Background: In New Zealand (NZ), 1 in 4 adolescents is affected by mental health issues (eg, depression and anxiety) and engages in risk behaviors (eg, harmful drinking and substance abuse), with rates among Māori youth being significantly higher. The majority of NZ secondary school students visit their local primary health care providers (PHPs) at least annually, yet most do not seek help for mental health and risk behavior (MHB) concerns. While youth think it acceptable to discuss sensitive issues during a consultation with their PHPs, unless problems are severe, such conversations are not initiated by PHPs. Early intervention for MHB concerns can prevent long-term health and well-being issues. However, this relies on the early identification of developing problems and youth being offered and accepting help. YouthCHAT is an electronic, multi-item screening tool developed in 2016 to assess MHB concerns among youth. YouthCHAT is completed before a consultation with the PHP, who can access a summary report straight away. A help question allows young people to identify issues that need addressing. A resource pack uses stepped care pathways to guide providers to use appropriate brief interventions.
Objective: This study aimed to explore the utility, feasibility, and acceptability of YouthCHAT when tailored for use with youth in primary care settings with large Māori populations. Objectives of the study are to evaluate the implementation of YouthCHAT in nurse-led youth clinics, school-based clinics, and general practice in Te Tai Tokerau (Northland, NZ); to develop a framework for the scaling up of YouthCHAT across further settings; to assess health provider and youth acceptability of the tool; to improve screening rates for mental health and help-seeking behavior; to enable early identification of emerging problems; and to improve brief intervention delivery.
Methods: Using a bicultural mixed-methods co-design approach, 3 phases over a 3-year period will provide an iterative evaluation of the utility, feasibility, and acceptability of YouthCHAT, aiming to create a framework for wider-scale rollout and implementation.
Results: Recruitment for the first phase began in September 2018. YouthCHAT was implemented at the first site in October 2018 and is expected to be at a further two sites in late January to early February 2019. The study is due for completion at the end of 2021.
Conclusions: YouthCHAT has potential as a user-friendly, time efficient, and culturally safe screening tool for early detection of MHB issues in NZ youth. The resource pack assists the clinician to provide appropriate interventions for emerging and developed youth mental health and lifestyle issues. Involving input from community providers, users, and stakeholders will ensure that modifiable elements of YouthCHAT are tailored to meet the health needs specific to each context and will have a positive influence on future mental, physical, and social outcomes for NZ youth.
International Registered Report Identifier (IRRID): PRR1-10.2196/12108
Mental health issues have overtaken cardiovascular disease and cancer as the leading cause of health loss in New Zealand (NZ) [, ]. The majority of people affected by mental health concerns (eg, depression and anxiety) also exhibit more than 1 risk behavior (eg, smoking, problem drinking, substance abuse, and physical inactivity) [ ]. These mental health and risk behaviors (MHBs) are the major contributing factors to NZ’s health loss [ ]. The Ministry of Health recognizes that to improve the health of NZ, reduction of these MHBs is needed [ ].
Most mental health disorders begin in adolescence [- ], and risk behaviors established at this time can continue into adulthood [ - ], significantly impacting on long-term mental, physical, and social well-being [ - ]. Mental health issues affect 1 in 4 of NZ youth [ , ], and the number of NZ secondary school students reporting mood disorders, self-harm, and peer problems has increased [ ]. NZ has the highest rate of youth suicide in the Organisation for Economic Cooperation and Development countries [ ]. Māori (the indigenous people of NZ) youth living in deprived, rural areas have significantly higher rates of MHBs and suicide than their non-Māori peers. Further, educational, employment, and health outcomes are worse for adolescent Māori, and their life expectancy is much lower [ - ].
Rather than disclose their MHB concerns at primary care, adolescents often present primarily with vague, physical symptoms [, , , - ]. Opportunistic discussions about MHB do not occur in primary health care unless the problems are severe [ , - ]. Yet, if the conversation is initiated by the clinician, young people are willing to discuss MHB [ , - ]. Screening for youth MHB concerns occurs in less than 50% of primary health care provider (PHP) consultations, with the result that over half of adolescent MHB concerns are not detected [ , , ]. Clinicians in primary care describe being underresourced in terms of time, appropriate screening tools, and experience in youth health [ , , ]. Screening can reveal issues that may otherwise be overlooked and facilitate discussions between PHPs and young people [ ]. This process can be therapeutic for youth, increasing their satisfaction with care and the likelihood that they will ask for help in the future [ , , ].
There are a number of MHB screening tools available , but it can be time-consuming to administer these and interpret the results [ ], and not all screening tools are suitable for use in all clinical contexts [ , ]. Where MHB screening for youth does occur, rates of follow-up and service use remain low [ , , ]. The referral of every positive screen to secondary services creates an overwhelming need for appointments, delaying timely access to care [ , , , , ]. In a stepped care approach, the primary health care team forms the hub of care for mild-to-moderate mental health issues. Increasing levels of care are added stepwise relative to the severity of more complex or worsening issues, providing effective management in primary care and more efficient use of specialist services [ ].
The NZ-developed electronic Case-finding and Help Assessment Tool is a multi-item, electronic screening tool for use in primary health care to screen adults for substance misuse (smoking, alcohol, and drugs), problem gambling, depression, anxiety, exposure to abuse, difficulty controlling anger, and physical inactivity . A youth version, YouthCHAT, has been developed using a co-design approach with input from clinicians and young people[ ], and it contains 4 additional youth-specific modules: sexual health, youth stress, conduct disorder, and eating issues [ , , - ]. For positive screens in the smoking, substance abuse, depression, and anxiety modules, branching logic links users to validated assessment tools (eg, the Substances and Choices Scale [ ], the Patient Health Questionnaire-Depression Adolescent version [ ], and general anxiety disorder assessment, GAD-7 [ ]). Some modules provide a nonclinical score that indicates the number of positive responses to questions (eg, the behavior or conduct module), and others simply indicate the presence of risky behavior (eg, gambling). The help question allows young people to prioritize concerns and indicate the areas where they are ready to accept help [ , , ]. A stepped care-based resource pack guides clinicians to effective evidence-based interventions. Youth health providers in Northland have also undertaken mental health credentialing through the Primary health organisation (PHO) in order to provide brief interventions to clients for low to moderate mental health issues at the time of the screening.
