School of Public Health and Interdisciplinary Studies

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The School of Public Health and Interdisciplinary Studies research institutes and centres play an important role in specialist teaching and research conducted by academic staff and postgraduate students. This places AUT students at the forefront of much of the ground-breaking research undertaken in New Zealand in the field of Biostatistics and Epidemiology, Psychology, Psychotherapy and Counselling, and Public Health.

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Barriers to and Recommendations for Equitable Access to Healthcare for Migrants and Refugees in Aotearoa, New Zealand: An Integrative Review
(Springer, 2023-09-04) Kanengoni‑Nyatara, Blessing; Watson, Katie; Galindo, Carolina; Charania, Nadia; Mpofu, Charles; Holroyd, Eleanor
The health system in Aotearoa New Zealand is predicated on equity in access to health services as a fundamental objective yet barriers to equitable access for migrant and refugees continue to exist. There is a paucity of studies that synthesise the experiences and realities of migrants, refugees and healthcare providers that hinder access to healthcare and provide recommendations to improve services. This review synthesised these barriers and recommendations, with an aim to improve equitable access to healthcare to migrants and refugees. An integrative review of 13 peer-reviewed research studies from EBSCOhost research databases published between January 2016 and September 2022. Studies included: (i) related to Aotearoa; (ii) had a focus on equitable delivery of healthcare to migrants and refugees; and (iii) had a full English text available. The PRISMA framework guided the reporting of the review. The findings were thematically analysed and presented using a narrative empirical synthesis. The findings were organised into three broad themes: attitudinal barriers, structural barriers, and recommendations. Attitudinal barriers included the lack of culturally competent healthcare providers, discrimination by healthcare providers, and personal, social, and cultural attributes. Structural barriers referred to policies and frameworks that regulated the accessibility of health services such as the cost of healthcare, accessibility and acceptability of interpreter services, length of allocated appointments and long waiting times for an appointment, difficulties navigating the health system, and logistical barriers. Recommendations focused on promoting a sense of belonging, enabling a whole-of-society approach that brings together all sectors involved in providing health care for collective impact, and advocating for government policies to create a system that addresses the core health service access needs. This review provides rich context-specific findings on the barriers to equitable access to healthcare and proposed interventions to enhance equitable health outcomes for migrants and refugees in Aotearoa. The review contributes to relevant policy decisions and has practical implications to build responsive health systems which are inclusive, equitable and best address the health needs of populations from diverse cultural backgrounds.
Codesign of a Digital Health Tool for Suicide Prevention: Protocol for a Scoping Review
(BMJ Publishing Group, ) Wepa, Dianne; Neal, Martin; Abo-Gazala, Waseem; Cusworth, Sally; Hargan, Jae; Mistry, Manoj; Vaughan, Jimmy; Giles, Stephen; Khan, Mehnaz; Power, Lucy
Introduction The role of digital health in providing psychological treatment and support for the prevention of suicide is well documented. Particular emphasis has been placed on digital health technologies during the COVID-19 pandemic. Providing psychological support reduces the burden of mental health conditions. The challenge is to provide support in the context of patient isolation, which highlights the role of digital technology (video conferencing, smartphone apps and social media). There is, however, a dearth of literature where experts by experience have been involved in the end-to-end process of developing digital health tools for suicide prevention. Methods and analysis This study aims to codesign a digital health tool for suicide prevention focusing on the enablers and barriers. The scoping review protocol is phase I within a three-phase study. The protocol will inform the second phase of the study which is the scoping review. The results of the review will inform a funding application to National Institute for Health and Care Research to codesign a digital health tool for suicide prevention (the third phase). The search strategy will follow the Joanna Briggs Institute Reviewer’s Manual for Scoping Reviews and incorporates the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist to ensure reporting standards are maintained. The methodology will be supplemented by frameworks by Arksey and O’Malley and Levac et al. The search strategy dates for screening are from November 2022 to March 2023. Five databases will be searched: Medline, Scopus, CINAHL, PsycInfo and Cochrane Database of Systematic Reviews. Grey literature searches include government and non-government health websites, Google and Google Scholar. The data will be extracted and organised into relevant categories. The results will be synthesised into themes and inform phase II of the study. Ethics and dissemination Ethics granted by the University of Bradford on 15 August 2022, reference E995. The project team will design a digital health tool, results will be published in a peer-review journal and disseminated through conferences. Study registration number Safety (Mental Health) Innovation Challenge Fund 2022–2023 Protocol RM0223/42079 Ver 0.1.
