Use of advance directives to facilitate supported decision-making in mental healthcare: learnings from Aotearoa New Zealand

Background Mental health peer support has grown significantly worldwide within the last three decades. As with other nations, Aotearoa New Zealand is currently in the process of expanding the peer support workforce within its mental health system. This is a promising development because peer supporters have the ability to make unique epistemic contributions to service delivery due to their distinct lived experience epistemologies and practices. Indeed, policy documents tend to charactertise the potential of peer support as transformative. However, literature has indicated that peer supporters face challenges when working within traditional mental health spaces. These include distrust from other mental health professionals, struggling against a dominant biomedical framing of mental distress, feeling relegated to an assistant clinician role, and ambiguities concerning role definition and scope. In this thesis I explore whether and how these challenges may contribute to peer supporters experiencing epistemic injustice. Aim I sought to explore how peer supporters experience and understand the epistemic conditions within the mental health system and what causal mechanisms may contribute to epistemic injustice in this context. As part of this investigation, I aimed to identify key factors that can aid in protecting peer support’s epistemic qualities when situated within mainstream mental health services. Methods I took a critical realist informed, contextual epistemic injustice approach to this research. The main phase of the study comprised 28 interviews, with 14 peer supporters and 14 clinicians. Following this, I drafted themes and a preliminary framework for peer support epistemic justice and consulted with six peer supporters to review the framework and develop it further. I analysed data using a critical realist adaptation of thematic analysis that considered epistemic injustice within each domain of critical realism’s stratified conception of reality. These findings were synthesised following consultation in order to create a framework that may facilitate peer support epistemic justice within Aotearoa New Zealand’s mental health system. Findings Peer supporters are well positioned to aid in system and service transformation. Their knowledge is derived from lived experience of mental distress and mental health services, resulting in a unique standpoint to provide compelling and actionable insights. Peer support’s lineage is partly within activist grassroots movements which held mainstream mental health systems to account. Elements of this adversarial relationship continue, with peer supporters frequently perceived as a counterbalancing force to clinical orientated services. The transformative discourse associated with peer supporters in policy suggests that peer supporters possess knowledge that is compelling, distinctive and disruptive to existing systems. Peer supporters operate within an epistemically precarious position in Aotearoa New Zealand. They are expected to transform the mental health system and challenge clinical culture within mental health services – while being paid less than other professions and lacking the usual markers of legitimacy that denote epistemic authority. Peer supporters are near the bottom of a systemic knowledge hierarchy which enshrines a medical episteme as the highest form of mental health knowledge. As a practice and knowledge system, peer support is at risk of losing its distinctive features and falling into a ‘mini clinician’ role. Being explicitly ‘out’ as having had mental health challenges can lead to stigmatising responses from mental health providers and further devalue how peer support knowledge is received. The epistemic agency of peer supporters can be protected by developing robust peer support leadership positions, orientating clinicians to the peer support’s role and historical context and building up national-scale advocacy and representation. The move to integrate peer supporters into mental health services must be paired with a sustained effort to ensure their knowledge system and epistemic agency are protected. Conclusions Peer support knowledge systems can positively impact Aotearoa New Zealand’s mental health system and mental health systems around the globe. As a workforce that straddles the line between experiential knowledge and professional training, peer supporters are particularly equipped to strengthen the voice of tāngata whaiora (service users) who themselves are at a marked risk of facing epistemic injustice. However, actualising their potential will require attending to the structural and relational conditions within the system which inhibit flourishing of peer supporter knowledge. This research is among the first to investigate epistemic injustice within a peer support context. Peer support is positioned by policy as a force for transformation but this transformative capability rests upon a move towards epistemic justice.

