In the French overseas department of French Guiana, in South America, nutrition therapy for the management of diabetes is based on French guidelines. However, this region is demographically diverse and includes several populations of Indigenous Peoples, Parikwene among others, also called Palikur. Due to socio-economical, cultural, and geographical differences, along with distinctions in the local food system, dietary recommendations, which many consider in the context of post-colonial power dynamics, are not well suited to local populations. In the absence of suitable recommendations, it is hypothesized that local populations will adapt their dietary practices considering diabetes as an emerging health problem.Manihot esculenta Crantz) consumption and diabetes were collected via semi-structured interviews and participant observation , namely via participating in activities related to the transformation of cassava tubers at swidden and fallow fields.Seventy-five interviews were conducted with community members and Elders, as well as healthcare professionals and administrators providing services to the Parikwene population of Macouria and Saint-Georges de l’Oyapock communes. Data regarding the representation of cassava , based on organoleptic properties . Preferences for the consumption of acidic couac were grounded in the Parikwene knowledge system, as well as attention to diabetes related symptoms and glucometer readings.These results provide important insights related to knowledge, attitudes, and practices in developing locally and culturally adapted approaches to providing dietary recommendations in the treatment of diabetes. In combIn comparison to France, the prevalence of diabetes is notably higher in French overseas departments . That isManihot esculenta Crantz; Euphorbiaceae; Centres Délocalisés de Prévention et de Soins) of the Andrée Rosemon Cayenne Hospital Center  record the largest number of treated diabetic patients in Saint-Georges de l’Oyapock  and rice , as well as root vegetables like potatoes , yams  and also cassava  has declared the necessity of adapting their program to the specificities of overseas territories .Fieldwork took place from June 2017 to July 2018. Altogether, 75 interviews were completed with 101 participants with a sex ratio (men/women) of 0.87. The breakdown of interviews is presented in 2.3.chaîne opératoire. This study was conducted within the scope of a wider research project whereby interview questions related to knowledge, attitudes and practices pertaining to diabetes and its treatment. Nomenclature and terminology were recorded in Parikwaki. Because various writing systems have been developed over time, preference was given to the system developed by Green et al. , namely via participating in activities related to the transformation of cassava tubers at swidden and fallow fields and observing each step of the operational sequence, or n et al. , preferr2.4.Chef coutumier, along with the Ethics Committee of the Université of Montréal (Certificate #: CERAS-2016-17-081-P). Overall, the working approach was conducted with respect to the International Society of Ethnobiology’s Code of Ethics , Proto-Arawak Peoples, to which Parikwene are linguistically related, are believed to have relied on domesticated cassava as an important food source, thus leading to the development of numerous Arawakan societies whose food systems have and continue to rely on cassava agriculture . To unde3.1.1.kaneg) from sweet cassava (awava). This differentiation is crucial as the content of cyanogenic compounds discerns the former from the latter; elevated concentrations of these toxins in bitter cassava varieties require elaborate transformation procedures to avoid cyanide toxicity  Schott; Araceae), sweet potatoes (Ipomoea batatas (L.) Lam.; Convolvulaceae) and various species of yam . However, bitter cassava tubers were more versatile as they were the main source of several derived foodstuff , patawa, or pataw  and açaí, or was ;added to bowls of palm nectars like bacaba, or as an accompaniment to main meals, such as grilled or boiled meats and fish, whereby couac is either added to an individual’s plate, or meat and fish are dipped in a communal platter of couac;Mangifera indica L.; Anacardiaceae) and pineapple (Ananas comosus (L.) Merr.; Bromeliaceae);as a dipping condiment for fruits, like mangoes  extracted from bitter cassava tubers and transformed into tapioca (kayut kuwagaki) was also used as an additive to hot beverages and bowls of palm nectars, but also in the preparation of specific dishes like kusimna, or tacacá. This dish is as varied as the choice of broth, including the liquid from which starch is extracted (karahu), which is thickened by tapioca and used in its preparation. Furthermore, cassava juice (karahu) could also be used to cook fish or meat (atit karahu) by adding hot peppers, atit . Finally, cassava flatbreads (wat marehpeket) and cassava beer (wonska) were also consumed occasionally or on special occasions , papayas , bananas , pineapples, and several citruses , starchy root vegetables, like dasheen, sweet potatoes and yams, as well as several medicinal plants  and strengthening social relations that ensure cultural and linguistic continuity. This maintains the species ubiquity in the collective cultural consciousness that ensures “persistence and memory of use in relationship to cultural change.” This relationship to change is tightly woven into cassava’s “role in narratives, ceremonies, or symbolisms.” Although these can be addressed through various angles, such as the place and role of wonska, or cassava beer in ceremonies, it is through its prominently featured place in narratives regarding health and diabetes and consequent adaptations to the operational sequence of couac production that it is illustrated hereinafter.Finally, activities related to harvesting and transforming cassava tubers are structured around collective events that solicit mutual help among families and the participation of several generations of family members. 3.2.“If we drop couac, we cannot eat. The problem is that we are going to die.” LS6022, Macouria.Due to the high starch content of cassava tubers, their consumption is featured in narratives provided by healthcare professionals. When asked about the factors responsible with the development of diabetes, cassava consumption was cited by 79.3% of participants linked to the healthcare sector. Some doctors in Cayenne cited the effect of cassava toxicity on pancreatic injury, LS4013 explains: “Couac is made from bitter cassava which must be washed well because otherwise it is toxic, especially for the pancreas.” Couac was not cited as a direct cause of diabetes, but one of many intertwined factors that involve transformations to Parikwene food systems  and lifestyle . However, one doctor from Macouria explains some of the difficulty related to language barriers when discussing dietary recommendations around couac:But actually, couac is part of… the glycemic indices which are still quite high as starchy foods […] Doctors, I think they take shortcuts, sometimes, when they explain to people who don't speak French very well, and so on. So, sometimes, they will tell them: 'No, no, but couac, ok, it's not worth it. Take that off [your plate], yeah.' LS6002, Macouria.Increasing with the ripeness of fruits and the cooking time of starchy tubers and grains, the GIs of a food can vary greatly according to a wide range of factors, such as species variety . MoreoveBecause nutritional and dietary advice and information is provided during visits and interactions with doctors and nurses, such information has naturally reverberated in Parikwene responses and explanations regarding the development and progression of diabetes. However, what is resoundingly clear is an overwhelming interpretation that healthcare professionals are blaming the consumption of couac in the development of diabetes. One resident from Macouria, LS6026, explains that “a lot of doctors say it’s because [Parikwene] Indians eat a lot of couac and they find diabetes. And then, they catch diabetes in the couac.” Considering the cultural importance of this dietary staple, some find it difficult to believe the perceived rhetoric, as exemplified by one resident from Saint-Georges, LS5008, who vehemently opposed the idea: “And then the doctors, they talked about not eating couac. It’s couac that has… ‘It’s couac that caused diabetes.’ It’s not couac! They said… Doctors, they said: ‘It’s couac that causes diabetes.’ But that’s not true, it’s not couac.”Some residents interviewed do not necessarily deny the evidence regarding the carbohydrate content of couac. When rationalizing the development of diabetes within the context of the nutrition and food transition experienced by Parikwene People, it is the approach taken by doctors and the simplicity of their messaging that is put in question, as one resident from Saint-Georges explains:That’s what they put in their heads. It’s the doctors, when they do campaigns, who say that… Well, it’s true, they [the research community] did research on couac and they said: ‘Couac has a lot of sugar.’ So, they [the doctors] say: ‘Couac gives diabetes.’ It’s the doctor when he campaigns, he prevents. That’s why they put it in their [Parikwene] head, they say that it’s couac that gives diabetes. For me, well, that’s not true. For me, it does not make any sense, it is not true… It is not true. It would be years back, and they are not diabetic. How did they [the Elders]… they died at 100 years, 90 years old, and they did not even have diabetes. Now, why now us, the descendants now, not even at 15, at 20, are we diabetic? For what reason? Why? Because we do not just eat couac. We consume everything that is not good for the body. LS5012, Saint-Georges.Another participant interviewed dismisses the centrality of couac by echoing narratives on the nutrition and food transition and recentering diabetes as a global phenomenon:I spoke with a doctor at the center and he said to me: ‘Yeah, but why among the Palikur Amerindian, there are a lot of… There are many diabetics? Because… Is it because of your food and all that?’ I said: ‘No.’ Because, well… Our elders, before, they have…well, they rarely had diabetes. Because they have eaten… They are not eating… I say: “Well, now, in relation [to the past], we use products… We eat your products, your food, and all that. Why, in mainland France, there are people, they are diabetics? And the United States… In the United States, well, they do not eat couac. And why are they diabetic?’ LS5010, Saint-Georges.in vivo study found that the long-term ingestion of cassava did not produce diabetes or pancreatitis in rats after 1 year of feeding  and acidic couac (puveye suweine), whose names characterize their organoleptic properties. In 72.9% of interviews (35/48), Parikwene participants considered acidic couac to be better for diabetics over sweet couac. In three interviews, participants stated that it did not affect diabetes any differently from sweet couac whereas participants in two other interviews specified that it depended on the person, adding that their personal experience was different to what they have observed among other members of their community. The only non-Parikwene participant to be familiar with these different types of couac also noted that acidic couac did not increase glycemia as dramatically than sweet couac. Accordingly, many diabetics interviewed switched from sweet couac to acidic couac in an effort to keep their glycemic levels lower. One participant from Macouria, LS6022, explains: “There is couac that is very sweet. The sweet couac, it is not good for diabetes. If you eat it, it raises your diabetes. There is the couac that is not really sweet. If you eat it, it’s good.”In relation to diabetes, couac and cassava tuber were discussed by participants in 93.3% of all interviews (70/75). Despite Parikwene narratives against the centrality of couac as a direct cause for diabetes, its consumption in dietary interventions for the management of diabetes was recognized, nonetheless. In 83.3% of interviews (40/48), Parikwene participants reported two principal types of couac that were involved in glycemic control, whereas this was only brought up by one non-Parikwene participant working as a home nurse. These were called sweet couac  for culinary purposes before the grated mass is left to ferment with the retted mass, thus further reducing the starch content in the end product. Although some Parikwene agroecological calendars report that the transformation of cassava tubers traditionally occurs in April  sweetness, due to its link with sugar and sweet foods, and (2) heat, due to explanations given to certain symptoms like the evacuation of fluids through polyuria and diarrhea as a consequence of the body overheating and needing to be cooled by replenishing with water, hence polydipsia . These sThe notion of hot and cold that underlines the description of diabetes and medicines is similar to the local Creole medicinal system , 90; thrChoices regarding which type of couac to consume for the management of diabetes are adopted on a personal basis. These choices are notably influenced by the experience of adverse reactions following the consumption of a specific type of couac, or other food items. The symptoms reported by diabetic participants include:numbness in the mouth;dry mouth;sudden fatigue and weakness;perspiration;increase in body heat;diarrhea;polyuria.Blood glucose levels were often measured with a glucometer during such events, either personally or assisted by a family member or nurse, to confirm whether there is hyperglycemia. Paying attention to body signals, symptoms of diabetes, and to glucometer readings were the primary practices in self-guiding dietary interventions around diabetes. One participant explains how the glucometer helps in confirming the effects of acidic couac on diabetes:Sweet couac raises diabetes. The doctor takes blood, he puts it in a device, he looks, it goes up a lot. If it goes up to 5 or 6 grams, it’s too high, it’s a lot. If it’s 1 or 1.60 or 2 and 2.80 grams, it’s good, it’s not that high. We see the difference when we eat sweet couac and acidic couac, we see the difference in the device. LS5032, Saint-Georges.Candida spp.) and bacteria  have been found to break down starches and sugars into organic acids . The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.MR conducted this study in the context of his doctoral thesis. AC and DD supervised the work as doctoral advisors. All authors contributed to the manuscript revision, read, and approved the submitted version.Gestions des territoires, des ressources et systèmes de santé autochtones comparés (Guyane française-Québec)”) from France’s CNRS to AC and DD, the OHM Oyapock, Labex DRIIHM (ANR-11-LABX-0010) and Labex CEBA (ANR-10-LABX-25-01), as well as a CIHR Doctoral Research Award (201510DAR-358297-196992) and a travel award from the Université de Montréal to MR.Financial support was provided by a PICS (N° 07779 “The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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There has been limited focus on understanding the barriers and facilitators to meeting the broader psychosocial needs of young people with mental illness from the perspectives of young people. This is required to advance the local evidence base and inform service design and development. The aim of this qualitative study was to explore young people’s (10–25 years) and carers’ experiences of mental health services, focusing on barriers and facilitators to services supporting young people’s psychosocial functioning.n = 12 parent–child dyads). Qualitative analysis was guided by the Social-Ecological Framework to identify barriers and facilitators at the individual (young person/carer level), interpersonal, and service/systemic level.This study was conducted throughout 2022 in Tasmania, Australia. Young people with lived experience of mental illness were involved in all stages of this research. Semi-structured interviews were conducted with 32 young people aged 10–25 years with experience of mental illness, and 29 carers  the complexity of young people’s psychosocial needs and (2) lack of awareness/knowledge of services available; at the interpersonal level: (3) negative experiences with adults and (4) fragmented communication between services and family; and at the systemic level: (5) lack of services; (6) long waiting periods; (7) limited service accessibility; and (8) the missing middle. Facilitators included, at the individual level: (1) education for carers; at the interpersonal level: (2) positive therapeutic relationships and (3) carer advocacy/support; and at the systemic level: (4) flexible or responsive services, (5) services that address the psychosocial factors; and (6) safe service environments.This study identified key barriers and facilitators to accessing and utilising mental health services that may inform service design, development, policy and practice. To enhance their psychosocial functioning, young people and carers want lived-experience workers to provide practical wrap-around support, and mental health services that integrate health and social care, and are flexible, responsive and safe. These findings will inform the co-design of a community-based psychosocial service to support young people experiencing severe mental illness. Youth mental illness remains a global public health challenge. In Australia, mental illness is one of the leading causes of burden of disease among youth , with suicide the leading cause of death among 15–24-year-olds . TasmaniDespite high prevalence of youth mental illness, service utilisation rates remain low. The gap between the need and access to mental health support is larger for youth than any other age group , with apPsychosocial wellbeing refers to young people’s broader functioning, such as social functioning, education, community engagement and day-to-day living. Nearly a quarter of Australian young people who experience mental illness report the psychosocial impact of their mental illness as ‘severe’ . A decliWhilst patient and public involvement is an essential part of public health research, meaningful involvement of young people with mental illness in research is lacking , 20. SupThis qualitative study was approved by the Monash University Human Research Ethics Committee, and reporting was guided by the Consolidated Criteria for Reporting Qualitative Research . This stn = 1) or did not respond to researcher attempts to organise an interview (n = 3). The final sample comprised of 61 participants, including 32 young people and 29 carers, of which 12 were carer-child dyads. Parental consent was sought for children under 16 years.Purposive sampling was used in this study, where young people aged 10–25 years with a living experience of mental illness and engagement with services in Tasmania were eligible to participate. Carers of a young person who met the criteria were also eligible to participate. A multi-pronged approach to recruitment was employed, via existing mental health consumer engagement organisations and peak bodies, which provide advocacy, representation, and information for people experiencing mental illness , youth mental health services across the state , and general youth community networks . Recruitment was conducted via multiple modalities, including various social media platforms of local youth services and organisations, in-person flyers on-site at various existing services, and via emailing lists of consumer engagement groups, which targeted carers . A total of 65 individuals expressed interest to participate, of which four did not proceed to interview due to change of mind (Tables Participants had the choice to participate in a semi-structured one-on-one or dyad interview (carer and child together) with the researcher, or a focus group with other young people or carers, depending on their personal preference. Participants chose the time, place and modality of the interview, including in-person, via phone, or over Zoom. All participants engaged in a one-on-one interview with the researcher, except two carer-child dyads who each participated in a dyad interview. Interviews were generally conducted during after-school/work hours or weekends, either via phone or Zoom. Young people and carers were asked about their experiences of accessing and engaging in mental health services, the barriers and facilitators that helped or hindered their utilisation of mental health services, the extent to which such services met their psychosocial needs, suggestions for how to overcome their identified barriers and recommendations for how services can better facilitate their psychosocial wellbeing. Interviews were semi-structured to allow for prompting and tailoring of questions based on each participant’s unique experience. Participants were each given a $30 voucher for their time and involvement. Interviews were approximately one hour in duration, all conducted by a female researcher, and were audio-recorded. Interviews were transcribed verbatim by the researcher and provided to participants for feedback/correction.th interview, yet the researcher continued interviews with the 12 remaining participants who had initially expressed interest in participating. Transcripts were coded by the same researcher who completed the interviews, and 50% were double-coded. Each coder independently coded and developed their own codebook, then the two researchers engaged in a collaborative discussion to compare codes, ensure consistency, and to group codes into various themes. The initial themes were then shared with the advisory group of young people, who engaged in an iterative process of collaboratively developing, refining and naming the themes.Deductive content analysis was conducted to identify the various barriers and facilitators to supporting young people’s psychosocial wellbeing. This analytic approach was chosen to effectively categorise the content discussed by participants as a barrier or facilitator, based on existing knowledge . BronfenA total of 14 subthemes were identified, including eight barriers and six facilitators across the individual, interpersonal, and systemic levels. Quotes are included from young people (YP) and carers (C), with the age of the young person identified . Figure Young people’s psychosocial needs: “there’s so much going on”Carers identified that the psychosocial functional impact of the young person’s mental illness was a barrier in itself to accessing support. The complexity, severity, and impact of mental illness influenced young peoples’ capacity, readiness, and motivation to access and/or meaningfully engage in support.He’s not motivated [to engage] at all. I can’t even get him out of bed, let alone to a service. C, 14yo, maleFor young people, this was described as a sense of feeling overwhelmed or overburdened by the functional impact of their mental illness combined with the pressures of everyday living and the thought of accessing and engaging in services.How can you even focus on getting help when you're worried about things like your housing, generally being able to eat throughout the week, because you can't afford it, or getting a job? There’s so much else to think about when you've got these kinds of stressors. Accessing support is a really big task to undertake when you're mentally ill and struggling to function. YP, 20yo, femaleA lot of us are really struggling down here, and we have been for a while. Like there’s no housing, and now cost of living is insane…We’re genuinely worried about getting our basic needs met like food, money, and a roof, so getting support for mental health isn’t always at the top of the list. YP, 23yo female2.Lack of awareness of supports: “I didn’t know where to go”Young people and carers reported that a lack of awareness of available and appropriate services and not knowing how or where to access support, often led to delayed help-seeking and increased severity of concerns.I honestly had no idea what I was doing. It was like going down a rabbit hole of confusion. YP, 15yo, femaleIf we had known where to go from the start, maybe she wouldn’t have been hospitalised. C, 13yo, femaleSome carers reflected that low mental health literacy among caregivers and the local community more broadly across the state may partly contribute to this lack of awareness.