Youth can complete YouthCHAT on an electronic device (eg, a tablet) before their consultation; completion takes approximately 5-15 minutes. A video briefly introduces the screen and explains confidentiality before giving the option to “start” or “exit” the screen. Upon completion of the screen, a clinical summary report is available to the clinician seeing them, indicating which domains screened positive, the severity of the condition (from validated assessments), and where help is sought. This report facilitates a conversation between the clinician and the young person, supporting shared decision making and youth input into their plan of care.
YouthCHAT has been successfully used in 1 rural NZ youth clinic and found to be acceptable to clinic staff (CS) and young people . A randomized trial in an urban high school indicates that YouthCHAT compares favorably to the HEEADSSS (Home, Education, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety) interview-based assessment, currently used to screen all Year 9 students in NZ low-decile secondary schools for psychosocial issues [ ].
This study will evaluate the implementation of the YouthCHAT program into primary health clinics in Te Tai Tokerau (Northland, NZ). Using a co-design approach, YouthCHAT, the processes around its use, and the stepped care resources offered will be tailored to meet the needs of local communities, with the aim of improving screening rates and brief intervention delivery for MHB concerns as well as developing a framework for scaling up the implementation of YouthCHAT more widely across Northland.
Specific objectives are to assess YouthCHAT with respect to the following:
- Utility (does YouthCHAT lead to increased screening and detection rates of mental health issues?)
- Feasibility (is it feasible to conduct e-screening and deliver stepped care support to young people attending youth clinics, school-based clinics, and general practice?)
- Acceptability (is YouthCHAT acceptable to clinicians to use as a screening and stepped care intervention tool for youth?)
- Provide a modifiable framework for scaling up implementation to meet specific health needs in specific contexts in consultation with community stakeholders, utilizing local agencies and cultural and community groups to deliver stepped care support.
Co-design and New Zealand Research
Considered the founding document of NZ, the Treaty of Waitangi was signed by Māori Chiefs and representatives of the British Crown in 1840. The agreement ratified the unification of Pākehā (Western settlers) and Māori as a nation while affording Māori values, traditions, and practices . Inherent in the Treaty of Waitangi is the Māori principles of kāwanatanga (giving governance to the Crown) and tino rangatiratanga (respecting Māori self-determination). The Treaty of Waitangi Act in 1975 [ ] outlined the principles of partnership, participation, and protection as representing the true intent of the Treaty [ - ]. The principles continue to be the foundation of the relationship between Māori and the New Zealand Government today [ ]. Research involving Māori in NZ must be carried out in accordance with the principles of the Treaty of Waitangi and ensure that Māori culture, values, and beliefs are respected and protected [ - ].
A randomized controlled trial, considered the epitome of clinical trials, would provide evidence about how an intervention is used in a controlled context with a specific population. However, these findings may not apply to the use of the intervention with real populations in actual clinical settings [- ], particularly in areas of wide cultural diversity, such as NZ [ ].
Kaupapa Māori (research for the benefit of Māori by Māori) is influenced by Māori culture, history, indigenous knowledge (Mātauranga), language (te reo), values, and worldview [, , , , - ]. The proverb “kaua e takahia te mana o te tangata” (do not trample on “mana” or dignity and status) highlights the guiding principle of Kaupapa Māori, to respect the mana not only of individuals but also of the Māori culture, values, and beliefs [ , , ]. The self-determination of Māori to identify challenges, solve problems, and form new knowledge (tino rangatiratanga) affords control over research processes and the protection of Mātauranga [ - ]. This study was not conceived as a Kaupapa Māori project; however, as the majority of participants are envisaged to be Māori, their culture, values, and beliefs must be validated, respected, and protected. Provided Māori retain control of the research, non-Māori researchers can undertake research involving Māori. To do so, they must first reflect on their own culture, worldview, values, and beliefs and, having done so, acknowledge, give credence to, and respect those of Māori [ - , ]. Non-Māori researchers can then work in partnership with Māori, as long the methodology affiliates with the principles and values of Kaupapa Māori and is undertaken in collaboration with those who will benefit from the research [ ].
In a co-design approach, research is undertaken with, rather than on, people [, ]. The research processes evolve in conjunction with and from the perspectives of the participants [ - ], allowing researchers to gain an understanding of context-specific requirements and challenges [ - ]. Participants become actively involved in the research process as partners, designers, and developers alongside the research team. The knowledge, experiences, ideas, and skills of the participants are used to help find acceptable and workable ways of identifying and overcoming problems [ , , ]. Co-design research, therefore, aligns with Kaupapa Māori, and in this study, researchers from both cultures will work alongside each other sharing research principles, processes, and skills in bicultural research [ ].