<p><strong>d/Deaf and hard of hearing people are disproportionately over-represented in prisons worldwide.</strong></p><p>There is a dearth of literature on the experiences of incarcerated d/Deaf and hard of hearing people, but existing literature is clear that this cohort experiences barriers during incarceration.</p><p>This research responds to the gap in literature, seeking a deeper qualitative understanding of the nature of supports for d/Deaf and hard of hearing people in prison in Aotearoa New Zealand.</p><p>This research examines the experiences of d/Deaf and hard of hearing people incarcerated in Aotearoa New Zealand and asks what barriers this cohort faces to accessing health and mental wellbeing care, what creates these barriers, and what support is needed.</p><p>This deeper qualitative understanding derives from semi-structured interviews with six professionals who support d/Deaf and hard of hearing people who are, or have been, incarcerated in Aotearoa New Zealand. These professionals have been working in their respective fields for decades and are either Deaf or work closely with the Deaf community, necessitating the use of New Zealand Sign Language in some interviews. Participant's experiences were analysed within the context of settler colonialism, audism, and oralism.</p><p>This thesis found prisons are a site of harm where d/Deaf and hard of hearing people experience barriers to accessing support for mental wellbeing and health care, as well as to accessing entertainment, grievance processes, and rehabilitation programs. Findings include that prison is audist-centric, the state creates and enforces barriers to health care for d/Deaf and hard of hearing people, communication is important but interpreters are not uniformly provided, and that these realities are detrimental to d/Deaf and hard of hearing people’s wellbeing. Participants’ calls for change, at an interpersonal, policy, state, and legislative level, echoed those of the existing literature. Highlighting d/Deaf and hard of hearing people’s negative experiences of incarceration has implications for how prisons regard human rights in their policies and practices. This thesis encourages ethical research in this space, honouring d/Deaf and hard of hearing people’s unique culture and characteristics.</p>

<p>While we know that rainbow people in Aotearoa New Zealand (that is, people of diverse sexualities, genders, and sex characteristics) experience high rates of adverse mental health outcomes, we know much less about the extent to which Aotearoa’s rainbow community members are receiving the mental health support they need. To address this gap I used mixed methods and a reflexive community-based approach to extend current understandings of rainbow mental health support experiences, and to explore how the provision of mental health care can be improved for rainbow people in New Zealand. I first conducted interviews with 34 rainbow community young adults about their experiences of accessing mental health support. My thematic analysis showed that rainbow people across New Zealand faced significant structural barriers to accessing mental health support. Participants understood mental health settings as embedded within a heteronormative and cisnormative societal context, rather than as a safe place outside this context. This, together with a widespread silence from mental health professionals around rainbow identity, meant that participants actively negotiated coming out in mental health settings. Participants shared a variety of perspectives as to whether it should be standard practice for mental health professionals to ask about rainbow identities, but agreed on a number of subtle acts that could communicate a professional or service is rainbow-friendly. Knowledge about sexuality, gender, and sex characteristic diversity, together with clinical skills of empathy, validation, and affirmation, were described as key components for the provision of effective mental health support. I conducted a second thematic analysis of data from a subset of the initial interviews, in which 13 participants discussed their experiences of accessing gender-affirming healthcare. Participants reported a lack of funding for gender-affirming healthcare in New Zealand, and described its provision a “postcode lottery”; the care available was largely dependent on the region participants were living in. Mental health assessments for accessing gender-affirming care were often described as tests of whether participants were “really” transgender, and participants discussed the need to express their gender in a particular way in order to access the healthcare they needed. Thematic analyses of interview data informed the development of an online survey about rainbow peoples’ experiences of accessing mental health support and gender-affirming healthcare in New Zealand (n = 1575). Survey results closely reflected interview findings, indicating that rainbow people have mixed experiences in New Zealand’s mental health settings, and that accessing gender-affirming healthcare is a lengthy and convoluted process. Finally, interview and survey data were used to develop a resource for mental health professionals, to guide their work with rainbow clients. I sought and incorporated feedback from key stakeholders (n = 108) during resource development. I then distributed the resource to mental health professionals around New Zealand, both in print and online. Overall, my research shows that widespread knowledge gaps compromise the ability of New Zealand’s mental health professionals to provide culturally competent support to rainbow clients. Knowledge from this thesis can be used to increase awareness of rainbow community members’ mental health support needs, and to inform mental health professionals’ training and self-reflection around sexuality, gender, and sex characteristic diversity.</p>

