Distinct profiles of mental health need and high need overall among New Zealand adolescents - Cluster analysis of population survey data.

OBJECTIVE: The objective was to identify clinically meaningful groups of adolescents based on self-reported mental health and wellbeing data in a population sample of New Zealand secondary school students. METHODS: We conducted a cluster analysis of six variables from the Youth19 Rangatahi Smart Survey (n = 7721, ages 13-18 years, 2019): wellbeing (World Health Organization Well-Being Index), possible anxiety symptoms (Generalized Anxiety Disorder 2-item, adapted), depression symptoms (short form of the Reynolds Adolescent Depression Scale) and past-year self-harm, suicide ideation and suicide attempt. Demographic, contextual and behavioural predictors of cluster membership were determined through multiple discriminant function analysis. We performed cross-validation analyses using holdout samples. RESULTS: We identified five clusters (n = 7083). The healthy cluster (n = 2855, 40.31%) reported positive mental health across indicators; the anxious cluster (n = 1994, 28.15%) reported high possible anxiety symptoms and otherwise generally positive results; the stressed and hurting cluster (n = 667, 9.42%) reported sub-clinical depression and possible anxiety symptoms and some self-harm; the distressed and ideating cluster (n = 1116, 15.76%) reported above-cutoff depression and possible anxiety symptoms and high suicide ideation; and the severe cluster (n = 451; 6.37%) reported the least positive mental health across indicators. Female, rainbow, Maori and Pacific students and those in higher deprivation areas were overrepresented in higher severity clusters. Factors including exposure to sexual harm and discrimination were associated with increasing cluster severity. CONCLUSION: We identified high prevalence of mental health challenges among adolescents, with distinct clusters of need. Youth mental health is not 'one size fits all'. Future research should explore youth behaviour and preferences in accessing support and consider how to best support the mental health of each cluster.

Flexible resources and experiences of racism among a multi-ethnic adolescent population in Aotearoa, New Zealand: an intersectional analysis of health and socioeconomic inequities using survey data.

BACKGROUND: As societies become increasingly diverse, understanding the complex nature of racism for multiple ethnic, social, and economic identities of minority youth is required. Here we explore the experience of racism between and among privileged majority adolescent groups and targeted minority (Indigenous and ethnic) adolescents in New Zealand. Using the concept of structural and embodiment flexible resources, which act as risk and protective factors, we examine the social and health effects on minority youth. METHODS: In this intersectional analysis, we use self-reported data from the Youth2000 survey series administered in 2001, 2007, 2012, and 2019 to large, representative samples of students from mainstream state and private schools in the Auckland, Tai Tokerau, and Waikato regions of New Zealand. Students were in school years 9-13 and mostly aged 13-17 years. Ethnic or migrant group, income level of country of origin, and migrant generation were used as measures of structural resources and perceived ethnicity as a measure of embodiment resource. Racism and its effects were measured as socioeconomic inequities (household, neighbourhood, and school-level deprivation); interpersonal discrimination (unfair treatment, bullying, and safety); and health inequities (forgone health care, symptoms of depression, and attempted suicide). We used generalised linear models to explore variations in economic, interpersonal, and health outcomes for Indigenous and migrant youth, adjusting for mediating effects of household deprivation and measures of flexible resources (migration generation, income level of country of origin, and perceived ethnicity). FINDINGS: We collected data from a total of 20 410 adolescents from the four survey waves between 2001 and 2019. Participants had a median age of 15 years (IQR 14-16). Socioeconomic, interpersonal, and health inequities varied with access to flexible resources among Maori and racialised migrant youth. Maori and racialised migrants from low-income and middle-income countries in particular experienced high levels of socioeconomic inequities. Racialised migrant youth experienced persistent socioeconomic inequities extending over three generations, especially Pasifika migrant adolescents. Minorities perceived as White experienced less discrimination and had more advantages than visibly racialised groups. Regression models showed that embodiment resources, and to a lesser extent structural resources, mediated, but did not eliminate ethnic disparities in socioeconomic status and interpersonal discrimination; these resources did not strongly mediate ethnic disparities in health. Trend analyses indicate consistency in these patterns with ethnicity-based inequities persisting or increasing over time. INTERPRETATION: Indigenous and ethnic minority experiences of racism are heterogeneous. Structural flexible resources (wealth) and, more substantially, embodiment flexible resources (perceived Whiteness) mitigate individual experiences of racism. In multi-ethnic western societies, anti-racist interventions and policies must address both structural deprivation and associated intergenerational mobility and colourism (ie, implicit and explicit bias against non-White youth). FUNDING: Health Research Council of New Zealand.

