Melbourne Graduate School of Education - Theses

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    Computer Algebra Systems in a Year 11 Mathematics Class: Students’ Use, Attitudes, and Factors Perceived to Influence Use
    Cameron, Scott William ( 2021-06)
    A computer algebra system (CAS) has the potential to automate many mathematical routines. The use of CAS in mathematics has been shown to support the development of understanding (e.g., Bawatneh, 2012; Heid, 1988). However, students need to be supported to develop a positive attitude towards CAS and learn how and when it can be used before they can benefit from the opportunities presented by CAS (Pierce & Stacey, 2002). While existing research has examined students’ attitudes and CAS use, little research has explored how these aspects change as students gain experience. Given that the students in this study were expected to use CAS for learning mathematics and in assessments, there is a motivation to understand how their CAS use can be supported. This thesis reports the investigation of one class of Year 11 mathematics students’ (n=13) CAS use, attitudes towards CAS, and factors perceived to influence CAS use and how these changed over approximately one school year. The context for this study was a Year 11 Mathematical Methods class in Victoria, Australia. Technology is to be incorporated into the teaching, learning, and assessment of Mathematical Methods, and there are several reasons why CAS was the predominant technology in this subject. The study aims to provide a new understanding that will support teachers who are working to support student CAS use in the mathematics classroom. When learning mathematics with CAS, students need to develop the capacity to make informed choices about when and how to use CAS so that they can benefit from the affordances presented by CAS. Understanding when students choose to use CAS, and the factors influencing students’ use, will provide new understanding to support teachers in developing targeted teaching interventions that may support students to use CAS. This study investigated CAS use in four topics studied over 8 months in one school year. Actual CAS use was determined by analysing student worksheets and CAS screenshots. Further uses of CAS were identified from thematic analysis of interviews that were conducted with nine students four times throughout the study. The findings of this study show that students made different choices about the use of CAS or pen-and-paper (P&P) based on whether problems were within or outside their anticipated P&P facility and the mathematical features of problems. Thematic analysis of interview data found that students used CAS to complete problems quickly, to supplement their P&P skills, and to check their answers. Negative attitudes towards CAS can form a barrier to the development of CAS use. However, few studies have used a cohort study methodology to determine how students’ attitudes change as they gain experience with CAS. This study contributes by comparing students’ attitudes towards CAS approximately one year apart to identify changes resulting from learning mathematics with CAS. This study defined attitudes towards CAS as consisting of beliefs about CAS and emotions when working with CAS. Data were collected via a questionnaire at the start and the end of the year. Students had a range of attitudes towards CAS at the start and the end of the study, but more students had a positive attitude towards CAS at the end than at the start. Students held (and experienced) a range of beliefs (and emotions); some contributed to a positive attitude, while others contributed to a negative one. Understanding why students do or do not use CAS may support teachers in developing targeted interventions to support CAS use. While existing studies have identified factors that influence CAS use, none have explored how these change as students gain experience with CAS. Analysis of questionnaire data showed that students perceived a range of beliefs and emotions to influence their CAS use and that their perceptions were unlikely to change. Additional factors were identified from the analysis of interview data. Overall, students perceived a greater range of factors to influence their CAS use at the end of the study than at the start. This study aimed to provide insights to assist teachers in supporting students learning mathematics with CAS. The findings presented in this study provide a detailed understanding of how and why students use CAS and students’ attitudes towards CAS. These understandings will be beneficial in informing teaching interventions to support CAS use and thus, student learning.
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    Supporting English as an Additional Language student wellbeing in secondary schools: Teacher perspectives and a group psychoeducational program
    Lyu, Mengyu Andy ( 2022)
    Objectives: There is increasing recognition that English as an Additional Language (EAL) students need additional support to thrive in an English-speaking country, particularly when adapting to a new country and developing English language skills. Yet, the understanding of their acculturative needs is limited. Further, no targeted interventions for their psychological adaptation or wellbeing are available in secondary school contexts. The present study aimed to address this gap in knowledge and practice. Methods: Mixed methods were used. In Phase 1, semi-structured interviews were conducted with three EAL teachers. In Phase 2, the adapted Coping with Study Abroad (CSA) program was piloted with 25 EAL students in an Australian secondary school. The effectiveness of the program was evaluated using a repeated-measures design (n = 20) and a qualitative feedback survey (n = 6). Results: EAL students experienced pervasive stresses in various aspects of school life, including learning (e.g., language barriers to participating in class activities) and wellbeing (e.g., negative emotions due to difficulty communicating in English). While the adapted CSA program provided an opportunity for EAL students to connect with each other, no significant changes were found between the pre- and post-intervention scores in proactive coping behaviours, psychological wellbeing, and negative stereotype about help-seeker. Conclusions: There are strengths and limitations in the current school practice and the adapted program for EAL students. To effectively support EAL students in secondary school, wellbeing support and English language skills development should work in synergy, with each enhancing the other.