“I work in the sector and it was still incredibly hard for me to get her in, so what about the majority of the parents across Tassie who would have no idea what to do or where to go? It’s really difficult.” C, 14yo, femaleCarers also discussed the burden of accessing supports for their child, and how multiple unsuccessful attempts of help-seeking had an adverse impact on their own wellbeing:The lack of available options for my child has affected my mental health as well. C, 17yo, maleWe were at a loss about how do we get support for him? Everywhere we went they said, ‘nope can't help you’, so I was pretty broken down by that stage…It’s taken a massive toll. I'm in grief. I hurt inside. C, 15yo, maleInvalidating experiences with adults: “no one would believe me”Young people frequently recounted negative experiences of their concerns being dismissed, invalidated, or misunderstood by adults, including their carers and clinicians.My parents basically thought that my mental health issues weren’t a real thing, they just didn’t believe me and didn’t get how serious it actually was until I ended up in ED. YP, 19yo, femaleI’ve seen probably over half a dozen different people, and very rarely were they actually helpful. Most of them I didn’t really feel like I could talk to them at all, and they just didn’t get how serious I was. YP, 17yo, femaleSome carers also had negative appraisals of their child’s clinicians, including not listening to their young person’s concerns, providing inconsistent care, and being unsupportive.He basically said that our daughter was never going to get better, she was likely to end up on the street, end up on drugs, she was likely to fall in with people who would rob us. That was just a really horrible experience. C, 18yo, femaleSuch experiences prevented or delayed young people from accessing support, resulting in elevation of mental illness , further decline in psychosocial functioning, and/or discontinuing their service engagement.I was like, “no mum, like you don't understand, this is making me not want to be alive”. She was always like, “you’re just being dramatic”. I guess she didn't understand or almost didn't believe it in a way. She didn't start to listen until after my suicide attempt in grade nine. YP, 20yo, femaleI didn't think they understood how serious it was because they kind of just put my name down for a session and then turned me away, even though I was at my lowest point. I never went back there. YP, 22yo, female2.Fragmented communication: “there’s lots of mixed messages”Last week I was able to talk to them about how I'm scared he's gonna hurt himself. Then next week he’s 18, I still think he's gonna hurt himself, but I get ‘sorry, can't talk to you. C, 18yo, maleI understand the need to respect the confidentiality, but our daughter was very upfront about you can tell my parents. She really would have benefited from keeping us more in the loop of what was going on, but they didn't do that at all. C, 15yo, femaleFragmented and inconsistent communication from mental health services was a predominant challenge faced by carers. Specifically, carers reported considerable difficulty with communication and confidentiality once their child turned 18.It was nice to have someone that I could trust and wouldn't go tell my parents, ‘oh he's been smoking weed’ and stuff like that. YP, 16yo, maleHome was never really a safe place for me so once they told mum, I ended up having to move out of home a few days after turning 17. It just made everything worse and I didn’t go back. YP, 21yo, femaleYoung people valued the confidentiality and privacy practices upheld by services, while some had difficult experiences when family became involved without their consent.I think it would have been really good for our daughters to have had the option for us to have been more involved in their care. They are both at home and we have provided a very stable, resilient, supportive home for them. I know that's not always the case for kids with mental health issues. But for our situation, it would have been really helpful for them to keep us in the loop more. C, 17yo and 19yo, femalesCarers wanted services to maintain transparent and consistent communication with families, where appropriate and as desired by the young person.Lack of services: “It’s just the tip of the iceberg”Young people and carers acknowledged the lack of holistic psychosocial supports/services in Tasmania, which was identified as a major gap to supporting young people’s broader functioning and recovery from mental illness.That broader psychosocial support is missing in the youth mental health space, like no one’s helping set them up for recovery and their future. C, 17yo, femaleTassie has nowhere near the amount of services that we actually need. In the North-West, there's basically nothing for us. YP, 18yo, maleIf your child doesn’t qualify for NDIS , it's nearly impossible to get that more intensive support…he needs help with education, healthy eating, maybe job opportunities, budgeting, getting his licence…but there’s no one in Tas to help with that. C, 16yo, maleYoung people and carers also identified the lack of clinicians in Tasmania as a key barrier to accessing any support. Participants recognised that the mental health workforce shortage in Tasmania is a significant barrier, with many services relying heavily on locum specialists from the mainland.I think one of the biggest challenges in Tasmania is we don't actually have enough workers, so if you can't find someone to click with, you’re screwed because there’s not many other options. YP, 22yo, femalePsychologists are great, but there's not many of them here and only so much they can do. You’re lucky to get monthly, so what’s happening in the in-between? More holistic support is needed. C, 14yo, femaleThe pool of specialists here is very small. She was engaged with [Tasmanian service] but they could only do telehealth because the psych was based in Victoria—there was no one in-person that she could see here. C, 13yo, femaleBoth young people and carers recognised that the currently available services were only addressing ‘the tip of the iceberg’, as they did not have capacity to provide in-depth, long-term, consistent holistic support that they felt was required.2.Long waiting periods: “There’s so much waiting”All young people and carers identified that long waiting lists for services, which have been exacerbated since the COVID-19 pandemic, have prevented or delayed engagement with supports.You can't be told that your very unwell and still suicidal child has to wait 2 months to see someone after leaving hospital. What are we supposed to do in the meantime? C, 16yo, maleJust getting into services is a headache. Even if you find the ‘right’ service, you have to wait months and months to get seen. You make that decision when you're quite low, and you really need it then and there. YP, 23yo, femaleParticipants recounted numerous experiences where long waiting times  had contributed to mental health escalation/crises, functional decline, increased severity, and being no longer eligible for the intended service.She deteriorated as she waited and ended up having a suicide attempt…when they finally contacted her they said, ‘oh you’re too high risk now, we can’t take you’. Then she’s back to square one with no support but she’s more severe. It’s ridiculous. C, 15yo, femaleWhile you’re waiting, your mental health is worsening…I actually ended up in hospital three times after that initial time, because there just wasn't any care. YP, 18yo, male3.Limited service accessibility: “accessing support is a nightmare”Young people consistently reported difficulties accessing services due to the location, distance and amount of travel required to attend.I had no one who could take me to appointments, and I live about an hour and 40 min by bus from Hobart CBD, so I had to stop because it was just too far away. YP, 17yo, femaleI wasn’t able to attend in-person, the closest service to me is over an hour away, it’s even longer by bus. And I know there’s worse-off kids than me further North who can’t get any help. YP, 20yo, maleParticipants also identified further logistical barriers to accessing supports, including costs and lack of after-hours support:When I was in high school, my parents were happy to pay for my psychologist. But then when I went to uni and I was living out of home, it would have been good to see someone but it wasn’t even an option because of the cost. YP, 24yo, femaleWe’re fortunate to be able to afford private mental health services, but this would be well out of reach for most families. C, 11yo, femaleThere are no psych clinics here that bulk bill. YP, 19yo, femaleWe've been sitting on the edge of our seat thinking what do we do after hours? God forbid he has a relapse psychotic episode after five or on a weekend. C, 16yo, maleThese logistical factors significantly limit the availability and accessibility of mental health services for young people in Tasmania.4.The missing middle: “we’re stuck in the middle”The majority of participants experienced significant difficulty accessing an appropriate service. Termed the “missing middle” by participants, young people consistently felt that they were being “bounced around services” as a result of their mental health severity not meeting various service eligibility criteria.I was told I’m too high risk for headspace but not risky enough for CAMHS, but there was nowhere else that would take me, so I literally had no support. YP, 16yo, femaleI found that there’s lots of places that will help if you're in kind of crisis or need low-level therapy support, but there isn’t just that middle spot where you need that ongoing holistic support. YP, 20yo, femaleHe’s had constant rejection by community mental health services from aged 14. Then