Rapid and unequal decline in adolescent mental health and well-being 2012-2019: Findings from New Zealand cross-sectional surveys.

OBJECTIVE: To investigate prevalence and trends in key mental health and well-being indicators among New Zealand secondary school students. METHODS: Representative cross-sectional youth health surveys with 2-4% of the New Zealand secondary school population were conducted in 2001, 2007, 2012 and 2019 (total n = 34,548). RESULTS: In 2019, 69.1% reported good well-being (95% confidence interval = [67.6, 70.6]; World Health Organization 5-item), 22.8% reported clinically significant depression symptoms (95% confidence interval = [21.4, 24.1]; Reynolds Adolescent Depression Scale-Short Form) and 41.8% reported possible anxiety symptoms (95% confidence interval = [40.5, 43.2]; Generalized Anxiety Disorder 2, adapted). Past-year prevalence of periods of low mood (38.3%, 95% confidence interval = [36.6, 40.1]), deliberate self-harm (24.1%, 95% confidence interval = [22.8, 25.4]), suicide thoughts (20.8%, 95% confidence interval = [19.2, 22.4]) and suicide attempts (6.3%, 95% confidence interval = [5.5, 7.0]) were observed. After relative stability from 2001 to 2012, there were large declines in mental health to 2019. The proportion reporting good well-being decreased (odds ratio 0.71, 95% confidence interval = [0.65, 0.78], p < 0.001), depression symptoms increased (odds ratio 1.96, 95% confidence interval = [1.75, 2.20], p < 0.001) and past-year suicide thoughts and suicide attempts increased (odds ratio 1.41, 95% confidence interval = [1.25, 1.59], p < 0.001; odds ratio 1.60, 95% confidence interval = [1.32, 1.92], p < 0.001). Past-year deliberate self-harm was largely stable. Declines in mental health were unevenly spread and were generally greater among those with higher need in 2012 (females, Maori and Pacific students and those from higher deprivation neighbourhoods), increasing inequity, and among Asian students. CONCLUSION: Adolescent mental health needs are high in New Zealand and have increased sharply from 2012 among all demographic groups, especially females, Maori, Pacific and Asian students and those from high-deprivation neighbourhoods. Ethnic and socioeconomic disparities have widened.

Prevalence, severity and impact of chronic pain among a representative cross-sectional study of New Zealand high school students.

AIM: To report the prevalence of self-reported chronic pain and severity among young people in New Zealand and explore the relationships between pain and mental health, substance use, socialisation and school engagement. METHODS: Prevalence of self-reported chronic pain frequency and severity are reported from an anonymous, representative cross-sectional self-administered health and well-being questionnaire by students aged 12-18 years in New Zealand. Multivariable models exploring chronic pain and mental health, substance use, socialisation and school engagement are reported controlling for age, sex, ethnicity, socio-economic status, disability and history of sexual abuse. RESULTS: Overall, 22.8% (95% confidence interval (CI) 21.2-24.5) of young people reported chronic pain for 6 months or more, with 3.2% (95% CI 3.1-4.5) reporting severe pain weekly or more often. Females and rural adolescents were more likely to report chronic and severe pain. Asian youth reported less pain than other ethnic groups. Increased severity of pain was associated more with poorer daily functioning and socialising than with frequency of pain. Severe pain occurring weekly or more often was more common among students who had a disability (2.3% 95% CI 1.8-2.7 vs. 9.8%, 95% CI 7.2-12.5) or a history of sexual abuse (2.4% 95% 1.9-2.9 vs. 8.5%, 95% CI 6.3-10.5). Those reporting chronic pain had higher proportions of self-reported significant depressive symptoms, lower well-being, lower school engagement and lower access to health care, particularly for those reporting higher levels of intensity and frequency of pain. CONCLUSIONS: Chronic pain is common in adolescent populations, and has a significant association with decreased daily functioning, socialising, school engagement and mental well-being. Adolescents with chronic pain report significant unmet health-care needs.