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    Re-engineering education in the shadow of the future: Examining national policy frameworks in Australia, Hong Kong and Singapore
    Crome, Jennifer Susan ( 2022)
    Abstract As a comparative policy study, the thesis explores how practices in education policy making in Australia, Hong Kong Special Administrative Region of the People's Republic of China ((HKSAR) – referred to throughout the thesis as Hong Kong) and Singapore, three advanced regional economies, work to re-engineer education in the shadow of the future. A policy sociology approach is taken to examine how education policy is used discursively and influenced by power, regimes of truth, acts of governmentality and biopolitics to administer and shape individuals and societies. Additionally, the thesis investigates the ways in which policy making for education is influenced by a country’s culture and history, globalisation, economic needs, and neoliberal agendas in order to construct the contributing subject-citizen. The sites chosen for analysis, Australia, Hong Kong and Singapore, were part of a broader study of education landscapes in the Asia Pacific region in a global childhood’s project (see Lee et al., 2023; Yelland et al., 2020). All three sites, subject to regional and global flows, have undertaken schooling reform in order to address wider societal and political needs. Moreover, the improvement and restructuring of schooling in the three sites has been in response to notions of crises or radically shifting times, and these presses have been used as an opportunity for policy reform. The thesis begins with an interrogation of the key policy documents, political speeches and authoritative statements that provided explicit direction to the education sector and launched education policy reform in the three locations. The analysis of policy texts also includes insights from social semiotics as education policy makers around the world increasingly employ a range of modalities and make use of options for dynamic and visually appealing presentation of information and ideas to represent education and its attendant goals. Additionally, the thesis examines the responses of the Singaporean and Australian media to the 2018 PISA results, along with the commentary by policy makers that made its way into newspaper articles and discourse. Finally, the thesis investigates the ways in which policy makers and politicians used the COVID 19 pandemic crisis as an opportunity to reinforce political agendas and to justify new technologies of governance. In particular, the thesis provides new insights into the ways in which policy making functions in the service of broader goals that idealise learner-citizens in ways that align with policy agendas, cultural values and the best interest of national futures to ensure the current and future economy is perpetuated and protected. The three key findings of the thesis are: a) the policies in all three locations reflect the national imaginaries of what the youngest citizens should look like including their capacities, attitudes, beliefs, and capabilities, b) education policy in the high performing education systems of Hong Kong and Singapore have shifted towards constructing more multidimensional learner-citizens than previous policy iterations have allowed for, and c) differently configured education systems in the Asia Pacific region discursively employed policy rhetoric to rationalise and justify national reform agendas with varying levels of success. The findings of this work underscore that reform tacitly reiterates ideological narratives concerned with education’s purposes and potential to primarily produce workers with the skills needed for global economic success and the pursuit of nationalist agendas. However, it is recommended that these ideological narratives must be challenged, and that policy makers should instead look to the intrinsic purposes of education and the opportunity education offers for genuine transformation. Indeed, returning to Foucault’s (1980) theorisations of power and its capillary nature, the prospect for citizens to collectively reject their subject positions and push back on the neoliberal discourses that dominate is entirely possible.