when he finally met their threshold at 17, they rejected him again as he was smoking dope. C, 19yo, maleEven when they say no, sometimes they wouldn't even do a referral to a new place so you would have to sort it out yourself…when your mental health is that awful, and you’re homeless, and you’re 17 years old, that is just not good enough. YP, 19yo, maleContinuously being told by services that they can’t help you is so frustrating, especially if you're currently experiencing quite severe mental illness. It's difficult enough to navigate for someone who's in a good head space. YP, 21yo, female“Community mental health here in Tasmania just doesn't really have a pathway. They can’t do stepping stones and referrals across services because the appropriate services for young people don’t even exist. C, 12yo, maleThe lack of services for the ‘missing middle’ has resulted in young people and carers navigating a complex and fragmented system with limited success.Education for carers: “support the supporter”We are informed and resilient, but many people are not. Most carers need practical support with managing and understanding the situation to help their young person and support for their own resultant mental health issues. C, 19yo, femaleIt would be good to have information on how to refer, knowing the who and how of making contact and what kind of support is available, and education and support around caring for/reaching out to your child. C, 12yo, femaleSeeing a psychologist one hour in a week is not enough. There's got to be stuff happening in between at home, so as a parent, it would be helpful to know what can I do that might help. C, 14yo, maleYoung people did not discuss this topic, yet carers consistently felt they needed more support to improve their mental health literacy and help them care for their child at home.Carers requested more information, awareness, or psychoeducation from services to help them meet their children’s psychosocial needs at home, particularly if they were experiencing challenges engaging with services.Positive therapeutic relationships: “find someone you click with”Young people and carers emphasised the importance of a positive, validating, trusting, and consistent relationship with their clinician/support person.She’s my counsellor but she’s also like my friend now, so I feel safe and comfortable talking to her about anything. YP, 17yo, femaleIt’s the best when it feels like you’re just like talking to a friend and getting a coffee, especially once it’s someone regular and I don’t have to retell my whole story every time. YP, 22yo, maleYoung people described feeling safe, comfortable, and motivated to engage when they were ‘matched’ with someone with a similar ‘vibe’, who was respectful, supportive, non-judgemental, and friendly.We were just a good match, like similar personality, and I felt like she really got me. YP, 16yo, femaleKnowing that they're also a part of the LGBT community makes it just feel a lot more comfortable and safe, because they’ve had some of the same experiences as me, and I know that they understand me and they’re not judging me. YP, 22yo, non-binaryParticipants also consistently recommended that services include peer support workers with lived experience of mental illness to better engage and address the broader psychosocial needs of young people experiencing mental illness. Young people felt that diverse lived-experience workers could more effectively provide that validation, acceptance, positive representation and unconditional support that they desire.It would be good to have a mentor who’s gone through something similar and come out the other side. They would be super compassionate, understanding, accepting and validating. YP, 18yo, femaleWe need youth peer workers here. They'll be able to work more flexibly and they'll probably have more success on the psychosocial side of things, like helping kids resume some activities or play a game of basketball or go shopping with them, get them out of the house. C, 16yo, male2.Carer advocacy and support: “it’s a case management role”Both young people and carers recognised that having a family member to support, persist, and advocate against various systemic obstacles was instrumental to accessing support.I have essentially been case managing my daughter and I didn’t give up. Without that, she'd probably be dead. C, 17yo, femaleI know that I’m very lucky to have very understanding and supportive parents. I definitely wouldn’t have come this far without them. YP, 21yo, femaleYoung people who did not have any family support valued having a support person/worker to provide more practical holistic support and advocacy on their behalf.Honestly having someone in my corner would have made the world of difference. Instead of being alone, someone who was there for me, I could ask questions, someone to count on, to talk to and help me out. YP, 19yo, femaleFlexible and responsive services: “support that meets our needs”Young people and carers agreed that services need to be flexible and responsive, in terms of how support is accessed and delivered. Participants emphasised the value of services providing various accessibility and engagement options, including outreach, drop-in, telehealth, and informal activities.More flexible access, because I didn’t want to let my parents know, so it was really hard to go to a physical place regularly. I found it easier when things were online and also having a drop in space, because I didn’t have to make an appointment. YP, 18yo, maleMore services need to deliver outreach, especially for us here and others in the rural areas, which is probably a large chunk of the state, they really need to get out in the community more. C, 13yo, femaleIt would be awesome if there was a person that physically came and checked in on her, or went for a walk or engaged her in some activities, like music or sport. C, 15yo, femaleYoung people also wanted support that better met their needs, in terms of the frequency, intensity, timing, and duration of support, including the potential for service provision to cover after-hours/weekends and longer duration of support over 12 months.She was literally always available…it was so comforting to know that I didn’t have to wait weeks and weeks in-between sessions…the regular contact was really good for me. YP, 23yo, femaleI think more long-term and consistent support is needed to actually make a difference. It would be ideal if they could spend a couple hours with her each week, rather than in and out. C, 16yo, femaleUltimately, young people valued services that gave them choice, and empowered them to engage when and how they needed to enhance their psychosocial wellbeing.2.Psychosocial support: “address the root causes”Participants recommended that services better address the contextual factors and stressors that are underpinning or impacted by young people’s mental health. Young people and carers both spoke about the need for holistic and integrated services that can support young people’s psychosocial wellbeing and provide respite for their carers.It would be really great to have services that address the root causes of young people's mental illness and all the life things that just don’t get addressed. Like help us to apply for housing or find safe accommodation or apply to uni. YP, 19yo, maleI think we need to have peer workers or support workers assisting with some of the things that a psychologist might recommend, like taking me out on public transport for exposure, helping out with remembering to take your medication or picking up medication, getting a job, finding a rental, cooking skills, all those things are so much harder with mental illness. YP, 22yo, femaleSome sort of support worker I think that would be really helpful to have someone to do all that organising and linking with other services, and just to be there whenever you need. YP, 17yo, femaleParticipants envisaged this type of service to be embedded alongside or within a mental health support/team  to provide integrated health and social care support via a multidisciplinary team. Carers also recommended this type of support, and acknowledged it would provide some respite for them too.I would actually benefit from knowing that he's got a support person who can just take the pressure off us for a bit, even a few hours a week would be good. C, 16yo, male3.Safe service environments: “feeling safe, supported, and connected”Participants acknowledged that the environment in which support is delivered can influence the young person’s willingness to engage. Young people reflected on positive experiences attending services that gave them a sense of safety , community, were non-clinical and home-like, and provided opportunities for connection with their peers.Just a safe space—that’s what I look for and notice straight away. YP, 19yo, femaleLittle things like the admin staff asking me my pronouns and making sure that other people are respecting the pronoun, it’s gender-affirming and it makes a huge difference. YP, 24yo, non-binarySafe spaces and opportunities for ongoing informal support from diverse staff in a more relaxed and pleasant setting integrated within the core mental health services. C, 21yo, femaleYoung people and carers consistently advised that more youth-friendly services are needed across the Tasmanian youth mental health sector. Young people consistently reinforced that having more diverse lived-experience workers to increase representation of various identities  may create more welcoming services in which young people feel safe, seen, heard, represented and respected.This study explored young people’s and carers’ experiences of mental health services in Tasmania, with a focus on their perceived barriers and facilitators to supporting young people’s psychosocial wellbeing. Barriers included, at the individual young person/carer level: (1) the complexity of young people’s psychosocial needs and (2) lack of awareness of supports; at the interpersonal level: (3) invalidating experiences with adults and (4) fragmented communication between services and family; and at the systemic level: (5) lack of services; (6) long waiting periods; (7) limited service accessibility; and 8) the missing middle. Facilitators included, at the individual level: (1) education for carers; at the interpersonal level: (2) positive therapeutic relationships and (3) carer advocacy/support; and at the systemic level: (4) flexible and responsive services, (5) services that provide psychosocial support; and (6) safe service environments. The findings are similar to those reported in previous international reviews that identify numerous systemic barriers to young people getting the relevant clinical support that they require  the miss–13. ThisParticipants identified a dearth of services in Tasmania to appropriately support the psychosocial functioning of young people experiencing mental illness. This was also confirmed in recent service mapping of community-based mental health services across Tasmania, as existing services do not have the capacity, integration, diversity and accessibility to meet the need . Young pYoung people and carers identified numerous service accessibility barriers, including long waiting lists, costs, and limited opening hours. Such barriers have been well-documented , 32, andYoung people and carers reflected on negative experiences of young people’s concerns being invalidated, dismissed