Conceptualising relational care from an Indigenous Maori perspective: A scoping review.

OBJECTIVE: To identify and describe the attributes of relational care from an Indigenous Maori healthcare consumer perspective. DATA SOURCES: CINAHL Plus, Ovid MEDLINE, ProQuest Nursing & Allied Health, Scopus, New Zealand Index, the Ministry of Health Library, New Zealand Research and Google Scholar were searched between 23 and 30 May 2022. METHODS: This scoping review used the Joanna Briggs Institute methodology for scoping reviews, thematic analysis and the Patterns, Advances, Gaps, Evidence for practice and Research recommendations framework for the synthesis of the findings. RESULTS: A total of 1449 records were identified, and 10 sources were selected for final review. We identified five relational attributes that were most important to Maori: (1) the expressive behaviours and characteristics of healthcare professionals (HCPs), (2) communication to facilitate the healthcare partnership, (3) appreciating differing worldviews, (4) the context in which healthcare is delivered and (5) whanaungatanga (meaningful relationships). CONCLUSION: The relational attributes identified are inextricably linked. Connecting with HCPs and developing a therapeutic relationship is fundamental to improving consumer experience and engagement with mainstream healthcare services. Whanaungatanga is fundamental to meaningful engagements with HCPs. Future research should explore how relational care is practiced in acute care settings when clinician-consumer interactions are time-limited, examine how the health system influences the capacity for relational care and how Indigenous and Western paradigms can co-exist in healthcare. IMPLICATIONS: This scoping review can inform future projects addressing health equity for Indigenous communities by creating environments that prioritise culturally safe relational care and value Indigenous knowledge systems. REPORTING METHOD: We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. NO PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Indigenous social exclusion to inclusion: Case studies on Indigenous nursing leadership in four high income countries.

AIMS AND OBJECTIVES: This discursive paper provides a call to action from an international collective of Indigenous nurse academics from Australia, Canada, Aotearoa New Zealand and the USA, for nurses to be allies in supporting policies and resources necessary to equitably promote Indigenous health outcomes. BACKGROUND: Indigenous Peoples with experiences of colonisation have poorer health compared to other groups, as health systems have failed to address their needs and preferences. Achieving health equity will require leadership from Indigenous nurses to develop and implement new systems of care delivery. However, little is known about how Indigenous nurses influence health systems as levers for change. DESIGN: A Kaupapa Maori case study design. METHODS: Using a Kaupapa Maori case study methodology, coupled with expert Indigenous nursing knowledge, we developed a consensus on key themes. Themes were derived from three questions posed across the four countries. Themes were collated to illustrate how Indigenous nurses have provided nursing leadership to redress colonial injustices, contribute to models of care and enhance the Indigenous workforce. RESULTS: These case studies highlight Indigenous nurses provide strong leadership to influence outcomes for Indigenous Peoples. Five strategies were noted across the four countries: (1) Indigenous nationhood and reconciliation as levers for change, (2) Indigenous nursing leadership, (3) Indigenous workforce strategies, (4) Development of culturally safe practice and Indigenous models of care and (5) Indigenous nurse activism. CONCLUSIONS: In light of 2020 declared International Year of the Nurse and Midwife, we assert Indigenous nurses' work must be visible to support development of strategic approaches for improving health outcomes, including resources for workforce expansion and for implementing new care models. RELEVANCE TO CLINICAL PRACTICE: Curating strategies to promote Indigenous nurse leaders around the world is essential for improving models of healthcare delivery and health outcomes for Indigenous Peoples.

Effects of Ethnic Classification on Substantive Findings in Adolescent Mental Health Outcomes.

Although most adolescents are healthy, epidemiological studies show that a significant number experience mental health challenges, and that Indigenous and ethnic minority youth tend to have poorer mental health outcomes. However, ethnic classification in adolescence is complex due to increasing multi-ethnic identification, and little is known about how different classification methods affect research conclusions. This study used a nationally representative adolescent sample from Aotearoa New Zealand (N = 8275; ages 12-18; 55% female; 32% multi-ethnic) to investigate the effects that five ethnic classification methods have on substantive findings in three mental health outcomes: overall psychosocial difficulties, deliberate self-harm, and suicide attempts. The results showed that, depending on the classification method used, reported outcomes within the same nominal ethnic group varied by an effect size (d) of up to 0.12, and the reported magnitude of difference between nominal ethnic groups varied by an effect size (d) of up to 0.25. These effects are substantial given that they are solely due to a change in method. The impact that ethnic classification method has on substantive findings highlights the importance of criticality and transparency in research involving ethnicity data.