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    Inverting the Past: The Flipped Pedagogical Model and Historical Understanding
    Landvogt, Charlene Louise ( 2022)
    This thesis explores how a flipped pedagogical approach can foster historical understanding. The study adopts the model of historical thinking advanced by Seixas (2017) and the Historical Thinking Project (2015). Historical thinking encompasses substantive and procedural knowledge: the former is concerned with the content of the past, the latter with the method of history. They are interrelated concepts that are equally important to historical thinking. Effective historical thinking enables students to demonstrate historical understanding. The flipped pedagogical model requires teachers to invert the teaching and learning process. Work traditionally learnt in class is completed prior to class as preparatory activities. Class time is subsequently devoted to in class activities that facilitate higher-order thinking. The flipped pedagogical model advanced in this study contains four interrelated components: required preparation, consolidation activities, in class activities, and summative assessment. This model can be applied to history curricular in order to facilitate historical understanding. Substantive knowledge is learnt prior to class as required preparation and reviewed during consolidation activities. Procedural knowledge is then learnt during in class activities as historical thinking concepts are applied to substantive matter. In the final component, students complete summative assessment to showcase historical understanding. There is a dearth of study evaluating the flipped pedagogical approach in history education generally, and the flipped pedagogical approach in Australian history classrooms specifically. This study is therefore concerned with examining the four components of the approach and the extent to which they can foster historical understanding. An action research strategy was used within a teacher research framework to investigate students’ perception of the flipped pedagogical approach in a Year 10 History classroom. Three forms of data were collected: student work samples, surveys, and focus groups. The project provides recommendations, in the form of a model of flipped pedagogy, that can assist teachers to deliver curricula that promotes historical understanding. This model addresses the role of the teacher, the role of the student, the interconnectedness of the four components of the flipped pedagogical model, criteria for resources or activities used and suggested teaching and learning activities.
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    Towards a Continuing Professional Development Framework for English-as-a-Foreign-Language Lecturers in Vietnam
    Nguyen, Hang ( 2022)
    This study aims to explore key elements of a continuing professional development (CPD) framework for English-as-a-foreign-language (EFL) lecturers in Vietnam to support professional identity development for teaching with technology. Such a framework is of significance since previous research indicates that CPD for EFL lecturers in Vietnam has not sufficiently supported lecturers in terms of the competencies required to teach with technology, nor has it supported the development of self, e.g., motivation for professional practice. The literature reviewed here reveals several dimensions of this problem, including (1) the conceptualisation of CPD as a ‘top-down’ approach in Vietnam, (2) the lack of a strong theoretical base to guide CPD regarding teaching with technology, (3) a limited implementation of CPD to support EFL lecturers to effectively teach with technology, and (4) CPD as an under- researched area to guide policy and practice in Vietnamese higher education (VHE). The CPD framework developed here is grounded in Self-Determination Theory (SDT) and the Technological Pedagogical and Content Knowledge (TPACK) framework and was used as a conceptual framework to guide the investigation of which elements are perceived to be important in a CPD framework for EFL lecturers in Vietnam. An exploratory sequential mixed methods design was used with two phases of data collection. In the first phase, a focus group was conducted with nine Vietnamese EFL experts in February 2018, to explore their perceptions of the key elements of the CPD framework to support EFL lecturers in Vietnam to effectively teach with technology while also developing other professional qualities. In the second phase, an online survey was administrated to EFL lecturers across Vietnam (n = 434) during October – November 2018 to examine their perceptions of how the elements are evident in their current teaching practice and CPD experiences. Four key findings emerging from the focus group and survey data helped to refine the final CPD framework. First, TPACK competence was considered the most important element of the CPD framework. It is conceptualised in VHE as three competence constructs: non- technological competence (referring to EFL lecturers’ competence in applying CK, PK, and PCK in teaching practice), Simple technological competence (referring to EFL lecturers’ competence in using TK), and Complex technological competence (referring to EFL lecturers’ competence in adopting complex TPK, TCK, and TPACK in their teaching practice). Second, autonomy and relatedness were perceived as additional important elements of the CPD framework, but less so than competence. Autonomy is defined as having (1) freedom and choice in teaching practice; (2) free choice to self-direct professional learning, and to choose what CPD activities will meet needs; (3) confidence to make decisions; and (4) support in terms of guidance and resources to make decisions. Relatedness is conceptualised in the VHE context as (1) having trust and respect from others (e.g., colleagues, students, leaders, the higher education system); (2) being connected to and having good relationships with people at work; and (3) having