival among adults in New Zealand.(2022) Yu, KaiIntroduction: Epidemiological and toxicological evidence has indicated that PM10 and PM2.5 exposure increase the incidence and mortality of lung cancer. It is possible that PM10 and PM2.5 exposure also reduce length of lung cancer survival from the time of diagnosis. This thesis aims to examine the survival differences among lung cancer patients exposed to different levels of particulate matter. Methods: This thesis conducted a secondary analysis of the association between PM2.5 and PM10 exposure and survival from lung cancer. Exposure data were obtained from the Ministry of Health and the Land Air Water Aotearoa. Participants consisted of Christchurch residents initially diagnosed with lung cancer in 2014. The Kaplan-Meier method was used for survival analysis and the log-rank test was conducted to compare whether survival probabilities differed between groups. Temperature, wind speed, relative humidity, O3, NO, NO2, SO2, CO, PM10 and PM2.5 (p<0.05 in univariate analysis) were included in the multivariable Cox proportional hazards model. Age and socioeconomic status were also included in the multivariable Cox proportional hazards model due to their important effect on lung cancer survival. In the competing risk model, death from lung cancer was regarded as the major event, and death from causes other than lung cancer was deemed the competing risk event. Adjusted survival curves for PM10 were drawn in accordance with the results of the Cox proportional hazards model. Results: A total of 176 lung cancer patients were eligible for the analysis. The lung cancer-specific mortality was 5.24 (95% CI: 2.88, 9.53) times higher in the high PM10 exposure group (PM10>19.82μg/m3) than in the low PM10 exposure group (PM10≤19.82μg/m3) in multivariable Cox proportional hazards model. The HR decreased to 1.87 (95% CI: 1.16, 2.98) in the competing risk model. The association between PM2.5 exposure and lung cancer survival was not statistically significant. For PM10, the high exposure group (150 days) suffered from a 193-day reduction in median survival time compared with the low exposure group (343 days) after adjusting age, socioeconomic status, temperature, wind speed, relative humidity, O3, NO, NO2, SO2, CO and PM2.5. Discussion: The correlation coefficient between PM and lung cancer mortality increases with the lagged years, reaching 0.9 in the fourth year and the highest in the seventh year. Therefore higher HR values for PM10 observed in this thesis can result from considering the latency effect of PM exposure. The association between PM2.5 exposure and lung cancer survival was not statistically significant. Highly correlated variables in this thesis may cause this result. Based on a shrunken survival time (a 193-day decrease in median survival) in the high PM10 exposure group (PM10>19.82μg/m3), this thesis proposes that PM10 exposure accelerates lung cancer progression in lung cancer patients. Conclusion: The finding that high PM10 exposure shortens lung cancer survival adds support for lung cancer patients to take action to reduce PM10 exposure, such as using an air purifier and avoiding outdoor activities when PM10 concentration is high. Future work can use the satellite-based measurement for accurate PM exposure estimates, increase the sample size, utilise a Cox proportional hazards model with time-dependent covariates or a non-proportional hazard model to deal with the inconstant hazard between high and low wind exposure groups, and account for additional variables, e.g., smoking, marital status and such.Item Open Access An investigation of stereotypy in relation to sleep disturbance in children on the autism spectrum : effectiveness of functional behaviour assessment-based interventions.(2022) Hunter, JoleneSleep is essential to our overall functioning and wellbeing. Children on the autism spectrum experience high rates of sleep problems that can be both chronic and severe, and which are associated with a wide range of detrimental effects for children and their families. Sleep problems can intensify the core symptoms of autism, including restricted and repetitive behaviours commonly known as stereotypy. The aetiology of sleep disturbance in autism is multifactorial, involving biological, psychological, social, medical, and environmental factors. Notwithstanding these determinants, sleep problems often have a behavioural basis. Functional behaviour assessment (FBA) is an evidence-based approach to identifying the environmental and behavioural factors underlying sleep problems for an individual, and to guiding the selection of behavioural sleep interventions (BSI). Children on the autism spectrum may engage in stereotypy at night, which may contribute to sleep problems by delaying sleep onset or the re-initiation of sleep following night wakings (NWs). It is generally unclear, however, whether established BSI techniques can effectively treat sleep-related stereotypy, particularly when it is automatically maintained, or which types of strategies may be required to treat such behaviour. Further, little is known about the characteristics of sleep-related stereotypic behaviours, nor its role in relation to sleep, including the extent to which stereotypy contributes to or is a co-occurring feature of sleep disturbance. Finally, there is lack of research investigating whether improving sleep problems may result in collateral benefits for children and parents, including children’s daytime stereotypy and wider symptoms of autism. The primary objectives of the present research were three-fold: (1) to investigate the effectiveness of function-based BSI to treat stereotypy in the context of sleep problems in children on the autism