Demographic discrepancies between administrative-prioritisation and self-prioritisation of multiple ethnic identifications.

Ethnic classification is an inherently subjective process, especially when multiple ethnic identifications are involved. There are two methods commonly used to classify multiple ethnicities into single categories: administrative-prioritisation (assignment via a predetermined hierarchy) and self-prioritisation (where individuals select their "main" ethnicity). Currently, little is known about whether the demographic composition of outputted ethnic groups differs by prioritisation method. This study utilised large-scale data of multi-ethnic children (N = 1,860), adolescents (N = 2,413), and adults (N = 1,056) from Aotearoa New Zealand to examine individual and contextual demographic characteristics associated with discrepancies between administratively-prioritised and self-prioritised ethnicity. Results showed that discrepancy rates, which exceeded 50%, were systematically associated with neighbourhood ethnic composition and socioeconomic deprivation, but largely not associated with gender, age, and birthplace. The contextual nature of self-prioritisation highlights the importance of researchers' choice of ethnic classification method. Implications are discussed in the context of increasing multi-ethnic prevalence.

Ethnicity classification systems for public health surveys: experiences from HIV behavioural surveillance among men who have sex with men.

BACKGROUND: Race and ethnicity classification systems have considerable implications for public health, including the potential to reveal or mask inequities. Given increasing "super-diversity" and multiple racial/ethnic identities in many global settings, especially among younger generations, different ethnicity classification systems can underrepresent population heterogeneity and can misallocate and render invisible Indigenous people and ethnic minorities. We investigated three ethnicity classification methods and their relationship to sample size, socio-demographics and sexual health indicators. METHODS: We examined data from New Zealand's HIV behavioural surveillance programme for men who have sex with men (MSM) in 2006, 2008, 2011, and 2014. Participation was voluntary, anonymous and self-completed; recruitment was via community venues and online. Ethnicity allowed for multiple responses; we investigated three methods of dealing with these: Prioritisation, Single/Combination, and Total Response. Major ethnic groups included Asian, European, indigenous Maori, and Pacific. For each classification method, statistically significant associations with ethnicity for demographic and eight sexual health indicators were assessed using multivariable logistic regression. RESULTS: Overall, 10,525 MSM provided ethnicity data. Classification methods produced different sample sizes, and there were ethnic disparities for every sexual health indicator. In multivariable analysis, when compared with European MSM, ethnic differences were inconsistent across classification systems for two of the eight sexual health outcomes: Maori MSM were less likely to report regular partner condomless anal intercourse using Prioritisation or Total Response but not Single/Combination, and Pacific MSM were more likely to report an STI diagnosis when using Total Response but not Prioritisation or Single/Combination. CONCLUSIONS: Different classification approaches alter sample sizes and identification of health inequities. Future research should strive for equal explanatory power of Indigenous and ethnic minority groups and examine additional measures such as socially-assigned ethnicity and experiences of discrimination and racism. These findings have broad implications for surveillance and research that is used to inform public health responses.

What has changed from 2001 to 2012 for sexual minority youth in New Zealand?

AIM: To provide an overview of the health and well-being of sexual minority high school students in New Zealand, investigate differences between sexual minority youth (SMY) and exclusively opposite-sex-attracted youth (EOSAY), and examine changes across survey waves. METHODS: Nationally representative cross-sectional surveys were completed in 2001 (n = 9011), 2007 (n = 8002) and 2012 (n = 8167). Logistic regressions were used to examine the associations between selected outcomes and sexual attraction across survey waves. RESULTS: SMY accounted for 6% of participants in all three waves, with a greater proportion being 'out' in 2012 (P < 0.0001). SMY were more likely to work as volunteers (OR = 1.37) than EOSAY, and the majority of SMY reported good general health, liking school and having caring friends. With the exceptions of binge drinking and being driven dangerously by someone, SMY reported comparatively diminished health and well-being relative to EOSAY. Increasing proportions of SMY had depressive symptoms from 2001 (OR = 2.38) to 2012 (OR = 3.73) compared with EOSAY. There were some differences between the sexes; female SMY were less likely to report positive family relationships (OR = 0.59) and liking school (OR = 0.55), and they were more likely to have been hit (2012 OR = 1.95) than female EOSAY. Male SMY reported especially high rates of suicide attempts (2012 OR = 5.64) compared with male EOSAY. CONCLUSIONS: Health services, schools, communities and families must be more responsive to the needs of SMY to ensure that disparities are addressed.