a sense of belonging to an institution or a community of practice with colleagues who share a profession. Third, context was considered an important overarching element in the CPD framework that impacted EFL lecturers’ CPD. It includes the external context in which the EFL lecturers work (e.g., at a macro, meso, and micro level), and internal context (e.g., lecturers’ motivation, teaching experience, expertise, and qualifications). Finally, statistical tests showed positive correlations between perceived competence, autonomy, and relatedness in both Vietnamese EFL lecturers’ teaching practice and CPD needs. The relationship between perceived autonomy and relatedness is the strongest, followed by perceived competence and autonomy, then perceived competence and relatedness. The proposed CPD framework for EFL lecturers in Vietnam, therefore, includes the following four elements: TPACK competence, autonomy, relatedness, and context (internal and external) as an overarching element. The three elements of competence, autonomy, and relatedness are inter-related. The study makes theoretical, practical, and methodological contributions to the field of CPD. Theoretically, it adds a new perspective to the literature by exploring CPD in VHE through the combined lens of SDT and TPACK, viewing CPD as the process of professional becoming in TPACK competence, autonomy, and relatedness, within the influence of context. It also confirms the relevance of the use of SDT and TPACK in an Eastern context, offering new insights from a Vietnamese case to enrich the SDT and TPACK literature, respectively. Practically, the proposed CPD framework could provide guidance for different CPD stakeholders (e.g., EFL lecturers, CPD program designers, policy makers, and higher education leaders) in developing lecturer TPACK competence, autonomy, and relatedness in CPD. Methodologically, the study develops a survey instrument that could be used in similar settings to explore lecturers’ TPACK competence, autonomy, and relatedness in their teaching practice and CPD. It also contributes to the CPD literature with the findings of a large-scale study that considers attributes other than competencies in CPD for EFL lecturers in Vietnam.
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    Effectiveness of computer-assisted instruction to teach vocabulary to students with mild Intellectual Disability
    Burt, Kenneth Clark ( 2022)
    Students with mild Intellectual Disability (ID) may have significant vocabulary knowledge gaps as compared to typically developing students because of limitations in their phonological loop, the part of working memory that processes language. This limits their academic growth and participation in employment and society post-school. This dissertation investigates the effectiveness of delivering a rich vocabulary intervention consisting of association, comprehension, and generation tasks based on Stahl’s Depth of Processing model delivered via a web-based Computer-Assisted Instruction (CAI) system designed using Mayer’s Cognitive Theory of Multimedia Learning. The original contribution to knowledge is that students with mild ID can make long-term vocabulary knowledge gains through a rich vocabulary intervention that manages cognitive load and delivered through CAI. A Design-Based Research methodology was used to test and refine an intervention implemented at a special school for students with mild ID in Victoria, Australia. A mixed methods approach captured quantitative knowledge gains from before and after the intervention and qualitative data in the form of teacher interviews, student focus groups, and observation notes. Two studies were conducted. Study 1 compared a rich vocabulary intervention design delivered using CAI versus traditional instruction. Study 2 was designed based on feedback from Study 1 and delivered the rich vocabulary intervention via CAI compared to a blended model of instruction. In the blended model association and comprehension tasks were delivered via CAI and generation tasks were delivered via traditional instruction. This thesis demonstrates that students with a mild ID can learn new vocabulary through a rich and robust intervention that includes deep-thinking tasks delivered via a computer and, importantly, that they can retain new knowledge five months later. Despite the purported benefits of multimedia’s moving images, audio, and interactive games, the intervention design used in this thesis was effective in CAI, traditional, and blended instruction modes. Additionally, qualitative data from teachers and students found positive responses to the interventions. Students particularly responded positively to entertaining animated characters and the natural-sounding voices used in story-telling and definitional videos. Teachers' responses suggest that they should design their own rich and robust vocabulary interventions considerate of cognitive load as they are in the best position to know the unique needs and existing knowledge of their students. As a result of this research, teachers should be encouraged to use more imagery and story context in their vocabulary instruction that challenges students to actively think about the target words, associations, contexts, and how they relate to existing knowledge. Teachers should also incorporate many generation tasks such as semantic mapping, semantic feature analysis, and drawing into their instruction as this research found a positive relationship between the number of these types of tasks and word knowledge gains. Researchers should continue this area of research with larger groups of students with mild ID, as opposed to case study research. The Word Associates Format test should also be studied further as the design used in this study was modified slightly from Read’s original format. Finally, this thesis encourages other researcher-practitioners to study vulnerable populations in authentic environments in order to reduce gaps between them and typically developing children.