<p>While we know that rainbow people in Aotearoa New Zealand (that is, people of diverse sexualities, genders, and sex characteristics) experience high rates of adverse mental health outcomes, we know much less about the extent to which Aotearoa’s rainbow community members are receiving the mental health support they need. To address this gap I used mixed methods and a reflexive community-based approach to extend current understandings of rainbow mental health support experiences, and to explore how the provision of mental health care can be improved for rainbow people in New Zealand. I first conducted interviews with 34 rainbow community young adults about their experiences of accessing mental health support. My thematic analysis showed that rainbow people across New Zealand faced significant structural barriers to accessing mental health support. Participants understood mental health settings as embedded within a heteronormative and cisnormative societal context, rather than as a safe place outside this context. This, together with a widespread silence from mental health professionals around rainbow identity, meant that participants actively negotiated coming out in mental health settings. Participants shared a variety of perspectives as to whether it should be standard practice for mental health professionals to ask about rainbow identities, but agreed on a number of subtle acts that could communicate a professional or service is rainbow-friendly. Knowledge about sexuality, gender, and sex characteristic diversity, together with clinical skills of empathy, validation, and affirmation, were described as key components for the provision of effective mental health support. I conducted a second thematic analysis of data from a subset of the initial interviews, in which 13 participants discussed their experiences of accessing gender-affirming healthcare. Participants reported a lack of funding for gender-affirming healthcare in New Zealand, and described its provision a “postcode lottery”; the care available was largely dependent on the region participants were living in. Mental health assessments for accessing gender-affirming care were often described as tests of whether participants were “really” transgender, and participants discussed the need to express their gender in a particular way in order to access the healthcare they needed. Thematic analyses of interview data informed the development of an online survey about rainbow peoples’ experiences of accessing mental health support and gender-affirming healthcare in New Zealand (n = 1575). Survey results closely reflected interview findings, indicating that rainbow people have mixed experiences in New Zealand’s mental health settings, and that accessing gender-affirming healthcare is a lengthy and convoluted process. Finally, interview and survey data were used to develop a resource for mental health professionals, to guide their work with rainbow clients. I sought and incorporated feedback from key stakeholders (n = 108) during resource development. I then distributed the resource to mental health professionals around New Zealand, both in print and online. Overall, my research shows that widespread knowledge gaps compromise the ability of New Zealand’s mental health professionals to provide culturally competent support to rainbow clients. Knowledge from this thesis can be used to increase awareness of rainbow community members’ mental health support needs, and to inform mental health professionals’ training and self-reflection around sexuality, gender, and sex characteristic diversity.</p>

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

Many ethnic groups traditionally value familism, which emphasises interdependence and the extended family unit. However, Aotearoa New Zealand's health system remains largely individual-oriented, with the implementation of family-centred care remaining inconsistent. This is known to have negative effects on Māori healthcare experiences and outcomes. Our research, exploring the experiences of ethnic Chinese using mental health services in Aotearoa New Zealand, indicated that this could also be a barrier for ethnic Chinese, who have similarly strong cultural links to familism, accessing mental health care. To balance the cultural importance of family involvement with the protection of individual patient autonomy, we propose a moderate Confucian familist approach, encouraging family involvement and participation in individual patients' care, with patients' consent. The approach acknowledges individual patients as interconnected members of a wider family unit, emphasising their reciprocal, mutual responsibility in maintaining a well-functioning, harmonious family. We highlight Whānau Ora as a potential exemplar for a culturally grounded, family-centred approach to mental health care which could be feasibly implemented and deliver positive outcomes. Parallels between Māori and ethnic Chinese cultural views around whānau, community, and collectivism suggest a Kaupapa Māori approach could also be beneficial to Aotearoa New Zealand's ethnic Chinese populations. However, ethnic Chinese lack the specific legal obligations empowering the implementation of interventions such as Whānau Ora. This is an obstacle which remains to be addressed before mental health services which are sensitive to the needs of ethnic Chinese or of other ethnicities can be effectively implemented.