Factors associated with consistent contraception and condom use among Maori secondary school students in New Zealand.

AIMS: The aims of this study are to provide a profile of sexual health behaviours of Maori youth and to identify factors associated with consistent condom and contraception use. METHODS: Multivariable analyses were conducted to determine relationships between consistent contraception and condom use among all 2059 sexually active Maori participants in the 2007 New Zealand youth health and well-being survey of secondary school students. RESULTS: Forty per cent of Maori students were currently sexually active; of these, 55.3% always used contraception, and 41.1% always used condoms. Risk factors for not using contraception were less than or equal to three sexual partners (males odds ratio (OR) 0.55, P = 0.04, females OR 0.35, P = 0.04) and regular cigarette use for females (OR 0.52, P = 0.02). Risk factors for not using condoms were 13- to 15-year-old females (OR 1.95, P < 0.01) and females who enjoyed sex (OR 0.52, P = 0.02). Family connection was associated with increased use of condoms among males (OR 1.07, P < 0.01). CONCLUSIONS: Reducing sexual risks, increasing opportunities for healthy youth development and family connectedness, alongside access to appropriate services, are required to improve the sexual health of Maori youth.

Impacts of sociodemographic factors, identities and neighbourhood safety on the relationship between urban green space and adolescent mental well-being: Findings from Tamaki Makaurau Auckland, Aotearoa New Zealand.

This study explored the relationship between green space accessibility (GSA) in residential area and adolescents' mental well-being, and whether the relationship was moderated by sociodemographic factors (sex, ethnicity, neighbourhood deprivation), identities (gender and sexuality minority, disability) and perceived neighbourhood safety simultaneously. Data from 3813 adolescents who lived in Tamaki Makaurau Auckland, Aotearoa New Zealand were obtained from the Youth19 Rangatahi Smart Survey. A Gaussian-based two-step floating catchment area method was employed to measure the spatial accessibility to green space at the neighbourhood level. The World Health Organization-5 Well-being Index was used to assess emotional well-being (EW), and the Reynolds Adolescent Depression Scale-short form was employed to measure depressive symptoms (DS). Through moderation analyses, results showed that perceived neighbourhood safety plays a vital role in the GSA - mental well-being association, with a negative trend in adolescents who reported being less safe in neighbourhoods. Adverse associations of GSA were found in gender and sexuality minority, disabled, Asian and Pacific adolescents, under the condition of not feeling safe in neighbourhoods all the time. The results showed marginalised adolescents tended to feel less safe in neighbourhoods, have lower EW and a higher level of DS. Additionally, the results from bivariate correlations showed there were inequalities in GSA for adolescents who lived in most deprived neighbourhoods and adolescents of Maori ethnicity. This study provides novel evidence of the importance of safe and inclusive green space for effectively promoting mental health and mitigating health inequalities of adolescents in urban areas.

RANGATAHI MAORI AND THE WHANAU CHOCOLATE BOX: Rangatahi wellbeing in whanau contexts.

Whanau (Maori understandings of family) are comprised of unique and vital relationships that support and scaffold rangatahi (youth) wellbeing, yet are often reduced to nuclear family structures within individualised notions of wellbeing. While rangatahi contend with racialised discourses in a colonial socio-cultural context, their whanau can be an important site for mitigating these challenges, supporting rangatahi agency and wellbeing. This article explores how whanau practices inform rangatahi wellbeing, drawing upon photo-projects and interviews with 51 rangatahi and their whanau. Interviews were thematically analysed, informing four themes that drew on Maori (the Indigenous people of Aotearoa) concepts and whakatauki: te haerenga whakamua, kotahitanga, he toa takitini and tatai hono. These themes speak to the significance of vitalising relationships between rangatahi, their whanau and beyond. We outline a strengths-based activity with rangatahi and their whanau, identifying and drawing from the delightful array of whanau relationships, qualities and characteristics that may be likened to a 'whanau chocolate box' for rangatahi to derive influence, systems of support and inspiration for future identities and inspiration.