Enhancing Health Outcomes for Māori Elders Through an Intergenerational Cultural Exchange and Physical Activity Programme: A Cross-Sectional Baseline Study
(Frontiers Media SA, 2023-12-12) Oetzel, JG; Zhang, Y; Nock, S; Meha, P; Huriwaka, H; Vercoe, M; Tahu, T; Urlich, J; Warbrick, R; Brown, G; Keown, S; Rewi, P; Erueti, B; Warbrick, I; Jackson, AM; Perry, T; Reddy, R; Simpson, ML; Cameron, MP; Hokowhitu, B
Background: The study offers baseline data for a strengths-based approach emphasizing intergenerational cultural knowledge exchange and physical activity developed through a partnership with kaumātua (Māori elders) and kaumātua service providers. The study aims to identify the baseline characteristics, along with correlates of five key outcomes. Methods: The study design is a cross-sectional survey. A total of 75 kaumātua from six providers completed two physical functioning tests and a survey that included dependent variables based in a holistic model of health: health-related quality of life (HRQOL), self-rated health, spirituality, life satisfaction, and loneliness. Results: The findings indicate that there was good reliability and moderate scores on most variables. Specific correlates included the following: (a) HRQOL: emotional support (β = 0.31), and frequent interaction with a co-participant (β = 0.25); (b) self-rated health: frequency of moderate exercise (β = 0.32) and sense of purpose (β = 0.27); (c) spirituality: sense of purpose (β = 0.46), not needing additional help with daily tasks (β = 0.28), and level of confidence with cultural practices (β = 0.20); (d) life satisfaction: sense of purpose (β = 0.57), frequency of interaction with a co-participant (β = −0.30), emotional support (β = 0.25), and quality of relationship with a co-participant (β = 0.16); and (e) lower loneliness: emotional support (β = 0.27), enjoyment interacting with a co-participant (β = 0.25), sense of purpose (β = 0.24), not needing additional help with daily tasks (β = 0.28), and frequency of moderate exercise (β = 0.18). Conclusion: This study provides the baseline scores and correlates of important social and health outcomes for the He Huarahi Tautoko (Avenue of Support) programme, a strengths-based approach for enhancing cultural connection and physical activity.
Health Care Providers’ Early Experiences of Assisted Dying in Aotearoa New Zealand: An Evolving Clinical Service
(Springer Science and Business Media LLC, 2023-07-22) Snelling, Jeanne; Young, Jessica; Beaumont, Sophie; Diesfeld, Kate; White, Ben; Willmott, Lindy; Robinson, Jacqualine; Moeke-Maxwell, Tess
Background In November 2021, assisted dying (AD) became lawful in Aotearoa New Zealand. A terminally ill person may now request, and receive, pharmacological assistance (self-administered or provided by a medical practitioner/nurse practitioner) to end their life, subject to specific legal criteria and processes. Exploring the experiences of health providers in the initial stage of the implementation of the End of Life Choice Act 2019 is vital to inform the ongoing development of safe and effective AD practice, policy and law. Aim To explore the early experiences of health care providers (HCPs) who do and do not provide AD services seven months after legalisation of AD to provide the first empirical account of how the AD service is operating in New Zealand’s distinctive healthcare environment and cultural context. Design Qualitative exploratory design using semi-structured individual and focus group interviewing with a range of HCPs. Results Twenty-six HCPs participated in the study. Through a process of thematic analysis four key themes were identified: (1) Difference in organisational response to AD; (2) challenges in applying the law; (3) experiences at the coal face; and (4) functionality of the AD system. Conclusion A range of barriers and enablers to successful implementation of AD were described. Adoption of open and transparent organisational policies, ongoing education of the workforce, and measures to reduce stigma associated with AD are necessary to facilitate high quality AD service provision. Future research into the factors that influence responses to, and experience of AD; the impact of institutional objection; and the extent to which HCP perspectives evolve over time would be beneficial. In addition, further research into the integration of AD within Māori health organisations is required.