or judged by health professionals or family members. Young people consistently report power imbalances and not feeling heard by professionals, which often results in service disengagement and pessimism/ambivalence to access supports in future . The theDevelopment and implementation of services that can provide integrated, holistic, and flexible psychosocial support for young people in the ‘missing middle’. This may include community-based services that: (1) have broader eligibility criteria tailored for those who currently fall in the ‘missing middle’; (2) have flexible/multiple methods of access and engagement; (3) are promoted/advertised within the community to increase awareness as a step-up/step-down option to current supports to facilitate continuity of care; and (4) utilise co-location to allow young people to stay with the same service but receive different levels of care as needed.Greater integration of health and social care within the youth mental health sector to better meet young people’s clinical and broader psychosocial needs .Services to employ diverse lived-experience peer support workers to work with young people experiencing mental illness.Greater capacity of services to be more flexible in how they engage and support young people, including assertive outreach, telehealth, longer duration of support over 12 months, after-hours accessibility, and greater frequency/intensity of contact dependent on the young person’s needs.Services to improve transparent communication with family/carers, particularly during the transition period of turning 18 years of age, by softening confidentiality laws to extend parental access to their child’s health information up to age 25 years, if their child has provided consent.Facilitate or provide more access to evidence-based resources, education or practical support to carers where appropriate.This study has provided valuable insights into the perspectives of carers and young people experiencing mental illness in Tasmania. The following lived-experience recommendations informed by young people and carers may help to guide service (re)design and development, by addressing the identified barriers and enhancing the facilitators to better support young people’s psychosocial wellbeing. These findings will directly inform the co-design and development of a new psychosocial service for young people in Tasmania. As the current findings align with prior international research, such recommendations may also be adapted and implemented across youth mental health sectors internationally.A key strength of this study is that young people were involved in every stage of the research. Youth experiencing mental illness are rarely included in research that concerns them, yet this should become standard practice. For this study, young people were involved in developing the aim, recruitment materials, data collection methods/questions, and supporting the analysis. This ensured that the research aligns with young people’s needs, perspectives, and experiences. Including both young people and carers in the same sample was another strength that enabled triangulation of the findings to provide a comprehensive understanding of the perspectives of two participant groups. This is particularly highlighted in the findings about fragmented communication and the differing views regarding engagement between services and families, which is crucial to informing holistic care. The sample of young people was largely representative in terms of a wide range of mental health concerns, psychosocial needs and demographic characteristics. The size of the sample, and inclusion of a broad age range of young people were also key strengths of the study that enriched the data to capture the experiences of numerous different consumers. The majority of young people had experience accessing services, which provided valuable insights into both the process of seeking support and receiving support. However, this may have biased the results as the sample represents a minority of young people with mental illness who actually access or engage in supports . This biThe current findings highlight individual, interpersonal, and systemic barriers that young people and carers face to getting their psychosocial needs met by mental health services. Lived-experience recommendations for public mental health service design, development, policy, and practice have been provided. To better support their psychosocial functioning, young people and carers want lived-experience peer support workers to provide practical wrap-around support, and they want services that integrate health and social care, and are flexible, responsive and safe. (Re)design and development of services to address the identified barriers across the youth mental health sector is needed to empower young people, enhance their psychosocial functioning and support holistic recovery from mental illness.


Alzheimer’s Disease (AD) provides an excellent case study to investigate emerging conceptions of health, disease, pre-disease, and risk. Two scientific working groups have recently reconceptualized AD and created a new category of asymptomatic biomarker positive persons, who are either said to have preclinical AD, or to be at risk for AD. This article examines how prominent theories of health and disease would classify this condition: healthy or diseased? Next, the notion of being “at risk”—a state somewhere in-between health and disease—is considered from various angles. It is concluded that medical-scientific developments urge us to let go of dichotomous ways of understanding disease, that the notion of “risk,” conceptualized as an increased chance of getting a symptomatic disease, might be a useful addition to our conceptual framework, and that we should pay more attention to the practical usefulness and implications of the ways in which we draw lines and define concepts. Alzheimer’s Disease (AD) is a slowly progressive neurodegenerative disease, the prevalence of which increases with age. It is considered to be the most common cause of dementia in older age-groups and, because of the decline in mental abilities and personality changes that characterize it, it is much-feared. Over the last decades, scientific understanding of the disease has changed significantly.probable AD.”In 1984, Alzheimer’s Disease was defined as a dual clinicopathological entity by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association workgroup  in the brain (plaques), followed by tau-pathology—aggregation of tau-protein in so-called neurofibrillary tangles, leading to neurodegeneration and ultimately cognitive decline , 2013. TProponents of the Aβ-hypothesis claim that earlier recognition of AD and medical treatment earlier in the process are key to preventing or slowing down cognitive decline. To gather evidence to support this claim, clinical trials need to be performed that focus on early detection and intervention. To align research efforts and to facilitate communication between researchers, new criteria and a new vocabulary for the different stages of AD have been proposed by two different expert groups: the International Working Group for New Research Criteria for the Diagnosis of AD (IWG) and the National Institute on Aging—Alzheimer’s Association (NIA-AA).preclinical disease, IWG defines it as a risk for developing disease. As Hampel et al. says:In the period 2011–2018 these two groups developed similar but subtly different accounts see . Both maThe IWG group considers the presence of brain Aβ accumulation in the absence of clinical features in the sporadic population to be indicative of an “at risk” group. In contrast, the NIA-AA group considers such individuals to indeed already have preclinical AD, suggesting that in time they would develop cognitive decline and the clinical dementia syndrome. This presents a fundamental hypothetical and conceptual difference of the two approaches. , 431.This situation raises the question: which of these two conceptualizations is the most defensible, given our concepts of health, disease, and risk? Apart from being interesting in itself, the reconceptualization of AD thus offers a great case-study to “test” our current medical-philosophical theories and conceptual frameworks—can they elucidate practical scientific and clinical questions with regard to definition and classification of pre-disease and risk? Making such an analysis contributes to the growing body of work investigating how concepts of disease “fit” with clinical and research practices e.g., .The goal of this article is, first, to gain a better understanding of the categories of “preclinical AD” and “being at risk for AD.” Should these asymptomatic states, in which evidence for Aβ accumulation and tau-pathology is present, be regarded as disease, or as a risk factor, or something else? The second goal is to diagnose some of the problems that current medical-philosophical theories run into when trying to conceptualize health, disease, and risk in light medicine’s move toward ever earlier detection of pre-disease states, of which AD is just one example  and AD-C . In their latest 2018 paper, however, they again complicate things by proposing a distinction between “Alzheimer’s pathological change” (if only evidence for Aβ accumulation is present) and “Alzheimer’s disease” . Both fall under the umbrella notion of “Alzheimer’s continuum”—a term that confusingly lacks any reference to disease or pathology  and Nordenfelt’s Holistic Theory of Health (HTH) , 2013.According to the BST, “health” is the statistically normal biological functional ability of all parts of the organism, contributing to its survival and procreation. Since health and disease are seen as mutually exclusive, disease is defined as any disturbance of health, that is, any statistically subnormal functioning of one or more parts of the organism. In Boorse’s own words: “A disease  is a type of internal state which reduces health, that is, reduces one or more functional abilities below typical efficiency” , 684. Inabsence of any cognitive symptoms. Boorse himself, however, has emphasized time and again that his theory represents a pathologist’s view, not a clinician’s, and he says: “to the pathologist, any process causing cellular dysfunction, no matter how local, is pathological”  defines health as “being in a bodily and mental state that is such that one has the ability to realize all their vital goals” , 24. Distout court. This is not what Nordenfelt intends. He says that not all instances of disease need to lead to illness, but that something is a disease only when it “tends to cause illness in most cases when it is instanced”  to become clinically demented. As explained earlier, this is how the IWG 2014 category of “preclinical AD-at risk of AD” should be understood: as having abnormal biomarkers indicating AD pathology, putting one at-risk for developing AD dementia or clinical AD. The latest NIA-AA framework ; when this risk is low, they speak of “at-risk” for AD:Based on the high-risk or low-risk dichotomy for a further progression to clinical AD, we propose to consider the terms of “preclinical AD” when the risk is particularly high  and that of AR-AD when the evolution to a clinical AD is less likely or still needs to be determined .  