Inequities in adolescent sleep health in Aotearoa New Zealand: Cross-sectional survey findings.

OBJECTIVES: To investigate ethnic inequities in, and social determinants of, adolescent sleep health in Aotearoa New Zealand. METHODS: Analysis of self-report data from a cross-sectional survey of secondary school students (12- to 18-year-olds). Analyses included weighted prevalence estimates of good and poor sleep health stratified by ethnicity, and multivariable logistic regression models concurrently adjusted for ethnicity, school year, gender, rurality, neighborhood deprivation, school decile, housing deprivation, sleeping elsewhere due to lack of adequate housing, unsafe environment, and racism. RESULTS: Inequities in social determinants of health were evident for Maori (Indigenous peoples of Aotearoa New Zealand; n = 1528) and minoritized (Pacific n = 1204; Asian n = 1927; Middle Eastern, Latin American, and African [MELAA] n = 210; and 'Other' ethnicity n = 225) adolescents. A greater proportion of Maori, Pacific, Asian, MELAA, and 'Other' adolescents had short sleep, compared to European (n = 3070). Maori, Pacific, Asian, and MELAA adolescents were more likely to report late bedtimes (after midnight), and Maori, Pacific, and 'Other' adolescents were more likely to report early waketimes (5 AM-6 AM or earlier), on school days. Rurality, neighborhood deprivation, school-level deprivation, housing deprivation, sleeping elsewhere due to inadequate housing, unsafe environments, and racism partially, but not fully, explained associations between ethnicity and short sleep, late bedtimes, and early waketimes. CONCLUSIONS: Ethnic inequities exist in adolescent sleep health in Aotearoa New Zealand. Socio-political actions are needed to address racism and colonialism as root causes of ethnic inequities in adolescent sleep, to ensure all young people are afforded the basic human right of good sleep health and associated mental and physical well-being.

Health and well-being needs of Indigenous adolescents: a protocol for a scoping review of qualitative studies.

INTRODUCTION: Improving the health of Indigenous adolescents is central to addressing the health inequities faced by Indigenous peoples. To achieve this, it is critical to understand what is needed from the perspectives of Indigenous adolescents themselves. There have been many qualitative studies that capture the perspectives of Indigenous young people, but synthesis of these has been limited to date. METHODS AND ANALYSIS: This scoping review seeks to understand the specific health needs and priorities of Indigenous adolescents aged 10-24 years captured via qualitative studies conducted across Australia, Aotearoa New Zealand, Canada, the USA, Greenland and Sami populations (Norway and Sweden). A team of Indigenous and non-Indigenous researchers from these nations will systematically search PubMed (including the MEDLINE, PubMed Central and Bookshelf databases), CINAHL, Embase, Scopus, the Informit Indigenous and Health Collections, Google Scholar, Arctic Health, the Circumpolar Health Bibliographic Database, Native Health Database, iPortal and NZresearch.org, as well as specific websites and clearinghouses within each nation for qualitative studies. We will limit our search to articles published in any language during the preceding 5 years given that needs may have changed significantly over time. Two independent reviewers will identify relevant articles using a two-step process, with disagreements resolved by a third reviewer and the wider research group. Data will then be extracted from included articles using a standardised form, with descriptive synthesis focussing on key needs and priorities. This scoping review will be conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. ETHICS AND DISSEMINATION: Ethics approval was not required for this review. Findings will be disseminated via a peer-reviewed journal article and will inform a broader international collaboration for Indigenous adolescent health to develop evidence-based actions and solutions.

More-Than-Human: A Cross-Sectional Study Exploring Children's Perceptions of Health and Health-Promoting Neighbourhoods in Aotearoa New Zealand.