Māori have been involved in the development of YouthCHAT. The tool has been translated into te reo Māori (Māori language) and tested to ensure acceptability among Māori youth and clinicians in Te Tai Tokerau . The same clinical educator (CE) who was part of the proof of concept trial noted above is a qualified nurse educator and registered nurse. As a coinvestigator and the Kaitautoko (support person or advocate) for this project, she will implement YouthCHAT in her clinical practice first and then train and work with other clinical staff as YouthCHAT is iteratively implemented in other clinics. Further, this research will be developed through engagement with young people, local iwi (confederation of Māori tribes), the local PHO and District Health Board, CS, and community providers for their input and participation. The cultural relevance of YouthCHAT and its implementation has been valued in its development. Equitable approaches will be taken with all participants in all locations, and the findings of this study may contribute to a long-term reduction in disparities between Māori and non-Māori young people. Engaging and partnering with stakeholders and users throughout the research process will respect Māori tikanga (customs and etiquette), and validation of Māori culture, values, and beliefs will be integral to the success of the study [ , ]. With the assistance of local project investigators, the bicultural, co-design approach will ensure that the YouthCHAT model initially employed, further scaled up, and then rolled out is culturally appropriate and meets the needs of the local community.
This study has received approval from the New Zealand Health and Disability Ethics Committee (reference 18/CEN/31) on May 05, 2018. A pragmatic rollout of YouthCHAT will take place over 3 years using an iterative process of implementation, modification, and evaluation to assess the processes for using YouthCHAT across different clinical settings in Te Tai Tokerau.
Whiringa Tuatahi Tahi (Phase 1)
After consultation with local health providers and other community resources, YouthCHAT will be implemented in 5 nurse-led youth clinics. Utility, feasibility, and acceptability data will be gathered and used to modify and improve YouthCHAT operational processes. The implementation of the YouthCHAT tool will be evaluated at each site. In response to the feedback received from participants at each clinic, modifications will be made to YouthCHAT processes.
Whiringa Tuatahi Rua (Phase 2)
After the changes from phase 1 have been incorporated and after further consultation with local providers and resources, using the updated implementation processes, YouthCHAT will be rolled out to 4 school-based clinics in Northland. Utility, feasibility, and acceptability data will be gathered and modifications made as before.
Whiringa Tuatahi Toru (Phase 3)
After the changes from phase 2 have been incorporated and after further consultation with local providers and resources, the updated implementation processes will then be used to roll out YouthCHAT to 3 general practice clinics in Northland. Utility, acceptability, and feasibility data will be gathered as before. The data from all 3 phases will be used to develop an implementation framework for a wider rollout of the YouthCHAT program across different primary health care settings in NZ.
Setting, Participants, and Recruitment
The YouthCHAT program is being implemented into the youth screening policies and procedures across all the clinics taking part in this study. Youth between 12-24 years of age visiting the clinic will be asked to complete YouthCHAT as per the clinic’s screening procedures. Feedback about YouthCHAT will be sought in the form of surveys, interviews, and focus groups from 3 participant groups: (1) the CE, (2) CS, and (3) young people aged 16-24 years who have used YouthCHAT.
All CS, including the CE, will be informed about the study and invited to participate by members of the research team before the implementation of YouthCHAT into their practice. All youth meeting the participation criteria will be informed about and invited to take part in the study after their consultation with the clinician. This will be done by either the clinician or by administration staff, depending on each clinic’s systems. Young people who are interested in taking part will leave their contact details and will be contacted by the research team to arrange a suitable time for the focus groups. All participation is voluntary. Written, informed consent will be obtained prior to their participation. Youth taking part in the focus groups will receive a NZ $20 voucher, and kai (food) will be provided.
The study participants will include youth (over 16 years old) who have used YouthCHAT, CS from participating clinics who use the YouthCHAT tool, and the YouthCHAT CE, who provides training and support in the use of YouthCHAT.
Youth under 16 years old will be excluded as parental consent would have to be sought, and since young people often visit clinics without parental or guardian knowledge, seeking such consent would violate their confidentiality. Youth over 16 who are not able to provide their own consent (eg, due to cognitive difficulties) will be excluded.
Utility Data and Measures
Data pertaining to each participating clinic’s screening rates for mental health issues and risky health behaviors and early identification of emerging problems and delivery of brief interventions before and after YouthCHAT implementation will be gathered by way of a summary report from the clinic administrator. The collated deidentified data will enable the calculation of screening rates and help-seeking behavior before and after the implementation of YouthCHAT. For all YouthCHAT modules, a simple “yes” or “no” metric will be used to determine rates of detection. Rates of health-seeking behavior will be assessed via the “help” question, which offers “yes,” “no,” and “yes but not today” responses that will be collected.
Acceptability and Feasibility Data
Acceptability and feasibility data will be gathered via surveys and interviews with the CE, CS, and focus groups with a subset of youth who have used YouthCHAT. Survey and interview questions will be framed around the mechanisms of normalization process theory (NPT): (1) coherence, for example, does it make sense for participants to implement YouthCHAT into their practice? (2) cognitive participation, for example, are participants able to easily engage with the tool? (3) collective action, for example, how hard is it to implement and use YouthCHAT? and (4) reflexive monitoring, for example, are there clear benefits of using YouthCHAT? Are the advantages or disadvantages of using the tool easily identifiable and how could disadvantages be minimized? [- ].
Surveys and semistructured interviews with CS will gather feedback on their experience of using YouthCHAT, for example, perceptions of its usefulness, whether they would recommend it to others, and concerns about privacy and identify aspects that limit or encourage the use of YouthCHAT in their daily practice. A CE semistructured interview will be conducted at the end of data collection to discuss program feasibility, utility, acceptability, and suggested improvements in the setup processes of YouthCHAT and in training for its use.
Focus groups will be held with youth participants to gather in-depth feedback on their experience including the acceptability of the electronic method, perceptions of the look of the electronic interface, and the length of screening; whether they would recommend it to others; and concerns about privacy. Interviews and focus groups will be audiotaped and transcribed with consent.