<p><b>Abstract Background: Migrants face specific mental health pressures. In addition, being a woman migrant might increase challenges. Digital tools for mental health and wellbeing (DTMH) have shown the potential to support people’s mental health and overcome some barriers to mental health care. However, there is limited research regarding how DTMH can better support migrants' mental health, and I identified no research about how DTMH can better support the mental health of women migrants in New Zealand. Aim: To investigate how DTMH can better support migrant women’s mental health in New Zealand with a particular focus on Brazilian women.</b></p> <p>Methods: I used a critical realist approach and sequential mixed-methods, comprising an online survey (n =104) and semi-structured interviews (n=10). Women who migrated to Aotearoa New Zealand at 18 years or over completed a brief online survey (n=104). Survey participants could opt in to be invited for semi-structured interviews to explore the topics more deeply; 48 did so. I purposely selected 10 Brazilian migrant women with varied experiences for the interviews. All 10 agreed and were interviewed. I used descriptive statistics to analyse the online survey data and an inductive thematic analysis to examine the semi-structured interviews. Survey findings were used to refine and focus interview questions as well as to select the interviewees. After each set of results was analysed, I triangulated the data and created a joint display to present the integrated findings on my primary research questions.</p> <p>Findings: Data from the online survey and semi-structured interviews demonstrated that being a migrant in Aotearoa New Zealand is hard and Brazilian migrant women (as well as migrant women, in general) are under pressure. Many seek help for their mental wellbeing; however, they experience this as a challenging journey. Many use digital resources to support their mental health. However, rather than using DTMH, which were built purposely to support mental health, they often used social media and internet resources to help connect to others and find social support. Integrated findings highlighted that they were open to DTMH but had usually found these unsatisfying or inaccessible (paid content). There were two key areas of insight regarding how DTMH could better meet participants needs. First, better promotion to increase DTMH reach, so migrant communities are aware of these resources. Second, improving DTMH engagement, improving features of the tools themselves such as increased chat or communication features, being free, and including a focus on active steps for mental wellbeing. There were key findings outside the primary research question: experiences of racism and discrimination were a key cause of distress, and many experienced a lack of culturally competent health care in Aotearoa New Zealand. Conclusions: This exploratory mixed-methods research suggests that Digital Tools for Mental Health have promise for supporting migrant women’s mental wellbeing. However, tailored promotion and specific areas of development of the tools appear important for Brazilian women in New Zealand. These findings can help support the wellbeing of this group and offer insights that may be valuable for supporting other migrant minorities. Keywords: migrant, immigrant, woman, digital, tools, mental health, wellbeing.</p>

Purpose For people of working-age diagnosed with heart failure, return to work (RTW) is often a significant rehabilitation goal. To inform vocational rehabilitation strategies, we conducted a qualitative study aiming at exploring patient experienced support needs, and barriers and facilitators to RTW. Materials and methods Ten men and eight women with heart failure (48–60 years) were interviewed in Denmark during 2022. A thematic analysis was conducted using the Sherbrooke model as framework. Results Multiple factors operating at different levels shaped participants’ RTW processes. Personal factors included motivation, mental and physical health, social relations, and financial concerns. Factors in the health care system shaping RTW included access to medical treatment, mental health care, and cardiac rehabilitation. Factors in workplace system shaping RTW included job type, employer support, and social relations. Factors in the legislative and insurance system shaping RTW included authorities’ administration of sickness benefits, professional assistance, vocational counselling, and interdisciplinary cooperation. Conclusion Findings illustrate a need to include vocational rehabilitation within comprehensive cardiac rehabilitation programmes, to identify people in need of support, to improve the coordination of care across the health and social care sectors, and to involve employers, health care professionals, and social workers in individualised RTW strategies. IMPLICATIONS FOR REHABILITATION Vocational re-integration is shaped by multiple factors operating at different levels (including personal factors, work-related factors, factors in the health care system, and factors in the legislative and insurance system). To improve return to work following heart failure, there is a need for multi-level initiatives, including policy measures and efforts to enhance continuity and coordination of care. People with heart failure in need of vocational support should be identified early within comprehensive cardiac rehabilitation programmes. Health care professionals should address work-related issues and provide individualised information and clear advice regarding timely and safe return to work. Individualised return-to-work plans should be developed within interdisciplinary teams across health and social care sectors and involve employers to ensure that they are aware of relevant work accommodations.

The original research project of this study was aimed to find out the components of culture and their impacts on ako (teaching-learning) within the early childhood teacher education programmes. Ethics Approval was obtained from AUT Ethics Committee. Under a socio-cultural theoretical framework, twelve lecturers from three Tertiary Education Organisations (TEOs) were interviewed. Three cohorts of student teachers from the same TEOs participated in focus groups. Using manual thematic coding, nine broad areas of cultural components were identified. These were bicultural contexts of Aotearoa, ethnicities and multi-culturalism, individual identities, cross-cultural interactions, comfort zone, female majority, socio-economic struggles, spirituality and technology. A recently developed framework for cultural sustainability (Soini and Dessein, 2016) were applied to these areas. Some of these components were identified as more inert and less dynamic, while the rest were recognised at the other end of the framework.The data and the principle findings were contextual to Aotearoa New Zealand. However, the discussion considered the overall global trends in relation to education.Keywords: Cultural diversity, cultural sustainability,