Imprisonment Following Discharge From Mental Health Units: A Developing Trend in New Zealand
(Frontiers Media SA, 2023-01-26) Skipworth, Jeremy; Garrett, Nick; Pillai, Krishna; Tapsell, Rees; McKenna, Brian
INTRODUCTION: Contemporary models of care for people with mental disorders continue to shift to community-based care, requiring fewer inpatient mental health beds, shorter inpatient lengths of stay, and less use of coercion. It has been suggested that some mentally unwell people, whose behavior can no longer be safely contained in overstretched mental health units where seclusion and restraint are discouraged, are now left to the criminal justice system to manage. It is unclear whether the risk of imprisonment following discharge from a mental health unit has increased over recent years. METHODS: A quantitative, retrospective cohort study design was used to investigate any association between an acute inpatient mental health service admission in Aotearoa (New Zealand), and referral to a prison mental health team within 28 days of hospital discharge, from 2012 to 2020. Data were extracted from the national mental health dataset managed by the Ministry of Health. RESULTS: Risk of imprisonment within 28 days of inpatient discharge increased over the study period. People experiencing this outcome were more likely to be younger, male, of Mâori or Pacific ethnicity, presenting with substance use and psychotic disorders who were aggressive or overactive, and were subject to coercive interventions such as seclusion and compulsory treatment during their admission. DISCUSSION: We concluded that contemporary models of less coercive predominantly community based mental health care may be increasingly reliant on the criminal justice system to manage aggressive and violent behavior driven by mental illness. It is argued from a human rights perspective that mental health inpatient units should retain the capacity to safely manage this type of clinical presentation.
Indigenous Social Exclusion to Inclusion: Case Studies on Indigenous Nursing Leadership in Four High Income Countries
(Wiley, ) Brockie, Teresa; Clark, Terryann C; Best, Odette; Power, Tamara; Bourque Bearskin, Lisa; Kurtz, Donna LM; Lowe, John; Wilson, Denise
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 Māori case study design. METHODS: Using a Kaupapa Māori 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.
Informing Women About Maternal Vaccination in Aotearoa New Zealand: Is It Effective?
(Elsevier, ) Young, Amber; Charania, Nadia; Gauld, Natalie; Norris, Pauline; Turner, Nikki; Willing, Esther
National Cross-Sectional Study of the Sociodemographic Characteristics of Aotearoa New Zealand’s Regulated Health Workforce Pre-Registration Students: A Mirror on Society?
(BMJ, 2023-03-13) Crampton, P; Bagg, W; Bristowe, Z; Brunton, P; Curtis, E; Hendry, C; Kool, B; Scarf, D; Shaw, S; Tukuitonga, C; Williman, J; Wilson, D
Objectives To provide a sociodemographic profile of students enrolled in their first year of a health professional pre-registration programme offered within New Zealand (NZ) tertiary institutions. Design Observational, cross-sectional study. Data were sought from NZ tertiary education institutions for all eligible students accepted into the first ar of a health professional programme for the 5-year period 2016-2020 inclusive. Variables of interest: gender, citizenship, ethnicity, rural classification, socioeconomic deprivation, school type and school socioeconomic scores. Analyses were carried out using the R statistics software. Setting Aotearoa NZ. Participants All students (domestic and international) accepted into the first ar of a health professional programme leading to registration under the Health Practitioners Competence Assurance Act 2003. Results NZ's health workforce pre-registration students do not reflect the diverse communities they will serve in several important dimensions. There is a systematic under-representation of students who identify as Māori and Pacific, and students who come from low socioeconomic and rural backgrounds. The enrolment rate for Māori students is about 99 per 100 000 eligible population and for some Pacific ethnic groups is lower still, compared with 152 per 100 000 for NZ European students. The unadjusted rate ratio for enrolment for both Māori students and Pacific students versus Other' students is approximately 0.7. Conclusions We recommend that: (1) there should be a nationally coordinated system for collecting and reporting on the sociodemographic characteristics of the health workforce pre-registration; (2) mechanisms be developed to allow the agencies that fund tertiary education to base their funding decisions directly on the projected health workforce needs of the health system and (3) tertiary education funding decisions be based on Te Tiriti o Waitangi (the foundational constitutional agreement between the Indigenous people, Māori and the British Crown signed in 1840) and have a strong pro-equity focus.