All information will be kept confidential, and analyzed data will be presented in a deidentified manner. HealthLink will provide secure storage of all YouthCHAT screening data and transmit encrypted, secure data to the clinics’ practice management system software by the same private network used for their electronic referrals. Participant data will be deidentified before being stored by the research team. Clinical data obtained through YouthCHAT will be available to relevant health providers. All surveys are Web-based and anonymous and will be completed using Qualtrics. Recordings of semistructured interviews and focus groups will be transcribed (without anything that could identify participants), and the recordings will be deleted. The transcriber will be asked to sign a confidentiality agreement. Data will be retained for 10 years as per the University of Auckland protocol.
Quantitative data will be analyzed using Microsoft Excel and a statistical software package. Analyses will include basic descriptive statistics (eg, number of youth screened and YouthCHAT summary data). Cross-tabulation analyses will explore differences in detection rates between different population subgroups (eg, ethnicity, age, and gender) across sites and compare pre-and post-YouthCHAT implementation. Subgroup analyses of differences in help-seeking behavior, uptake of the initiative, and delivery of interventions will also be analyzed if there are sufficient numbers to permit such analysis. This information will provide insights into important heterogeneities in our population of interest that may aid an effective intervention strategy.
Focus groups and semistructured interviews will be audiotaped and confidentially transcribed, and suggestions will be categorized and tabulated. Any modification to the implementation processes will follow majority opinion. Data will be analyzed using a general inductive approach , with collated text categorized and thematically analyzed according to the mechanisms of NPT. Data will be independently coded by 2 researchers, with a consensus reached by adjudication [ - ].
Presentation of the results will depend on the nature of the data collected. If substantial qualitative data allows, a thematic analysis will be conducted and presented separately. Irrespective of this, the results will be synthesized in the discussion.
Recruitment for the first phase began in September 2018. YouthCHAT was implemented at the first site in October 2018 and is expected to be at a further two sites in late January to early February 2019. The study is due for completion at the end of 2021.
Early detection intervention for mental health disorders and risky behaviors in youth can prevent long-term health and psychosocial issues [, , , ]. For this to happen, it is imperative that a means of detecting existing and developing MHBs in adolescence is found and timely management initiated [ ]. Interventions need to respect the ability of youth to change risk behaviors and provide them with the resources, skills, and support to do so [ , , , , , , , , ]. YouthCHAT promotes wellness planning and supports youth to self-manage. The systematic approach of screening and provision of guides for stepped care intervention aims to lead to the early and more comprehensive intervention of youth mental health, substance misuse, and other lifestyle issues, which will have substantial impacts on future physical, mental, and social health as well as well-being. It is anticipated that a successful rollout of YouthCHAT will be associated with improved health and social outcomes through early identification of and intervention for mental health concerns, leading to an improvement in youth help-seeking behavior.
Complex interventions, such as YouthCHAT, with the potential to improve health outcomes, can only do so if they can be successfully implemented and then integrated or normalized into routine clinical practice [- ]. However, this will not happen unless those who will be using the tool find it acceptable and unless its delivery is feasible. The implementation of YouthCHAT requires the necessary internet capability and availability of mobile devices, such as tablets, for the completion of the screen. The feasibility of implementing YouthCHAT relies on more than technological infrastructure, it is dependent on the impact YouthCHAT has on the people who will be using it [ - ]. For example, if clinical staff see the benefit of using YouthCHAT in their daily practice, enhancing engagement with young people and improving health outcomes while reducing their workload, then it is feasible that the tool can become normalized in their daily practice [ , ]. Feasibility is also reliant on factors that encourage or inhibit the uptake of the screen by young people, for example, the length of the screen, ease of completion, and the electronic interface. A co-design approach will assist the research team to identify and overcome barriers to the use of YouthCHAT.
With the assistance of local project investigators, the co-design, bicultural approach will ensure that the YouthCHAT model initially employed, further scaled up, and then rolled out, is culturally appropriate, meets the needs of the local community, and is easily integrated into practice. This study, underpinned by NPT, seeks to develop YouthCHAT as a sustainable, culturally acceptable, cost-effective, and time-saving screening tool for clinicians in primary care to identify mental health concerns and ultimately improve equity for Māori youth. This is particularly important in rural NZ where provider recruitment and retention remain difficult.
If YouthCHAT can be implemented across a variety of primary health care settings in NZ, it has potential to be a user-friendly, time efficient, and culturally safe screening tool for early detection of psychosocial issues in NZ youth. The resource pack assists clinicians to provide appropriate intervention for emerging and developed youth mental health and lifestyle issues. The bicultural approach involving input from community providers, users, and stakeholders will ensure that modifiable elements of YouthCHAT can be tailored to meet the specific health needs of each context and could have a positive influence on future mental, physical, and social outcomes for NZ youth.
This study would not have been possible without the support of Manaia and Te Tai Tokerau PHOs and Northland District Health Board who run the youth and school-based clinics in Northland. The authors would like to acknowledge the support of the Youth Health Governance Group (the Group), which has general practice and iwi representation as equal partners. Included on this Group are representatives for all Northland iwi providers (Ngāti Hine Health Trust, Ki A Ora Ngātiwai, Te Hau Ᾱwhiowhio o Otangarei Trust and Te Ha Oranga o Ngāti Whātua contracted through Manaia, and Te Hiku Hauora and Te Hau Ora O Ngāpuhi). This study is being funded by the 2017 Global Alliance for Chronic Diseases-Health Research Council Funding, HRC Reference: 17/705. RM would not have been able to pursue the doctoral study without receiving the University of Auckland HABITS Digital Mental Health Doctoral Scholarship in Psychological Medicine, the University of Auckland Scholarship in General Practice, and a New Zealand Nursing Education and Research Foundation McCutchan Trust Scholarship. RM would also like to acknowledge the 2 cosupervisors for PhD—Associate Professor Simon Denny and author MJS.