A disconnect between children's ideas and their incorporation into environmental design, in the context of rapid urbanisation and climate crises, compelled us to reflect on children's meaningful participation in positive environmental change. Our research aimed to bring new knowledge to the fore using a participatory, child-centred approach to understanding children's perceptions of health and health-promoting neighbourhoods in Aotearoa New Zealand. The cross-sectional Neighbourhoods and Health study was conducted with 93 primary school-aged children (approximate ages 8 to 10 years) from two schools in Otepoti Dunedin and two schools in Tamaki Makaurau Auckland from June 2020 to August 2021. We present a framework of twelve child-centred topics of importance for health (Healthcare and 'not getting sick', 'How you feel', and Taking care of yourself), health-promoting neighbourhoods (Proximity, safety and feel, Range of 'places to go', 'Friendly streets', and 'No smoking'), and those common to both (Connections with other humans, Healthy food and drink, Exercising and playing sport 'to keep fit', 'Nature' and 'helping the environment', and Recreational activities). The more-than-human theory was used to situate our study findings, and we explored three threads evident in children's thinking: (1) care for humans and non-humans, (2) vital interdependence of human-non-human relations, and (3) understanding complex urban environments through everyday activities. We conclude that the thriving of humans and non-humans in urban environments is important to children in Aotearoa New Zealand. We affirm that children have clear and salient ideas about health and health-promoting neighbourhoods.

Indigenous adolescent health in Aotearoa New Zealand: Trends, policy and advancing equity for rangatahi Maori, 2001-2019.

Background: Rangatahi Maori, the Indigenous adolescents of Aotearoa New Zealand (NZ), have poorer health outcomes than Pakeha (NZ European /other European/"White") adolescents. We explored the influence of policies for Indigenous youth by presenting health trends, inequities and contrasting policy case examples: tobacco control and healthcare access. Methods: Cross-sectional representative surveys of NZ secondary school students were undertaken in 2001, 2007, 2012 and 2019. Health indicators are presented for Maori and Pakeha adolescents (relative risks with 95% CI, calculated using modified Poisson regression) between 2001-2019 and 2012-2019. Policy examples were examined utilising Critical Te Tiriti Analysis (CTA). Findings: Rangatahi Maori reported significant health gains between 2001 and 2019, but an increase in depressive symptoms (13.8% in 2012 to 27.9% in 2019, RR 2.01 [1.65-2.46]). Compared to Pakeha youth there was a pattern of persistent Maori disadvantage, particularly for racism (RR 2.27 [2.08-2.47]), depressive symptoms (RR 1.42 [1.27-1.59]) and forgone healthcare (RR 1.63 [1.45-1.84]). Tobacco use inequities narrowed (RR 2.53 [2.12-3.02] in 2007 to RR 1.55 [1.25-1.93] in 2019). CTA reveals rangatahi Maori-specific policies, Maori leadership, and political support aligned with improved outcomes and narrowing inequities. Interpretation: Age-appropriate Indigenous strategies are required to improve health outcomes and reduce inequities for rangatahi Maori. Characteristics of effective strategies include: (1) evidence-based, sustained, and comprehensive approaches including both universal levers and Indigenous youth-specific policies; (2) Indigenous and rangatahi leadership; (3) the political will to address Indigenous youth rights, preferences, priorities; and (4) a commitment to an anti-racist praxis and healthcare Indigenisation. Funding: Two Health Research Council of New Zealand Project Grants: (a) Fleming T, Peiris-John R, Crengle S, Parry D. (2018). Integrating survey and intervention research for youth health gains. (HRC ref: 18/473); and (b) Clark TC, Le Grice J, Groot S, Shepherd M, Lewycka S. (2017) Harnessing the spark of life: Maximising whanau contributors to rangatahi wellbeing (HRC ref: 17/315).

New Zealand Youth19 survey: vaping has wider appeal than smoking in secondary school students, and most use nicotine-containing e-cigarettes.