INTRODUCTION: Without personal experience or specific background knowledge of an issue, individuals exposed to news media are limited in their ability to gauge the accuracy of media content. The perception of people with mental illness as dangerous or incompetent allows for discrimination to occur, often resulting from inaccurate portrayals in the media.METHOD: A small, qualitative study was undertaken to explore key informant perspectives on the representation of mental health issues in the current Aotearoa New Zealand media context. Eight semi-structured interviews were carried out with key informants; each participant provided at least one of the following perspectives: mental health professional, mental health advocate, mental health consumer and/or media personnel.FINDINGS: The participants in this research found that news media strongly influence how the public views mental health, but believe media representation has improved in recent years. However, participants described an absence of stories illustrating successful interventions and felt that the portrayal of mental illnesses are still misrepresented and stigmatised by the media. Mental health services and mental health professionals were seen as poorly represented by the news media, which was thought to deter help-seeking and hinder trust.CONCLUSION: Public attitudes towards mental health have a significant impact on the lives of those experiencing mental distress. The news media have the ability to change public perceptions; however, this influence can be either harmful or helpful. Mental health stories need to be consistently contextualised and use inclusive language in order to a make a positive large- scale change in public attitudes.

Globally, we face a significant treatment gap in mental health care, with extensive wait times, exorbitant prices, and concerns about appropriateness for non-Western clients. Digital single-session interventions (SSIs) may offer a promising alternative. SSIs target particular mechanisms that underlie broad-ranging psychopathology, including deficits in problem-solving skills. Developed in the United States, Project SOLVE is a digital SSI that teaches problem-solving skills to adolescents. This study evaluated the acceptability, appropriateness, and utility of an adapted version, Project SOLVE-NZ, among rangatahi (young people) in Aotearoa New Zealand. Additionally, we evaluated a comparable online activity, Project Success-NZ, as a potential active control condition in a future randomized controlled trial of Project SOLVE-NZ. A sample of school students and teachers completed Project SOLVE-NZ and Project Success-NZ. Feedback on the interventions was collected through focus groups and semistructured interviews. Interviews were recorded, transcribed, and analyzed using reflexive thematic analysis. In total, 12 students (aged between 13 and 14 years; female students: n=6, 50%) participated in a focus group, and 8 teachers (teaching experience: mean 8.75, SD 7.96 years; female teachers: n=5, 62.5%) participated in individual interviews. Participants endorsed the sociocultural relevance of Project SOLVE-NZ and Project Success-NZ to rangatahi in Aotearoa New Zealand and viewed all existing adaptations favorably. Participants felt that the interventions would be valuable to a wide range of rangatahi, helping to fill gaps in students' learning and providing benefits to mental health. Participants also believed that the interventions may be particularly relevant for youths experiencing economic hardship. Interestingly, most participants had no preference for either Project SOLVE-NZ or Project Success-NZ, and they believed that both interventions could provide ongoing support to rangatahi throughout the school year. Teachers provided some suggestions on increasing student engagement with the interventions, namely, through increased cultural and gender representation, visual and literacy aids, whakawhanaungatanga (relationship building), and teacher guidance. Overall, interviews revealed that both interventions were perceived as acceptable, appropriate, and useful for rangatahi in New Zealand and highlighted further adaptations that could be made prior to a randomized controlled trial of Project SOLVE-NZ across schools nationwide. Digital SSIs show promise in addressing the mental health treatment gap for adolescents. Both Project SOLVE-NZ and Project Success-NZ were well-received by students and teachers in Aotearoa New Zealand and may provide benefits to youth mental health. We make the following recommendations for others interested in designing digital SSIs or similar tools for young people: involve rangatahi and relevant stakeholders in the design process, consider how the intervention will be implemented, ensure that the intervention accommodates a range of cognitive abilities, and ensure that the intervention reflects the diversity of rangatahi today.

The healthcare system in Aotearoa New Zealand is currently undergoing a far-reaching overhaul. When it comes to mental health reforms, it is helpful to look at the road ahead, while paying attention to the road behind. Policies and services concerning the mental health and addiction sectors have undergone various reforms; first, during the transition from a hospital-centered to the current community-based system, and second, in the successive attempts to improve this system. In this article, we provide an overview of the current mental health and addiction health care system. We also discuss the impact of colonization on community mental health, the emergence of community-based mental health and addiction policy and services in Aotearoa New Zealand, and the challenges along the way. Finally, we identify five key areas requiring special attention during the current period of reform. Over all, we believe there is broad support for reducing the emphasis on individualized approaches to mental wellbeing and moving all systems and structures towards models inclusive of social context, including approaches that incorporate service users' perspectives, family, communities, and culture. We look forward to policy and services with a much stronger orientation to the diverse needs of our population.