Conflicts of Interest
Multimedia Appendix 1
Health Research Council of New Zealand peer review report.PDF File (Adobe PDF File), 460KB
- Ministry of Health. 2016. Health Loss in New Zealand 1990–2013. A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study URL: https://www.health.govt.nz/system/files/documents/publications/health-loss-in-new-zealand-1990-2013-aug16.pdf [accessed 2018-11-12] [WebCite Cache]
- Ministry Of Health. 2015. Health and Independence Report 2015 URL: https://www.health.govt.nz/system/files/documents/publications/health-and-independence-report-2015-oct15.pdf [accessed 2018-11-13] [WebCite Cache]
- Jones PB. Adult mental health disorders and their age at onset. Br J Psychiatry Suppl 2013 Jan;54:s5-10. [CrossRef] [Medline]
- World Health Organisation. Child and adolescent mental health URL: http://www.who.int/mental_health/maternal-child/child_adolescent/en/ [accessed 2018-11-13] [WebCite Cache]
- McGorry PD, Purcell R, Goldstone S, Amminger GP. Age of onset and timing of treatment for mental and substance use disorders: implications for preventive intervention strategies and models of care. Curr Opin Psychiatry 2011 Jul;24(4):301-306. [CrossRef] [Medline]
- Prime Minister's Science Advisory Committee. Minister's Science Advisory Committee. 2011. Improving the Transition Reducing Social and Psychological Morbidity During Adolescence URL: http://www.pmcsa.org.nz/wp-content/uploads/2011/06/Improving-the-Transition-report.pdf [accessed 2018-11-12] [WebCite Cache]
- Youth health: Enhancing the skills of primary health care practitioners in caring for all young New Zealanders, A resource manual. Christchurch, New Zealand: The Collaborative for Research and Training in Youth Health and Development Trust; 2011.
- Taliaferro LA, Borowsky IW. Beyond prevention: promoting healthy youth development in primary care. Am J Prev Med 2012 Jun;42(6 Suppl 2):S117-S121. [CrossRef] [Medline]
- Sanci L, Chondros P, Sawyer S, Pirkis J, Ozer E, Hegarty K, et al. Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing. PLoS One 2015;10(9):e0137581 [FREE Full text] [CrossRef] [Medline]
- Goodyear-Smith F, Warren J, Elley CR. The eCHAT program to facilitate healthy changes in New Zealand primary care. J Am Board Fam Med 2013;26(2):177-182 [FREE Full text] [CrossRef] [Medline]
- Bartlett R, Holditch-Davis D, Belyea M. Problem behaviors in adolescents. Pediatr Nurs 2007;33(1):13-18. [Medline]
- Băban A, Crăiun C. Changing health-risk behaviors: A review of theory and evidence-based interventions in health psychology. Journal of Cognitive and Behavioral Psychotherapies 2007;7(1):45-56.
- Clark T, Fleming T, Bullen P, Denny S, Crengle S, Dyson B, et al. Youth2000 Survey Series. 2012. The Health and Wellbeing of New Zealand Secondary School Students in 2012. Youth’12 Overview URL: https://www.fmhs.auckland.ac.nz/assets/fmhs/faculty/ahrg/docs/2012-overview.pdf [accessed 2018-11-12] [WebCite Cache]
- Fleming TM, Clark T, Denny S, Bullen P, Crengle S, Peiris-John R, et al. Stability and change in the mental health of New Zealand secondary school students 2007-2012: results from the national adolescent health surveys. Aust N Z J Psychiatry 2014 May;48(5):472-480. [CrossRef] [Medline]
- Organisation for Economic Co-operation Development, Social Policy Division. OECD Family Database. Paris: Organisation for Economic Co-operation Development; 2012. Teenage suicide (15-19 years old) URL: https://www.oecd.org/els/family/CO_4_4_Teenage-Suicide.pdf [accessed 2018-11-13]
- Mental Health Commission. Wellington, New Zealand: Mental Health Commission; 2011. Child and youth mental health and addiction URL: https://www.mentalhealth.org.nz/assets/ResourceFinder/Child-and-youth-mental-health-and-addiction-2011-MHC.pdf [accessed 2018-11-12] [WebCite Cache]
- Malatest International. Wellington, New Zealand: Ministry of Health; 2016 Jan. Evaluation Report: The Youth Primary Mental Health Service URL: https://www.health.govt.nz/system/files/documents/publications/evaluation-report-youth-primary-mental-health-service-dec16.pdf [accessed 2018-11-12] [WebCite Cache]
- Ministry of Health. Wellington, New Zealand: Ministry of Health; 2018. Mental Health and Addiction Workforce Action Plan 2017-202 URL: https://www.health.govt.nz/system/files/documents/publications/mental-health-addiction-workforce-action-plan-2017-2021-2nd-edn-apr18.pdf [accessed 2018-11-12] [WebCite Cache]
- Houkamau CA, Sibley CG. Māori Cultural Efficacy and Subjective Wellbeing: A Psychological Model and Research Agenda. Soc Indic Res 2010 Sep 8;103(3):379-398. [CrossRef]
- Kovach M. Emerging from the margins: Indigenous methodologies. In: Brown L, Strega S, editors. Research as Resistance. Toronto: Canadian Scholars’ Press; 2015.