OBJECTIVE: To investigate smoking and vaping in secondary school students (aged 13-18 years) in New Zealand (NZ) following the introduction of 'pod' e-cigarettes, which have been associated with the rapid escalation of youth vaping elsewhere. METHODS: Data on smoking and vaping were collected in 2019 as part of a comprehensive youth health survey (N=7,721). RESULTS: Vaping was 2-3 times more prevalent than smoking, with 10% of students vaping regularly (monthly or more often), and 6% weekly or more often, compared with 4% and 2%, respectively, for tobacco smoking. Nicotine-containing e-cigarettes were sometimes or always used by 80% of regular and 90% of weekly vapers. Regular and weekly smoking was rare in low deprivation (affluent) areas, whereas regular and weekly vaping prevalence was similar across the socioeconomic spectrum. More than 80% of ever-vapers (N=2732) reported they were non-smokers when they first vaped, and 49% of regular vapers (N=718) had never smoked. CONCLUSIONS: A significant proportion of New Zealand adolescents, many of whom have never smoked, use nicotine-containing e-cigarettes regularly. Implications for public health: Vaping is less harmful than smoking, but it is not harmless. Public health action is needed to support young non-smokers to remain smokefree and vape-free.

The Associations Between Cultural Identity and Mental Health Outcomes for Indigenous Maori Youth in New Zealand.

Objectives: To explore the relationships between Maori cultural identity, ethnic discrimination and mental health outcomes for Maori youth in New Zealand. Study Design: Nationally representative, anonymous cross-sectional study of New Zealand secondary school students in 2012. Methods: Secondary analysis of Maori students (n = 1699) from the national Youth'12 secondary school students survey was undertaken. Theoretical development and exploratory factor analysis were undertaken to develop a 14-item Maori Cultural Identity Scale (MCIS). Maori students reporting > 8 items were classified as having a strong MCIS. Prevalence of indicators were reported and logistic regression models were used to explore how wellbeing (WHO-5), depressive symptoms (Reynolds Adolescent Depression Scale-SF), and suicide attempts were associated with the MCIS. Results: After adjusting for age, sex, ethnic discrimination and NZ Deprivation Index (NZDep), a strong Maori cultural identity (MCIS) was associated with improved wellbeing scores (OR 1.53, 95% CI 1.18-2.01) and fewer depressive symptoms (OR 0.53, 95% CI 0.38-0.73). Experiencing discrimination was associated with poorer wellbeing scores (OR 0.50, 95% CI 0.39-0.65), greater depressive symptoms (OR 2.2, 95% CI 1.55-3.18), and a previous suicide attempt (OR 2.47, 95% CI 1.71-3.58). Females less frequently reported good (WHO-5) wellbeing (OR 0.33, 95% CI 0.26-0.42), increased (RADS-SF) depressive symptoms (2.61, 95% CI 1.86-3.64) and increased suicide attempts [OR 3.35 (2.07-5.41)] compared to males. Wellbeing, depressive symptoms and suicide attempts did not differ by age or neighborhood level socio-economic deprivation, except those living in neighborhoods characterized as having medium level incomes, were less likely to have made a suicide attempt (OR 0.49, 95% CI 0.27-0.91). Conclusions: Maori youth who have a strong cultural identity were more likely to experience good mental health outcomes. Discrimination has a serious negative impact on Maori youth mental health. Our findings suggest that programmes, policies and practice that promote strong cultural identities and eliminate ethnic discrimination are required to improve mental health equity for Maori youth.

Health and wellbeing of Maori secondary school students in New Zealand: Trends between 2001, 2007 and 2012.

OBJECTIVE: To describe the health status over time of Maori secondary school students in New Zealand compared to European students. METHODS: Anonymous representative health surveys of New Zealand secondary school students were conducted in 2001, 2007 and 2012 (total n=27,306 including 5,747 Maori). RESULTS: Compared to 2001, Maori students in 2012 experienced improved health, family and school connections. However, considerable inequity persists with Maori students reporting poorer health, greater exposure to violence and socioeconomic adversity compared to European students. When controlling for socioeconomic deprivation, inequity was substantially reduced, although worse Maori health outcomes remained for general health, mental health, contraceptive use, healthy weight, substance use, access to healthcare and exposure to violence. There was some evidence of convergence between Maori and European students on some indicators. CONCLUSIONS: There have been significant improvements for Maori youth in areas of health where there has been investment. Priority areas identified require adequate resourcing alongside addressing systematic discrimination and poverty. Implications for public health: Socioeconomic contexts, discrimination, healthcare access and identified priority health areas must be addressed to improve equity for Maori youth. Building on these gains and hastening action on indicators that have not improved, or have worsened, is required.