In April 2003 the Alberta government integrated specialized mental health services, formerly organized independently, with the health regions, which are responsible for general health services. The objective of this article is to determine whether the transfer was associated with an increase or decrease in the share of resources in the region allocated to mental health care relative to total spending for health care. The measure of the share for mental health care is the total costs for mental health care resources as a percentage of total health care spending. Resources and spending examined were those that were actually or potentially under the regions' control. Annual costs for mental health services in the province were obtained for a seven-year period (fiscal year [FY] 2000 through FY 2006) from provincial utilization records for all residents in the province. Unit costs were assigned to each visit. The trend in the share measure was plotted for each year. The share for mental health care increased overall from FY 2000 (7.6%) to FY 2003 (8.2%), but returned to pre-FY 2003 levels in the three years after the transfer (7.6%). Despite concerns expressed before the transfer by federal and provincial reports over the level of expenditures devoted to mental health care, the integration of mental health services with other health services did not result in an increase of the share for mental health care.

Indigenous people experience higher rates of kidney failure than do non-Indigenous Peoples. However, compared to Indigenous patients, health care systems deliver kidney transplantation to non-Indigenous patients at a substantially higher rate and more frequently as the first treatment of kidney failure. Indigenous Māori patients in Aotearoa New Zealand report numerous barriers to kidney transplantation. We explore the perspectives of clinicians as stakeholders in the delivery of kidney transplantation. In 2021/2022 we conducted in-depth qualitative interviews with key stakeholder clinicians within kidney transplantation services in Aotearoa New Zealand, asking them about the issues for Māori patients. We used thematic analysis informed by critical theory to identify key findings and used structural coding to categorize the themes at the level of society, health system, and health services. We interviewed 18 clinicians (nine nephrologists, including two transplant nephrologists, and nine nurses, including six transplant coordinators). We identified nine themes from stakeholders related to delivery of kidney transplantation services to Māori patients and whānau (family), categorized according to three main levels: Firstly, at the level of society (the impact of colonization and distrust). Secondly, the health care system (failure to prevent and manage kidney disease, health care model delivers inequitable outcomes, and inadequate Māori health professional workforce). Thirdly, health care services (transplantation reliant on patient and family resources, complex assessment causes untimely delays, clinical criteria for transplantation, and lack of clinician ability to effect change). Delivery of kidney transplantation to Indigenous Peoples is impacted at the level of society, health care system, and health care service. To address inequities, a broad approach that addresses each of these levels is required.

INTRODUCTION: The social work profession has a long-standing history of contributing to health care in Aotearoa New Zealand. Traditionally, hospitals have been the stronghold for the profession. However, both international and national evidence demonstrates that social workers have also been integrated in primary health care practices (PHCPs). Primary health care (PHC) provides care in the community and is recognised for its potential to achieve health equity across all population groups. This article reports on a small, qualitative research project which explored the perceptions of key stakeholders about social work integration into PHC and the experiences gained by social workers working within PHCPs regarding their contributions to the achievement of national aspirations for PHC.METHODS: Semi-structured, one-to-one interviews with 18 participants representing three groups (social workers, other PHC professionals and key informants) were undertaken in 2012. The interviews took place in various locations in Aotearoa New Zealand. A general inductive approach was used to identify key themes. FINDINGS: Three key themes were identified from the data: these are issues of context, namely social work professional factors, organisational factors in PHC and lastly, wider factors in the health care system. The integrated social workers enhanced the access of populations to coordinated care, increased engagement with communities, and strengthened the workforce, among other things. These unique contributions towards the PHC vision were well recognised by all groups, with participants calling for the establishment of integrated social work positions on a larger scale. CONCLUSION: The study evidences the successful integration of social workers into PHC practices in Aotearoa New Zealand. This viable model should be of special interest for key stakeholders regarding the design of local, holistic, PHC services which serve populations most affected by health and social inequalities. Importantly, “health for all”, as anticipated by the PHC vision needs long-term and real commitment especially by financial decision-makers.