Paediatric COVID-19 Vaccination Coverage and Associated Factors Among Migrant and Non-migrant Children Aged 5–11 Years in Aotearoa New Zealand: A Population-Level Retrospective Cohort Study
(Wiley, 2023-09-19) Charania, Nadia; Linda, Kirkpatrick; Janine, Paynter
Objective Children with migrant and refugee backgrounds may experience immunisation inequities due to barriers to accessing and accepting vaccines. In Aotearoa New Zealand (NZ), national reporting can mask inequities in coverage by migration background. This study explored paediatric COVID-19 vaccine uptake among children with migrant and refugee backgrounds. Methods This population-level retrospective cohort study compared rates and determinants of paediatric COVID-19 vaccine uptake as of July 2022 amongst migrant and non-migrant children who were aged between 5 and 11 years as of January 2022. Linked de-identified administrative and health data available in Statistics NZ’s Integrated Data Infrastructure were used, and univariate and multivariable logistic regression were conducted to determine associations. Results Of the total study population (N = 451,323), 3.5% were overseas-born migrant children, 31.3% were NZ-born migrant children, and 65.3% were NZ-born non-migrant children. Only 50.8% (229,164 out of 451,323) of children had received at least one dose. Migrant children were significantly more likely to have received a COVID-19 vaccination than non-migrant children. Logistic modelling revealed that all factors, including ethnicity, gender, age, family type, household income, deprivation, region, parent COVID-19 vaccination status, and child’s previous COVID-19 infection, significantly influenced COVID-19 vaccine uptake. The largest contributing factor was parents’ COVID-19 vaccination status. Conclusions The findings suggest that NZ’s paediatric COVID-19 vaccination programme was able to address logistical and motivational barriers commonly identified amongst migrants and refugees. Implications for public health As parents’ vaccination status is an important factor in vaccinating their own children, continuous efforts are needed to support confident parental COVID-19 vaccine decision-making. To address social inequities, engagement with marginalised communities to co-design tailored and localised approaches is recommended.
Relationship Between Perceived and Measured Body Size Among Pacific 14-Year-Olds in Aotearoa | New Zealand: Findings from the Pacific Islands Families Study
(Wiley, 2023-05-25) Lousich, Katrina L; Tautolo, El-Shadan; Schluter, Philip J
AIM: Pacific people carry a disproportionate burden of socio-cultural and economic determinants of health in Aotearoa | New Zealand (NZ), and 61.7% of Pacific children aged 0-14 years are overweight or obese. Yet Pacific children's self-perception of their body size is unknown. This population-based study aimed to investigate the concordance between measured and perceived body size in a cohort of Pacific 14-year-olds in NZ, and to assess how this relationship is influenced by their cultural orientation, socio-economic deprivation and degree of recreational internet use. METHODS: The Pacific Islands Families Study tracks a cohort of Pacific infants born in the year 2000 at Middlemore Hospital, South Auckland. This study is a nested cross-section of participants at the 14-year postpartum measurement wave. Following strict measurement protocols, body mass index was measured and categorised according to the World Health Organization classifications. Agreement and logistic regression analysis methods were employed. RESULTS: Of 834 participants with valid measures, 3 (0.4%) were measured as being underweight, 183 (21.9%) as normal, 235 (28.2%) as overweight and 413 (49.5%) as obese. Overall, 499 (59.8%) perceived their body size to have a lower classification than that when measured. Neither cultural orientation nor deprivation was significantly related to weight misconception but recreational internet use was, with higher use associated with increased misconception. CONCLUSIONS: Improving body size awareness together with the risk of higher recreational internet use is likely to be an important component in any population-based healthy weight intervention formulation for Pacific adolescents.