- Ministry of Health. Wellington, New Zealand: Ministry of Health; 2017. Suicide Facts: provisional data URL: https://www.health.govt.nz/publication/suicide-facts-2015-data [accessed 2018-11-12] [WebCite Cache]
- Mariu KR, Merry SN, Robinson EM, Watson PD. Seeking professional help for mental health problems, among New Zealand secondary school students. Clin Child Psychol Psychiatry 2012 Apr;17(2):284-297. [CrossRef] [Medline]
- Bradford S, Rickwood D. Psychosocial assessments for young people: a systematic review examining acceptability, disclosure and engagement, and predictive utility. Adolescent Health, Medicine and Therapeutics 2012;3:111-125 [FREE Full text] [CrossRef] [Medline]
- Schaeuble K, Haglund K, Vukovich M. Adolescents' preferences for primary care provider interactions. J Spec Pediatr Nurs 2010 Jul;15(3):202-210. [CrossRef] [Medline]
- Viner RM, Barker M. Young people's health: the need for action. BMJ 2005 Apr 16;330(7496):901-903 [FREE Full text] [CrossRef] [Medline]
- Roberts J, Sanci L, Haller D. Global adolescent health: is there a role for general practice? Br J Gen Pract 2012 Nov;62(604):608-610 [FREE Full text] [CrossRef] [Medline]
- Alexander SC, Fortenberry JD, Pollak KI, Bravender T, Davis JK, Ostbye T, et al. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr 2014 Feb;168(2):163-169 [FREE Full text] [CrossRef] [Medline]
- Ham P, Allen C. Adolescent health screening and counseling. Am Fam Physician 2012 Dec 15;86(12):1109-1116 [FREE Full text] [Medline]
- Kang M, Bernard D, Booth M, Quine S, Alperstein G, Usherwood T, et al. Access to primary health care for Australian young people: service provider perspectives. Br J Gen Pract 2003 Dec;53(497):947-952 [FREE Full text] [Medline]
- Denny S, Balhorn A, Lawrence A, Cosgriff J. Student access to primary health care and preventive health screening at a school-based health centre in South Auckland, New Zealand. N Z Med J 2005 Jul 15;118(1218):U1561. [Medline]
- Hacker K, Arsenault L, Franco I, Shaligram D, Sidor M, Olfson M, et al. Referral and follow-up after mental health screening in commercially insured adolescents. J Adolesc Health 2014 Jul;55(1):17-23. [CrossRef] [Medline]
- Gadomski AM, Fothergill KE, Larson S, Wissow LS, Winegrad H, Nagykaldi ZJ, et al. Integrating mental health into adolescent annual visits: impact of previsit comprehensive screening on within-visit processes. J Adolesc Health 2015 Mar;56(3):267-273 [FREE Full text] [CrossRef] [Medline]
- Chisolm DJ, Klima J, Gardner W, Kelleher KJ. Adolescent behavioral risk screening and use of health services. Adm Policy Ment Health 2009 Nov;36(6):374-380. [CrossRef] [Medline]
- Brown JD, Wissow LS. Discussion of sensitive health topics with youth during primary care visits: relationship to youth perceptions of care. J Adolesc Health 2009 Jan;44(1):48-54 [FREE Full text] [CrossRef] [Medline]
- Ungar M, Theron L, Liebenberg L, Tian G, Restrepo A, Sanders J, et al. Patterns of individual coping, engagement with social supports and use of formal services among a five-country sample of resilient youth. Glob Ment Health (Camb) 2015;2:e21 [FREE Full text] [CrossRef] [Medline]
- Kadivar H, Thompson L, Wegman M, Chisholm T, Khan M, Eddleton K, et al. Adolescent views on comprehensive health risk assessment and counseling: assessing gender differences. J Adolesc Health 2014 Jul;55(1):24-32 [FREE Full text] [CrossRef] [Medline]
- The Lancet. Maturing dangers. The Lancet 1995 Apr 22;345(8956):997-998. [Medline]
- Walker Z, Townsend J, Oakley L, Donovan C, Smith H, Hurst Z, et al. Health promotion for adolescents in primary care: randomised controlled trial. BMJ 2002 Sep 07;325(7363):524 [FREE Full text] [Medline]
- Klein JD, McNulty M, Flatau CN. Adolescents' access to care: teenagers' self-reported use of services and perceived access to confidential care. Arch Pediatr Adolesc Med 1998 Jul;152(7):676-682. [Medline]
- Jacobson LD, Wilkinson C, Owen PA. Is the potential of teenage consultations being missed?: a study of consultation times in primary care. Fam Pract 1994 Sep;11(3):296-299. [Medline]
- Webb MJ, Kauer SD, Ozer EM, Haller DM, Sanci LA. Does screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care improve health outcomes? A systematic review. BMC Fam Pract 2016 Dec 04;17:104 [FREE Full text] [CrossRef] [Medline]
- Wissow LS, Brown J, Fothergill KE, Gadomski A, Hacker K, Salmon P, et al. Universal mental health screening in pediatric primary care: a systematic review. J Am Acad Child Adolesc Psychiatry 2013 Nov;52(11):1134-1147.e23 [FREE Full text] [CrossRef] [Medline]
- Connors EH, Arora P, Blizzard AM, Bower K, Coble K, Harrison J, et al. When Behavioral Health Concerns Present in Pediatric Primary Care: Factors Influencing Provider Decision-Making. J Behav Health Serv Res 2018 Jul;45(3):340-355. [CrossRef] [Medline]
- Brown JD, Wissow LS. Screening to identify mental health problems in pediatric primary care: considerations for practice. Int J Psychiatry Med 2010;40(1):1-19. [CrossRef] [Medline]
- Gardner W, Kelleher KJ, Pajer K, Campo JV. Follow-up care of children identified with ADHD by primary care clinicians: A prospective cohort study. J Pediatr 2004 Dec;145(6):767-771. [CrossRef] [Medline]
- Sanci L, Grabsch B, Chondros P, Shiell A, Pirkis J, Sawyer S, et al. The prevention access and risk taking in young people (PARTY) project protocol: a cluster randomised controlled trial of health risk screening and motivational interviewing for young people presenting to general practice. BMC Public Health 2012 Jun 06;12:400 [FREE Full text] [CrossRef] [Medline]
- Hickie IB, Groom GL, McGorry PD, Davenport TA, Luscombe GM. Australian mental health reform: time for real outcomes. Med J Aust 2005 Apr 18;182(8):401-406. [Medline]