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    Examining Teacher Knowledge, Beliefs and Practice of Geography Inquiry in Australian Secondary Schools
    Lee, Shu Jun ( 2022)
    Despite an international turn towards using inquiry as a core approach for teaching and learning in school geography, there is limited understanding of how jurisdictions represent knowledge and pedagogy in the intended geography curricula, and what teachers what teachers in these jurisdictions know and believe about geography inquiry and how they actually enact it. This study set out to address these research gaps on teaching geography through inquiry and to explore the intersections between inquiry and subject knowledge in the intended and enacted geography curricula. Taking Victoria one of the most populous states of Australia as a case, the central research question was “What are the knowledge, beliefs and practice of geography inquiry amongst secondary teachers in Victoria?” Employing mixed methods research, the study comprised three phases of investigation. The first phase made use of document analysis to compare secondary geography curriculum documents from six international jurisdictions including Australia. This global context provided the backdrop for understanding the secondary geography curriculum documents from Victoria. The second phase surveyed the state’s secondary teachers about their beliefs, knowledge and practice of teaching geography through inquiry. The third phase employed case studies research exploring in-depth the practice of three teachers in three different school settings in metropolitan Melbourne. An extensive literature review led to the development of an original analytical framework which guided the analyses of the data. In the final discussion, the analyses from all three phases are considered together with the goal of refining and extending existing theory. Overall, this study’s findings suggest that the knowledge for teaching geography through inquiry is a dynamic collection of rich and situated knowledge constructed through experiences and social interactions in and with practice. At the same time, teachers’ beliefs are deeply intertwined in these experiences and interactions. Powerful professional knowledge for teaching geography through inquiry therefore is generated in and through teachers’ curriculum-making of high epistemic-quality geography inquiry lessons. As a contribution to the powerful knowledge debate, this study argues that the nature of knowledge in geography is such that geography inquiry is key to experiencing and developing powerful knowledge in geography. Additionally this study argues that everyday knowledge contributes to the construction of new specialised knowledge in geography. Powerful geography inquiry teaching practices that enable students to make epistemic gains during inquiry learning therefore include maintaining a stance that values and builds on students’ everyday knowledge, providing opportunities for all students for epistemic access, activating students’ commitment towards and effort in assuming epistemic agency, and enabling students to make epistemic ascent through purposeful use of dialogue and questions. This study concludes by proposing a model for ‘enacting powerful teaching of geography through inquiry’ which both augments concepts of pedagogical content knowledge and incorporates concepts of powerful knowledge and knowing.
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    Reconceptualising disability and inclusion: Enacting relational ways of knowing, being and doing with Bush Kinder
    Christiansen, Amy Lyndall ( 2022)
    In the past decade over 170 ‘nature kindergarten’ programs have emerged in Victoria, Australia in which children and their early childhood teachers and educators routinely engage with local places – beaches, creeks, bush, parklands - for extended periods each week. While legally and ethically mandated to include all learners and pedagogically and philosophically premised on inclusive theories, quality standards and curriculum frameworks, little is known about how these new practice approaches conceptualise and support inclusivity for children with a range of diverse abilities. Dominant positivist and developmental discourses in research concerned with ‘disability’ in early childhood education tend to emphasize what children cannot do, pathologising difference, locating the problem within and trying to fix individual children while ignoring the relational, political, ethical and performative nature of dis/ability and inclusivity. This study seeks to resist and disrupt these dominant traditions. Situated within a post qualitative methodological orientation, this research puts post foundational, common worlds and feminist new materialist theoretical perspectives to work, employing pedagogical narration (Pacini-Ketchabaw et al., 2015) and writing as method (Richardson, 2000) to think with theory (Jackson & Mazzei, 2017) in everyday encounters with one ‘Bush Kinder’ on the unceded lands of the Wurundjeri-Woiwurrung people of the Kulin Nation the traditional custodians of Narrm (the Australian city also known as Melbourne). Re-presenting encounters with Place, children, teachers, parents and more-than-human others, I make visible and trouble essentialised and romanticised conceptions of children, ability and nature, which are antithetical to the ethical and political entanglements of real and