“She vaccinated my baby and that’s all…” Immunisation Decision-Making and Experiences Among Refugee Mothers Resettled in Aotearoa New Zealand
(Springer Science and Business Media LLC, 2023-07-13) Charania, Nadia A
Background To prevent disease outbreaks, refugee children must be age-appropriately immunised. This qualitative study gained an in-depth understanding of refugee mothers’ vaccine decision-making and experiences accessing immunisation services for their children post-resettlement in Aotearoa New Zealand. Methods An interpretive description methodology involving focus groups with refugee mothers (N = 45) was conducted in Auckland, one of the resettlement locations. Mothers were asked about their perceptions of vaccine-preventable diseases and vaccines, their experiences of attending immunisation events, and their suggestions for improvements to immunisation services. Data were analysed following the phases of reflexive thematic analysis. Results Four themes were constructed. Do I have a choice? Mothers displayed pro-vaccination sentiments and parental obligation to vaccinate their children to protect their health, which underpinned their compliance with the national vaccine schedule. Transnational vaccine perceptions and behaviours It was evident that comparing their health experiences in their origin countries reinforced their positive perceptions of and trust in vaccines, health providers and their recommendations, the health system and government in New Zealand. Information sharing with their transnational networks had the potential to influence vaccine perceptions and behaviours in home and host countries. Unanswered questions and concerns Mothers discussed how many of their questions and concerns about immunisations and post-vaccine management went unanswered. Relationships and experiences matter Mothers stressed the importance of who vaccinated their child and how it was administered, highlighting that health providers’ demeanour and competence influence their immunisation experiences. Conclusions Health providers are encouraged to focus on creating a positive immunisation experience for refugee background families. Qualified interpreters and provision of culturally and linguistically appropriate information are required. Transnationalism at the individual level appears to influence vaccine perceptions and behaviours among refugee-background mothers. Future research focusing on caregivers with child(ren) who are not fully vaccinated would be beneficial.
Supporting Patients and Their Carers to Participate in Infection Prevention and Control Activities: The Views of Patients, Family Members and Hospital Staff From Bangladesh, Indonesia, and South Korea
(Elsevier, 2023-06-30) Park, JY; Pardosi, JF; Islam, MS; Respati, T; Nurhayati, E; Chowdhury, K; Charania, NA; Seale, H
BACKGROUND: Hand hygiene reminders for healthcare workers (HCWs) are commonly used to empower patients. However, this approach overlooks the role of family carers in delivering direct contact care in Asian countries. Limited knowledge exists regarding empowerment strategies for patients and their family carers in infection prevention and control (IPC) recommendations. This study aimed to provide a comprehensive exploration of IPC empowerment within the context of family involvement in care provision across Bangladesh, Indonesia, and South Korea METHOD: In-depth interviews were conducted in five tertiary-level hospitals in Bangladesh, Indonesia, and South Korea. A total of 64 participants through 57 group interviews were interviewed, comprising two groups: 1) patients and family/private carers; and 2) HCWs. RESULT: The study identified barriers to engaging patients and family carers in IPC measures. These included concerns about the patient-HCW hierarchical relationship, lack of knowledge about healthcare-associated infection, IPC, and patient zone, perceptions of IPC as a barrier to family connections, and disempowerment of patients in IPC due to family bonds. CONCLUSION: This study provides diverse perspectives on IPC empowerment, revealing challenges faced by patients, family carers, and HCWs. The interlaced relationship established by social norms of family carer provision hinders the empowerment of family carers. Acknowledging the cultural influence on healthcare arrangements and its implication for IPC empowerment is crucial in mitigating these barriers.