- Goodyear-Smith F, Warren J, Bojic M, Chong A. eCHAT for lifestyle and mental health screening in primary care. Ann Fam Med 2013;11(5):460-466 [FREE Full text] [CrossRef] [Medline]
- Thabrew H, Corter A, Goodyear-Smith F, Goldfinch M. Randomized Trial Comparing the Electronic Composite Psychosocial Screener YouthCHAT With a Clinician-Interview Assessment for Young People: A Study Protocol. JMIR Res Protoc 2017 Jul 31;6(7):e135 [FREE Full text] [CrossRef] [Medline]
- Goodyear-Smith F. University of Auckland. 2011. Evolution of the eCHAT: Case-finding to improve health and happiness [MD] URL: https://researchspace.auckland.ac.nz/bitstream/handle/2292/10622/whole.pdf?sequence=2 [WebCite Cache]
- Goodyear-Smith F, Arroll B, Coupe N. Asking for help is helpful: validation of a brief lifestyle and mood assessment tool in primary health care. Ann Fam Med 2009;7(3):239-244 [FREE Full text] [CrossRef] [Medline]
- Goodyear-Smith F, Arroll B, Coupe N, Buetow S. Ethnic differences in mental health and lifestyle issues: results from multi-item general practice screening. N Z Med J 2005 Apr 01;118(1212):U1374. [Medline]
- Goodyear-Smith F, Arroll B, Kerse N, Sullivan S, Coupe N, Tse S, et al. Primary care patients reporting concerns about their gambling frequently have other co-occurring lifestyle and mental health issues. BMC Fam Pract 2006 Apr 10;7:25 [FREE Full text] [CrossRef] [Medline]
- Goodyear-Smith F, Corter A, Suh H. Electronic screening for lifestyle issues and mental health in youth: a community-based participatory research approach. BMC Med Inform Decis Mak 2016 Dec 08;16(1):140 [FREE Full text] [CrossRef] [Medline]
- Goodyear-Smith F, Coupe NM, Arroll B, Elley CR, Sullivan S, McGill A. Case finding of lifestyle and mental health disorders in primary care: validation of the 'CHAT' tool. Br J Gen Pract 2008 Jan;58(546):26-31 [FREE Full text] [CrossRef] [Medline]
- Christie G, Marsh R, Sheridan J, Wheeler A, Suaalii-Sauni T, Black S, et al. The substances and choices scale (SACS)--the development and testing of a new alcohol and other drug screening and outcome measurement instrument for young people. Addiction 2007 Sep;102(9):1390-1398. [CrossRef] [Medline]
- Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001 Sep;16(9):606-613 [FREE Full text] [Medline]
- Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006 May 22;166(10):1092-1097. [CrossRef] [Medline]
- Harris SK, Knight JR. Putting the Screen in Screening: Technology-Based Alcohol Screening and Brief Interventions in Medical Settings. Alcohol Res 2014;36(1):63-79 [FREE Full text] [Medline]
- Goodyear-Smith F, Martel R, Darragh M, Warren J, Thabrew H, Clark TC. Screening for risky behaviour and mental health in young people: the YouthCHAT programme. Public Health Rev 2017;38:20 [FREE Full text] [CrossRef] [Medline]
- New Zealand History. Wellington, NZ: Ministry for Culture and Heritage; 2017. The Treaty in brief. Page 2 – Treaty FAQs URL: https://nzhistory.govt.nz/politics/treaty/treaty-faqs [accessed 2018-09-25] [WebCite Cache]
- New Zealand Legislation. 1975 Oct. Treaty of Waitangi Act 1975 URL: http://www.legislation.govt.nz/act/public/1975/0114/107.0/DLM435368.html [accessed 2018-11-12] [WebCite Cache]
- The English version of the Treaty of Waitangi. 2013 Dec 23. Waitangi Tribunal Internet URL: https://www.waitangitribunal.govt.nz/ [accessed 2018-09-25] [WebCite Cache]
- Nursing Council of New Zealand. Wellington, New Zealand: Nursing Council of New Zealand; 2011. Guidelines for Cultural Safety, the Treaty of Waitangi and Māori Health in Nursing Education and Practice URL: https://bit.ly/2Ql8Iad [accessed 2018-11-13] [WebCite Cache]
- New Zealand History. 2018. The Treaty in brief: Page 1 – Introduction URL: https://nzhistory.govt.nz/politics/treaty/the-treaty-in-brief [WebCite Cache]
- Ministry of Health. Wellington: Ministry of Health; 2014. Treaty of Waitangi principles URL: https://www.health.govt.nz/our-work/populations/maori-health/he-korowai-oranga/strengthening-he-korowai-oranga/treaty-waitangi-principles [WebCite Cache]
- Cram F, Phillips H. Claiming Interstitial Space for Multicultural, Transdisciplinary Research Through Community-up Values. IJCIS 2012 Jun 01;5(2):36-49 [FREE Full text] [CrossRef]
- Cunningham C. A framework for addressing Māori knowledge in research, science and technology. Pac Health Dialog 2000 Mar;7(1):62-69. [Medline]
- Porsanger J. An Essay about Indigenous Methodology. Nordlit 2004 Jul 01;8(1):105-120. [CrossRef]
- Wilson C. Decolonizing Methodologies: research and indigeneous peoples. Social Policy Journal of New Zealand 2001:214-218 (forthcoming) [FREE Full text]
- Oetzel J, Scott N, Hudson M, Masters-Awatere B, Rarere M, Foote J, et al. Implementation framework for chronic disease intervention effectiveness in Māori and other indigenous communities. Global Health 2017 Sep 05;13(1):69 [FREE Full text] [CrossRef] [Medline]
- Patsopoulos NA. A pragmatic view on pragmatic trials. Dialogues Clin Neurosci 2011;13(2):217-224 [FREE Full text] [Medline]
- Peters D, Adam T, Alonge O, Agyepong I, Tran N. Implementation research: what it is and how to do it. BMJ 2013 Nov 20;347:f6753. [CrossRef] [Medline]
- Wehipeihana N, McKegg K. Values and Culture in Evaluative Thinking: Insights from Aotearoa New Zealand. Evaluation 2018 Apr 16;2018(158):93-107. [CrossRef]
- Andrzejewski J, Symcox L, Baltodano M. Mai i te maramatanga, ki te putanga mai o te tahuritanga: From conscientization to transformation. In: Social Justice, Peace, and Environmental Education: Transformative Standards. New York: Taylor & Francis, Inc; 2009.