has called “desktop diseases.”Desktop diseases are discovered when studies show a factor  is associated with a negative health outcome , and then a clinical trial shows that an intervention affecting that risk factor reduces the risk of that outcome event associated with negative health outcomes that can be positively influenced by intervention in the factor. , 2061This notion is identical to the notion of “risk-based disease” as defined by Interventions modulating these biomarkers have been shown to reduce the likelihood of developing fractures, myocardial and cerebral infarctions” physiological processes in AD are not fully known, other interpretations may well be possible. It might be argued that what matters is cognitive dysfunction caused by neurodegeneration, and that the presence of Aβ and tau biomarkers constitutes a non-pathological modifiable risk factor for this. However, contrary to the risk-based diseases mentioned, AD biomarkers are not successfully modifiable.Although in most of their work NIA-AA state that Aβ and tau biomarkers are indicative of pathological processes that are going on in the brain, in the above statement they seem to imply that these biomarkers are in fact risk factors (for developing cognitive impairments) and that the risk can be mitigated by intervening on these biomarkers. This raises the question whether Aβ and tau biomarkers in CSF or PET are just like low bone mineral density, hypertension or hyperlipidaemia: not pathological in themselves, but risk factors for pathology. Above, I have argued that on my interpretation of Boorse’s theory, Aβ deposits and tauopathy Yet another way to approach the distinction between  disease and risk factor is by understanding it as an instance of the line drawing problem . As discAlthough Schwarz holds a mainly Boorsian disease concept, he departs from Boorse in the way he argues the line between low-normal function and dysfunction should be drawn. This should not be done based on mere “statistical normality” but on a combination of prevalence of a specific trait or level of functioning in combination with its negative consequences , 2017. HSchwarz agrees that there are no exact guidelines for settling the line-drawing issue in borderline cases, and that judgments in some cases may go either way. In the case of ductal carcinoma in situ (DCIS)—the most commonly diagnosed form of breast cancer—he concludes that according to his approach this is not a disease . Rather,A challenging question that the previous reflections confront us with, is whether the binary distinction between health or normality on the one hand, and disease or pathology on the other, is still viable. Giroux claims that: “Boorse relies heavily on the possibility of making a clear distinction between a disease and its causation. Yet, it could be asked whether such a distinction can be drawn so easily” , 187. Ththe model for understanding Alzheimer’s dementia fails to take other causal - and mitigating - factors into account and thus gives a wrong picture with regard to dementia risk  states as “at risk,” or “disease,” is a matter of decision and of drawing the boundaries “in a reasonable place” . What isAlzheimer’s Disease provides an excellent case study to investigate new and emerging conceptions of health, disease, pre-disease, and risk. A first conclusion that can be drawn is that the notion of “risk” is underdeveloped in two classic medical-philosophical theories of health and disease, the BST and the HTH, while this notion is becoming ever more important in contemporary medicine. Both theories have insufficiently incorporated new scientific insights showing the complexities of pathophysiological processes. Both fail to take the temporal dimensions of pathophysiology into account and appear to see “disease” primarily as a state, rather than as a process that develops over time. Moreover, both implicitly appear to assume that diseases are mono-causal rather than multifactorial complex pathological networks. Hence, they tend to see health and disease as two clearly demarcated, mutually exclusive states. This does not seem in line with current scientific understanding of disease processes.As the Alzheimer case illustrates, progress in medical science enables us to make visible ever smaller lesions and to find disruptions in functioning at the molecular and sub-molecular level. The chances for people with those micro-pathologies of ever developing clinical symptoms is less than 100%, but higher than the chances of people without this specific pathology. This implies that in many—perhaps in most—of these cases disruptions will never lead to overt illness, raising the question whether it is useful to put all these micro-pathologies in one basket with serious and even life-threatening diseases. It appears more apt to challenge binary ways of thinking in which health and disease are mutually exclusive categories and instead to understand them as complex, multi-dimensional continua between complete health and symptomatic disease. To demarcate specific states within such a field, a criterion of practical usefulness should be used, in the awareness that classifying such (temporary) states is a matter of drawing boundaries in “reasonable places,” and “reasonableness” is related to the practical purpose of line-drawing in specific circumstances. This pragmatic approach will help us to make sense of the blurring boundaries between health, disease and risk, created by the multi-causal process-view of disease.symptomatic disease, that is, a risk of getting Alzheimer’s dementia, and the notion of preclinical disease  should best be avoided. The concept of “risk of symptomatic disease”—as distinct from a risk of getting some asymptomatic pathology—is a useful addition to our conceptual framework and better captures what is at stake for potential patients than the notion of preclinical disease. This does not preclude that for specific research-purposes other concepts and different lines may be more useful.Finally, from the point of view of potential patients, the magnitude of the probability of getting symptomatic AD, especially dementia, is what matters most. For purposes of communicating with potential patients or research-subjects, therefore, the notion of risk factor should be specified as risk of


Over 60 million tons of E‐waste is expected to be generated in 2023, with associated significant impacts on health and the environment. To reduce the number of products sent to landfills, “Right to Repair” (RtR) movements are gaining momentum in many countries, including the UK, USA, and EU member states. While Universities are seen as important stakeholders to drive forward sustainable design practices, there is currently little work looking at training undergraduate design engineers in the principles of designing household products in support of RtR. In particular, the project‐based learning (PBL) pedagogy shows promise in engaging and training students with the skills and knowledge required to successfully design products for RtR. In this paper, a pilot‐study of teaching engineers is presented to design products compatible with RtR principles, alongside many technical skills, in a first‐year PBL course. The key outputs of this paper are the design of the module, which can be used to help inform first‐year engineering education, the high engagement of students, with 100% of respondents agreeing that they intend to try to implement sustainable design practices in future, and some of the innovative features that students implement in their projects. The right to repair movement is growing and aims to ensure that all the products are repaired, so that they last longer, which is a key way to reduce E‐Waste. Here, the design and implementation of a project‐based learning university course is presented to help embed the tools for designing for the right to repair. Alongside greater consumer rights, RtR can help to reduce E‐Waste, the generation of which is expected to reach over 60 million tons in 2023, and is associated with significant health and environmental impacts. RtR includes both a social movement, for example, the promotion of repair cafes and parties, and a drive for legislation to embed those principles in law. Some RtR laws now exist in the European Union, the United Kingdom, and in several U.S. state legislators.The right‐to‐repair (RtR) movement aims to ensure that consumers have the right to simply and cost‐effectively repair and fix their products and equipment, including electronic and consumer goods.1 Impl and European‐based “The Right to Repair Campaign”, aim to promote the repairable design of products so that they last longer. RtR is seen as a driving force to move away from the “take‐made‐dispose” model of production, toward a more circular mode of production and re‐use. Hernandez et al. identified five major constraints that restrict product repairability by consumers, thereby reducing the chance to move to a more circular economy. For the design of products that embrace RtR, these can also be seen as principles to design against. These five constraints are:Lack of knowledge of how products work.Lack of spare parts, technical information, and restricted contracts.Lack of economic incentives to repair a product.Lack of engagement, emotional and economic attachment to products.Lack of design and manufacturing features promoting repairability.Repair organizations and collectives, including the US‐based “Repair Association”, founded in 2013,12 and shows that the average worldwide E‐waste collection rate  is 22.8%, and this low rate is explicitly linked to the 12th UNSDG (“Ensure sustainable consumption and production patterns”). Universities worldwide are seen as having a crucial role in creating a more sustainable future, as expressed through the UNSDGs. Universities can act as pillars, nationally, internationally, and locally, in driving sustainable development. Accordingly, in this paper, we outline a pilot study for teaching the principles of RtR to first‐year undergraduate students on a design‐engineering course. We intend this research to act as guidance for how RtR principles can be taught to undergraduate students from diverse backgrounds.Furthermore, the UN's 2022 Report on Sustainable Development Goals (UNSDGs)16 sho1.2 Of these eighteen learning outcomes, two have links to sustainability:C5: Design solutions for complex problems that meet a combination of societal, user, business, and customer needs as appropriate. This will involve consideration of applicable health and safety, diversity, inclusion, cultural, societal, environmental, and commercial matters, codes of practice, and industry standards.C7: Evaluate the environmental and societal impact of solutions to complex problems and minimize adverse impacts.The ability of graduate engineers to consider their work's ethical and sustainable impact has often been described as lacking. As outlined, Universities can play a key role in creating a sustainable future. Engineering education courses have begun to shift focus to address this, often with courses creating a greater focus on sustainability. Engineering learning outcomes for UK‐accredited university courses are defined by eighteen learning outcomes, through the Accreditation of Higher Education Programs (AHEP 4).19 Of  with guidelines from ABET driving the requirements for sustainability in USA engineering degree programs. Although many universities follow the same learning outcomes, the approaches taken to achieve them are diverse. Some programs elect to run dedicated sustainable design