The Relationship Between Sleep Duration and Health Among Pacific Adolescents Within New Zealand: Findings From the Pacific Islands Families Study
(Wiley, ) McLay, Laurie; Tautolo, El-Shadan; Iusitini, Leon; Richards, Rosalina; Galland, Barbara; Schluter, Philip J
OBJECTIVE: Sleep insufficiency is bi-directionally associated with adverse behavioural, physical and mental health outcomes in paediatric populations. However, little is known about the degree of sleep insufficiency and its effect on Pacific adolescents' wellbeing. METHODS: A cross-sectional study of 14-year old Pacific adolescents nested within a longitudinal birth cohort was conducted. Self-reported sleep duration was related to sentinel physical, mental, and risk taking behaviour measures in crude and adjusted logistic regression models. Complete case and multiple imputed analyses were conducted. RESULTS: 916 Pacific adolescents were eligible, with a mean age of 14.2 years. Valid sleep data were available from 828 (90.4%) participants, with only 220 (26.6%) meeting the recommended amount of sleep. Insufficient sleep duration was associated with significantly higher rates of depressive symptoms and risk taking behaviours. In multiple imputed analyses, increased body mass index was also significantly related. CONCLUSIONS: Sleep insufficiency is ubiquitous among Pacific adolescents and associated with negative impacts on their health and wellbeing. IMPLICATIONS FOR PUBLIC HEALTH: Insufficient sleep duration is amenable to change. Bespoke, culturally responsive public health strategies that draw attention to the importance of positive sleep practices are needed. Particularly, among adolescents who are at risk of experiencing the greatest burden of insufficient sleep.
The Threat of Gambling to Public Health in Ghana: Time to Act
(SAGE Publications, 2024-08-07) Badu, Emmanuel; Crawford, Gemma; Hallett, Jonathan; Bellringer, Maria E; Vujcich, D
What Do Health Care Professionals Want To Know About Assisted Dying? Setting the Research Agenda in New Zealand
(Springer Science and Business Media LLC, 2023-04-10) Young, Jessica; Snelling, Jeanne; Beaumont, Sophie; Diesfeld, Kate; White, Ben; Willmott, Lindy; Robinson, Jacqualine; Ahuriri-Driscoll, Annabel; Cheung, Gary; Dehkhoda, Aida; Egan, Richard; Jap, James; Karaka-Clarke, Te Hurinui; Manson, Leanne; McLaren, Cam; Winters, Janine
Background New Zealand recently introduced law permitting terminally ill people to request and receive assisted dying (AD) in specified circumstances. Given the nature and complexity of this new health service, research is vital to determine how AD is operating in practice. Objective To identify research priorities regarding the implementation and delivery of AD in New Zealand. Methods Using an adapted research prioritisation methodology, the researchers identified 15 potential AD research topics. A mixed-methods survey of health professionals was undertaken where respondents were asked to rate the 15 topics according to the relative importance for research to be conducted on each issue. Respondents could also suggest additional research areas, and were invited to participate in a follow-up interview. Results One hundred and nineteen respondents completed the survey. 31% had some experience with AD. The highest rated research topic was the ‘effectiveness of safeguards in the Act to protect people’; the lowest rated topic was research into the ‘experiences of non-provider (e.g., administrative, cleaning) staff where assisted dying is being provided’. Respondents suggested 49 other research topics. Twenty-six interviews were conducted. Thematic analysis of interview data and open-ended survey questions was undertaken. Six research themes were identified: general factors related to the wider health system; the experiences of health care providers at the bedside; medico-legal issues; the impact of AD; experiences on the day of dying; and the overall effectiveness of the AD system. Key issues for stakeholders included safety of the AD service; ensuring access to AD; achieving equity for ‘structurally disadvantaged’ groups; and ensuring the well-being of patients, families/whānau, providers and non-providers. Conclusions Based on early experiences of the implementation of the AD service, health professionals provide important insights into what research should be prioritised post-legalisation of AD. These findings can be used to shape the research agenda so that research may inform law, policy and best practice.

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