- Tipene-Matua B, Phillips H, Cram F, Parsons M, Taupo K. Old ways of having new conversations. Katoa Ltd 2009 (forthcoming) [FREE Full text]
- Smith L. Decolonizing Methodologies. London: Zed Books Ltd; 2013.
- National Ethics Advisory Committee. Ministry of Health. Wellington, New Zealand: Ministry of Health; 2012. Āhuatanga ū ki te tika me te pono mō te Rangahau Māori: Māori Research Ethics - An overview URL: https://neac.health.govt.nz/system/files/documents/publications/neac-maori-research-ethics-an-overview-2012.doc [accessed 2018-11-13] [WebCite Cache]
- Goodyear-Smith F, Jackson C, Greenhalgh T. Co-design and implementation research: challenges and solutions for ethics committees. BMC Med Ethics 2015 Nov 16;16:78 [FREE Full text] [CrossRef] [Medline]
- Morales E, Rousseau J, Passini R. Using a Co-Design Methodology for Research on Environmental Gerontology. J Gerontol Geriatric Res 2015;01(03). [CrossRef]
- Janols R, Lindgren H. A Method for Co-Designing Theory-Based Behaviour Change Systems for Health Promotion. Stud Health Technol Inform 2017;235:368-372. [Medline]
- Te Morenga L, Pekepo C, Corrigan C, Matoe L, Mules R, Goodwin D, et al. Co-designing an mHealth tool in the New Zealand Māori community with a “Kaupapa Māori” approach. AlterNative: An International Journal of Indigenous Peoples 2018 Jan 23;14(1):90-99. [CrossRef]
- Peters D, Tran N, Adam T. Implementation Research in Health: A Practical Guide. In: Implementation Research In Health. Geneva: World Health Organization; 2014.
- Ramaswamy V, Gouillart F. Build the co-creative enterprise. Harv Bus Rev 2010 Oct;88(10):100-9, 150. [Medline]
- Sanders E, William C. Harnessing people’s creativity: Ideation and expression through visual communication. In: Langford J, McDonagh-Philp D, editors. Focus groups: Supporting effective product development. UK: Taylor & Francis, Inc; 2002.
- Sanders E, Stappers P. Probes, toolkits and prototypes: three approaches to making in codesigning. CoDesign 2014 Mar 06;10(1):5-14. [CrossRef]
- Hudson M, Russell K. The Treaty of Waitangi and Research Ethics in Aotearoa. Bioethical Inquiry 2008 Nov 27;6(1):61-68. [CrossRef]
- May CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009 May 21;4:29 [FREE Full text] [CrossRef] [Medline]
- May C. A rational model for assessing and evaluating complex interventions in health care. BMC Health Serv Res 2006 Jul 07;6:86 [FREE Full text] [CrossRef] [Medline]
- Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med 2010 Oct 20;8:63 [FREE Full text] [CrossRef] [Medline]
- Petty NJ, Thomson OP, Stew G. Ready for a paradigm shift? Part 1: introducing the philosophy of qualitative research. Man Ther 2012 Aug;17(4):267-274. [CrossRef] [Medline]
- Hacker KA, Penfold RB, Arsenault LN, Zhang F, Murphy M, Wissow LS. Behavioral health services following implementation of screening in Massachusetts Medicaid children. Pediatrics 2014 Oct;134(4):737-746 [FREE Full text] [CrossRef] [Medline]
- Bradford S, Rickwood D. Young People's Views on Electronic Mental Health Assessment: Prefer to Type than Talk? J Child Fam Stud 2015;24(5):1213-1221 [FREE Full text] [CrossRef] [Medline]
- Logan J, Crosby A, Hamburger M. Suicidal ideation, friendships with delinquents, social and parental connectedness, and differential associations by sex: findings among high-risk pre/early adolescent population. Crisis 2011;32(6):299-309. [CrossRef] [Medline]
|CE: clinical educator|
|CS: clinical staff|
|MHB: mental health and risk behavior|
|NPT: normalization process theory|
|NZ: New Zealand|
|PHO: primary health organization|
|PHP: primary health care provider|
Edited by N Kuter; submitted 07.09.18; peer-reviewed by S Bradford, E Sturgiss; comments to author 24.09.18; revised version received 08.10.18; accepted 09.10.18; published 09.01.19Copyright
©Rhiannon Mary Martel, Margot Louise Darragh, Aniva Joanne Lawrence, Matthew John Shepherd, Tracey Wihongi, Felicity Anne Goodyear-Smith. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 09.01.2019.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.