modules within the course, for example, modules in Sustainability assessment for design, while some integrate sustainability within sections of the course such as UNSDGs in design modules. This can often lead to sustainability being taught in an abstract manner with difficulties in matching student perception of sustainability with the learning outcomes from the programs. In response to this Malz et al. developed a course for Bachelor's and Master's students in mechanical, biomedical, and industrial engineering, introducing a sustainable way of thinking, and training skills required to develop more sustainable solutions. This interdisciplinary approach aimed to promote the development of design competencies and social competencies within the project. The course covered material selection and material life cycle using GRANTA EduPack and sustainable design guidelines. This approach, combined with industry engagement, allowed students to learn and apply relevant basic methods from the field of product development and material selection. Other institutions have dedicated programs focusing on sustainable engineering at the Bachelor's and Master's levels. These aim to give a coherent and consistent thread of sustainability throughout the student's education, leading to increased awareness and an increased ability to solve problems using sustainable solutions.Similar learning outcomes for higher education (HE) are demonstrated in other countries,20 wit This states that for sustainability competencies to reach all students the curricula must include a significant number of compulsory courses in which they are developed.Sánchez‐Carracedo et al. developed tools to embed and assess education for sustainable (ESD) development within engineering curricula.24 Thi with guidance to define what it means to be an engineer who is equipped to protect and improve our planet and lives. This work has been conducted in alignment with ABET accreditation standards. Implementation of this framework was conducted in a project‐based learning (PBL) course at Arizona State University, with students able to use and engage in a multi‐faceted way with each competency, making connections between competencies during their course.Further frameworks for embedding sustainability within engineering education HE courses have been outlined by “Engineering for One Planet”28 wit:Shifting paradigms around sustainabilityRigidity of the existing education systemLack of new methods of teachingLack of resources to teach sustainabilityOver the past decades, as ESD has gained traction in HE, there has been a corresponding increase in the literature reviewing it. Thus, some areas of deficiency have been identified along with suggestions by various authors. Zhang et al. outlined some of these challenges as30:ShThus, depending on the institution and place, the students will not be equally educated for future challenges including sustainability.311.3 Leiva‐Brondo et al. assessed university students' sustainability and UNSDGs knowledge, noting intermediate knowledge but low SDG awareness, highlighting the role of educational institutes. In the UAE, Al‐Naqbi et al. found strong positive attitudes but moderate behaviors toward ESD. A study at California Polytechnic State University revealed barriers to ESD adoption, including time constraints, lack of course promotion, and relevance issues. They suggested integrating sustainability into existing courses rather than creating standalone ones. Fisher et al. found that exposing students to sustainability in a class is more effective than multiple sustainability courses, with course type being more impactful than quantity.Comprehensive publications on incorporating ESD into engineering study plans are lacking.33 Lei Lozano et al. compared a variety of pedagogical approaches in their effectiveness in developing sustainability competences. They observed that even though lecturing and case studies are among the most widely used techniques, they were the least effective in ESD. Active approaches like project or problem‐based learning, while working in interdisciplinary teams, were found to be the most effective. Segalas et al. also mentioned that courses with community‐oriented and constructive pedagogies were highly effective in developing students' knowledge of sustainable development. Howell presented the findings from an interdisciplinary ESD course that used the “flipped classroom” design where students prepared for the core content before coming to the classroom, while the in‐class sessions had more active‐leaning exercises, reflective practices, and mini‐lectures. More than 90% of the students reported the classes to be more engaging when using this approach for ESD. Barth et al. considered the importance of both formal and informal learning for the development of ESD competencies. They especially talked about the role of interdisciplinarity and the need for students' self‐responsibility, where some of the learning happens without explicit assistance from the instructor, for example, the research or skill development outside the class.Future engineers must acquire a broad skill set, encompassing both technical and non‐technical abilities. Vital soft skills such as independent learning, critical thinking, handling criticism, and social interactions are best developed through active student engagement in the learning process.38 Loz1.4The overwhelming themes emerging from engineering and design education literature show evidence that project‐based University programs, can engage students and help to embed fundamental principles, practical and technical skills, and specific knowledge focused on UNSDGs. This highlighted that a PBL‐based course, teaching the principles for sustainable design, toward tackling UNSDG 12, could be highly effective. While the RtR is becoming an important societal movement, we have not yet noted many examples of tackling this problem explicitly in engineering PBL courses. Some of the prescribed learning outcomes in UK and international engineering degrees align well with RtR principles, and consequently, it is a relevant topic.Detail the design of a multi‐disciplinary engineering design module that teaches engineering science fundamentals, design and ideation, analysis skills, hands‐on skills, and teamwork.A resource to show engineering educators some of the possible benefits of teaching in a project‐based way, even in the initial stages of an engineering degree.Documenting the successful implementation of RtR principles, employing engineering science to achieve technically viable solutions, and measuring student engagement through the module.Assessing the motivation of students and progress toward becoming future engineers who are engaged in solving global challenges.Accordingly, in this paper, we present and analyze a novel pilot study, for a first‐year PBL university engineering design course, where students are given a project to design and make a household product according to RtR principles. We initially present an overview of the course design, including the content, assessment, and pedagogy. To evaluate the impact of the project on students, we used an anonymous questionnaire and conducted a focus group, which we used alongside their outputs to give an overview of what student priorities are, and what they learned during the module. All questions asked and the data are included in We finish off this paper by presenting some lessons and takeaway points for educators.22.1The module (or “class”) we discuss in this paper is called “Prototyping”. It is in the first year of the “Global Design Engineering” degree which is a design‐focused general engineering degree at The Engineering and Design Institute (TEDI‐London), a specialized HE provider in the United Kingdom which teaches almost entirely using PBL. Each year in TEDI‐London comprises three, 10 weeks long, teaching blocks, and Prototyping took place in the second block of the year. In the prior block, students had two concurrent modules: “Introduction to Engineering Design” (ITD) and “Reverse Engineering” (RE). which is an international competition set by “Engineers without Borders”. Students were tasked to define a problem and design a solution, taking into account social, environmental, and economic considerations. They mainly focused on developing a concept rather than a physical prototype.In the ITD module, students took part in the “Engineering for People, Design Challenge”,43 whiIn the RE module, students were tasked to tear down a consumer product , investigate its function, and mathematically analyze the behavior of internal components . RE provided students with experience in investigating many of the core components of RVC and how they function and fit together. This was useful for the design and build phase of the upcoming Prototyping module.2.2 This explicitly links the goal and specification of what we want the students to learn (content), how we measure the student's progress against that specification (assessment), and how we implement that (pedagogy). We summarize the course construction in Figure  some of which can be classed as the “enduring outcomes”, which are the most fundamental outcomes that occur during the learning experience. The enduring outcomes are complemented by the “important‐to‐know” outcomes that are needed to achieve the enduring outcomes. Other learning opportunities are classed as “good‐to‐be‐familiar‐with” outcomes, which benefit learners but are not crucial to the learning experience.The initial design of the Prototyping module was constructed using the content‐assessment‐pedagogy (CAP) framework.44 Thi and subtractive manufacturing principles, and justifying material selection. Good‐to‐be‐familiar‐with outcomes include project planning and management, overcoming group work problems, and clarity of report writing and presentation.The enduring outcomes are to embed the skills required for prototyping and demonstrate these as a key step for evaluation and problem‐solving within the user‐centered design process, while also developing students' understanding of sustainable design more broadly. Some other “enduring outcomes” include building students' ability to sketch, develop and iterate ideas with colleagues, and produce CAD models. Students must also develop and apply basic engineering models to inform a design, for example, to calculate the required torque from a DC motor, which will give a suitable kinematic performance of the RVC. Furthermore, students should engage in developing and coding, using Arduino, a relevant algorithm for the RVC, for example, a system to detect walls and change the motor direction as a result. Not every student in each team necessarily engages in physically prototyping the Arduino, hence, this is considered important‐to‐know outcomes. Other important‐to‐know outcomes include reading and analyzing technical literature, implementing design for additive46 and2.3In the Prototyping module, students were tasked to redesign and build the RVC. Students had to consider the environmental impact of their material and design choices; focusing on how these affect the lifecycle of the product under the RtR movement. The module was split into three phases; 1) ideation and planning, 2) building and implementation, and 3) test and evaluation. Cycling back through these phases was encouraged as part of the user‐centered design process.The content was presented in a