spectrum, and to examine the maintenance of treatment effects and acceptability to parents of the selected treatments; (2) to investigate whether and how stereotypy may contribute to sleep disturbance, and the characteristics (e.g., type, topography, function) of sleep-related stereotypy across individuals; and (3) to examine whether treating sleep problems produces collateral benefits for children and parents, including change in children’s daytime stereotypy. Three empirical studies in this thesis used single-case experimental (multiple baseline or AB) design to evaluate the utility of function-based BSI to treat sleep problems including sleep onset delay (SOD) and NWs in 12 children (5 girls and 7 boys, aged 3-10 years) with formal diagnoses of autism spectrum disorder. In 10/12 children, sleep-related stereotypy occurred during SOD and/or NWs and appeared to interfere with the initiation and/or re-initiation of sleep. A fourth, qualitative study thematically analysed the clinical assessment reports for 15 children on the autism spectrum (aged 3-15 years; including the children in Studies 1-3) to further examine the potential role of stereotypy within sleep problems, and characteristics of children’s behaviour. A systematic review of the research literature was conducted to investigate the types of collateral effects that may occur following a BSI for children on the autism spectrum. Psychometric measures administered pre- and post-treatment in Studies 1-3 of this thesis were used to assess whether the BSI produced change in core symptoms of autism and internalising and externalising symptoms in participant children, as well as in parents’ sleep quality, wellbeing, and relationship quality, with data examined using modified Brinley plots. Collectively, results demonstrate the preliminary effectiveness, durability, feasibility, and social validity of a variety of function-based BSI, including preliminary evidence for strategies that may effectively reduce automatically maintained sleep-related stereotypy. Tentative support was found for procedures that manipulate the motivating operations for stereotypy and sleep, including sleep restriction. Findings demonstrate that a heterogeneous range of behaviours including motor and vocal stereotypy and repetitive manipulation of objects can accompany sleep problems in children on the autism spectrum and may contribute to sleep disturbance by delaying the initiation of sleep, and/or re-initiation of sleep following NWs. Results also showed that stereotypy may differentially affect sleep across and within children, which may have differing implications for behavioural treatment. Finally, an evaluation of the collateral effects of BSI in the research literature and in participant children and parents in Studies 1-3 indicate that BSI may produce a range of untargeted, beneficial effects including a reduction in children’s daytime stereotypy, however, collateral effect results were mixed and inconsistent. Overall, findings emphasise the importance of utilising FBA to inform BSI for children on the autism spectrum, which may necessarily include strategies that specifically target automatically maintained behaviour. Future research is needed to better understand how sleep problems and core symptoms of autism interact across and within children, and address how these relationships are treated in the sleep context.Item Open Access An evaluation of the ParentWorks parenting programme for families with acknowledged care and protection issues.(2022) Keys, NikkiFamilies that have care and protection concerns are considered a high-risk cohort due to multiple risk factors such as psychosocial and socioeconomic stress and mental health concerns, which greatly increase the probability of child maltreatment. For this reason, many parents involved with child protection services have limited or no contact with their children, yet may still be expected to engage in parenting programmes as part of reunification plans. This study examined the efficacy of ParentWorks, a 13-week parenting programme based on the Positive Parenting Programme (Triple P; Sanders, 2008) and specifically adapted for high risk parents in Aotearoa New Zealand with care and protection concerns. This study employed a two-phase mixed methods research design. Quantitative data included pre- and post-programme measures of participant mental health (depression and anxiety) and stress (general tension/stress and parenting stress) from the last five years of the programme. Qualitative data, gathered through semi-structured interviews, examined recent participants’ reflections of the programme shortly after completing it, and their subjective accounts of changes in mental wellbeing and stress. Results from the quantitative analyses showed a nonsignificant trend towards improved mental health, with significant changes in participants’ self-reported stress. The findings from the qualitative data identified five themes from the interviews: programme benefits, applied learning, group connectedness, self-image, and general thoughts and suggestions for ParentWorks. Taken together, these results suggest that ParentWorks is effective in reducing stress symptoms among participants, while changes in mental health may be indirect and do not seem to be as closely connected with course participation. The findings are discussed in light of their consistency with prior literature showing quantitative analyses in similar populations and their fit with a meta-synthesis of parents’ qualitative experiences of parenting programmes. Finally, an application of a logic model from Triple P research is considered in relation to the ParentWorks programme, allowing exploration of potential areas for growth.