blended fashion, with online material to cover fundamental topics including, mechanics, electrical science, manufacturing, CAE, and design principles; and in‐person sessions twice a week for 4 h each. These sessions were split between tutorials, case studies, and unstructured group project time, which comprised the majority of the time. The size of the teams was 3 to 5 students. Students were assessed through a group presentation  and an individual report, with high marks awarded for exceptional practical skills, improving through iteration, and insightful engineering analysis of the components. on how others had designed repairable electrical products. Some of the principles discussed by Hernandez et al., including creating an emotional attachment to products, economic incentives, modularity, and easy disassembly through manufacturing innovation were evident in the case studies. After this, students were invited to ideate for implementing RtR principles in their own designs. Students used a 2 × 2 matrix  and using hardware Arduino boards, as these skills were required for RVC control.During the ideation and planning phase, students were presented with data highlighting the magnitude of the E‐Waste problem, and then with a series of case studies47 on In the building and implementation phase, students were encouraged to start designing and fabricating their prototypes. Students were not prescribed set tasks during this period and were encouraged to plan and make their own decisions. Most of the time was spent in group project time where they could decide on how best to progress the project. Aside from such unstructured time, students had tutor‐led CAD sessions where they were given tasks to help prepare them for designing the prototypes. They were also given free time where they could ask for guidance on how to implement their design in CAD. Students were also given some tutorial sessions covering mechanics fundamentals to help them design their prototypes. For example, they underwent a case study of a remote‐controlled car, where they calculated the required angular velocity and torque for a given speed and acceleration. Makerspace technicians were available to provide hands‐on support for fabrication, such as 3D printing, laser‐cutting, or microcontroller implementation.RtR scope: how simple would it be to repair, should a certain component fail?The electromechanical design: is the RVC speed appropriate for the task? How could this be altered? Does the RVC appropriately dodge obstacles?In the testing and evaluation phase, students were required to evaluate, improve, and iterate their designs. The types of evaluations were varied and could include:Students were encouraged to carry out testing and evaluation throughout their building and implementation and circle back between these phases. During this final phase, students completed an individual report and a group presentation for their assessment.3The prototyping module was carried out over ten weeks of teaching time. To gather information a survey and focus group was conducted. Out of 40 registered students, 14 participated in the survey and 5 were part of the focus group. The following subsections present the findings for the two research questions posed in Section 3.1We planned to measure a successful implementation of RtR principles by gathering evidence, in the student work, for the five design constraints by Hernandez et al. and the two AHEP learning outcomes . Our initial thought was what you use for your coat, the poppers. When you close it, it won't move, but then you can easily remove it.”“The creative freedom and challenging prompts.”“The first part of bringing your own ideas and imagining your own robot vacuum. Then to try implement these ideas to create a more sustainable one while following the brief.”“One of the most interesting things is the fact that we can use our creative freedom and prototype our own iterations.”The freedom to design, and the relatively unpressured environment where innovation was encouraged, proved to be major aspects of the module which drove engagement. For example, when asked (in the anonymous survey) “What were your favorite parts of the project during Prototyping? What interested you the most?” some representative responses included:Figure In the survey responses, as shown in Figure Another of the RtR design constraint was 4: “Lack of engagement, emotional and economic attachment to products”. One of the groups took this challenge to heart by creating a prototype with a strong visual style, as shown in Figure 493.2Figure We noted many examples of innovative design practice we observed through the practical, prototyping phase of the project. Furthermore, in feedback from the focus group, we found evidence that students have embedded the sustainable design principles taught through the module and had started to evidence them in their wider work. The survey results, as summarized in Student E: “It's all kind of instilled in us now. I don't think… after those projects… it's possible to conduct any project or go into anything without thinking about these things [sustainable design practices]. That's just how we've been trained.”Another student added the following quote below, which, in summary, demonstrates the belief that, in order to reduce E‐waste, in some cases it is best to not design a product at all.Student A: “I feel like one of the things that kind of just like, is it necessary? There are things we were [considering] designing, wanting to make, but we now think: is this actually needed? It's just like a waste of the resources we have, it might be nice, but is it necessary in the first place? It's made me pretty angry at some stuff that I wasn't beforehand… look how many custom parts there are here… you can't buy any of these anymore. Why have they done this? Why is this all proprietary? It's really frustrating, so much stuff, but it's like they didn't think in the slightest about what we were learning in Prototyping,” thereby avoiding the creation of products with poor environmental impact. They present a more systematic method for our students' desire to avoid designing unsustainable products, and this type of framework may be fruitful for a further, more specialized study. It is interesting to note that the response to Q8 in the survey  had only 35.7% of agreement from respondents. This suggests that our cohort may hold more moderate views on sustainability policies.He and Gu presented a methodology for sustainable design, to aid in the generation of optimized products with a low environmental impact,50 the3.3: Mechanical (22.5% of students), Electrical and electronic (15.8%), General (15.7%), and Civil (13.7%), showing that most engineering undergraduates take specialized single‐discipline degrees. Global Design Engineering has a broad scope similar to General Engineering.TEDI‐London is a new, specialist HE institute that presently teaches one degree program, a bachelor's degree in “Global Design Engineering”. Thus, the students here do not completely represent the wider engineering cohort in the UK. In the country, the distribution of engineering degree subjects taken in 2020/2021 was51: MeDue to the current small size of TEDI‐London, this pilot study has a small sample size without a separate control group. However, the insights and sustainability‐themed course design principles tested and presented here are significant. They will pave the way for broader research studies in the future.4Overall, the teaching team found the Prototyping module to be a satisfying one to teach, with strong engagement and attendance from the large majority of students. There was quantifiable evidence to suggest that the enduring outcomes of the module, including the technical skills required for prototyping, development, and ideation were well practiced through the module, and a large majority of students showed a marked improvement in these abilities. These enduring outcomes were evidenced by the quality of the physical prototypes produced, and the reflections from the questionnaire, focus group, and the formal reports. Students' ability to apply engineering science models to inform a design was mixed, with some students demonstrating excellent analytical skills , while others went into less depth. As a teaching team, we reflect that we may need to include better guidance on how to achieve excellence in this area through more explicit marking guidelines. for RtR espoused by Hernandez et al., students clearly designed around three of them, with some innovative examples of problem‐solving and design. The remaining two were: “lack of knowledge of how products work” and “lack of economic incentives to repair a product”. While these principles are valid, the specific learning outcomes of this module did not encompass these themes, and thus the students avoided doing work that would not gain them credit in the formal assessments. We believe that students in different types of degree programs such as, for example, Engineering Management may be better suited to tackle these types of problems, particularly if they were part of a multidisciplinary team.Of the five design principles15 for4.1 This trend enables institutions to learn from one another and implement lessons derived from PBL experiences. Accordingly, here we have set out some summarized points to help give clear points for educators to take away. Furthermore, we have summarized some of our findings in the diagram in Figure The learning environment at TEDI‐London, which primarily employs PBL, differs from traditional engineering HE institutions; however, it is important to note a growing trend toward the adoption of problem‐based and PBL methodologies,52 ThiEmbedding a project with sustainable themes, which is directly linked to some of the UNSDG, strongly drives engagement for a wide range of students.Knowledge appears to be well embedded by the end of the module, and students are keen to apply their skills to a range of future projects. They showed deeper engagement with the “designed world”. They recognize when products are designed poorly and are especially unhappy with the “planned obsolescence” approach to design.Where applicable, physical making and rapid prototyping helps to drive innovation and engagement.Students were highly motivated to show off their findings to others; in some cases, leading to further excitement and engagement.Most students wish to work for companies that have a sustainable agenda. They believe that they themselves can help to drive change if they have the correct training.Projects that involve relevant technical analysis increase the motivation of engineering students. For example, in this case, students could specify DC motors, carry out kinematic analysis, employ CAD for casing, and do tensile testing of materials. The choice of a small‐scale device, with many small components and sensors provided a range of technical tasks for students in this project.Groups should have students with a range of skill levels, and progress needs to be monitored regularly to ensure that all students feel that their teammates are pulling their weight.Structuring PBL with significant tutor‐led activities at the start of the module, and then increasingly allowing students to guide their own learning worked well in this module.The summary points are:The authors declare no conflict of interest.Supporting InformationClick here for additional data file.