imagined global childhoods in contemporary Australia (Malone, Tesar & Arndt, 2020a). As others have argued before me, disability and ability are co-constituted and need to be complexified as dis/ability (Goodley, 2018). Inclusivity therefore involves broader entanglements of relatedness and mutual belonging (Taylor & Giugni, 2012). Activating these conceptions in theory and practice requires that we write with disability otherwise in early childhood education - against the dominant traditions of developmentalism and interventionist approaches. Here I enact this reconceptualisation through pedagogical narration - attuning to what children can do instead of what they can’t and emphasizing the broader relational, political and ethical entanglements of humans, more-than-humans, materials and place which are always already present in early childhood education and mutually implicated in processes of dis/ablement. I employ writing as a method of inquiry (Richardson, 2000; Richardson & St. Pierre, 2017; St. Pierre, 2021b) to generate small, situated knowledges which open new possibilities for thinking and doing in education. Holding developmental, scientific and neurological knowledges about children, ‘disability’ and ‘nature’ alongside to enact relational ways of knowing, being and doing-with in early childhood education, making visible possibilities for reconceptualising dominant, deficit focused conceptions of ‘disability’ and ‘inclusion’. Drawing on Haraway (2016) and Lenz Taguchi (2009) I offer possibilities for more response-able, inclusive and intra-active early childhood pedagogies and activist-practitioner-researcher subjectivities which attune to and amplify the lived experiences of dis/abled children themselves as well as the human and more-than-human others they are always already entangled with in the common worlds of Bush Kinder. This post qualitative work materializes new potentialities for knowing, being and doing with, disrupting traditional knowledges and practices which seek to know children through instrumental, developmental and ableist frames of reference which render difference as deficit.
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    Increasing Underachievement of Australian Highly Able Secondary Students
    Ireland, Christine Helen ( 2022)
    This research explored the problem of Australia’s decreasing achievement levels of its high ability students (HAS). International and national assessments demonstrate that this problem is a reality for Australian schools. For example, the Program for International Student Assessment and the Trends in International Mathematics and Science Study indicate decreasing scores for Australian HAS over the past two decades. Similar results have also been evident in the Australia’s National Assessment Program – Literacy and Numeracy. These decreases in achievement may ultimately lead to a potential loss of talented individuals needed to solve significant national problems. The study utilised a mixed methods approach. Teachers’ and students’ surveys provided perceptions of HAS extension activities. In addition, teachers and students were asked for their perceptions of how HAS regarded curriculum differentiation (CD) strategies during extension activities. Participants also provided information relating to obstacles to extension for HAS. Teachers shared information regarding their level of training in gifted education, and their reactions to gifted education issues. Australian mixed-ability, junior secondary Science classes provided the context for this research. Small groups of HAS were selected by the Science teacher in each class group. Results showed significant differences between teachers’ and students’ perceptions of learning obstacles and the nature of strategies for HAS. Further, the results demonstrated the significance and need of HAS voice to be considered when designing extension problems for HAS.
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    Developing effective wellbeing interventions using universal bite-sized, online, school-based PPIs
    Francis, Jacqueline Janet ( 2022)
    With high rates of mental illness and illbeing among children worldwide, it is important to find ways of building the vocabulary, knowledge and skills needed to protect and nurture student wellbeing. Schools provide an opportune place for teaching children about wellbeing. Universal, bite-sized, online positive psychology interventions (PPIs) designed to build wellbeing among school aged cohorts, provide one option for all schools, including resource poor schools. However, understanding effectiveness is important. The RE-AIM framework was used here to plan for and evaluate PPI effectiveness, and to guide answers to the overarching thesis question: Is the brief universal online PPI HQthrive effective in increasing primary school students’ wellbeing, in terms of process and outcome effectiveness? This thesis includes discovery, development and evaluation phases of HQthrive. The discovery phases included a systematic literature review and focus group research to determine existing needs, value and fit for PPIs within the primary school context. Focus groups involved 44 grade 5/6 students and 38 teachers, from six country and three city Victorian primary schools. Focus groups included rich picture mapping, as well as focus group discussion. The development phase included co-design of the online PPI HQthrive, for grade 5/6 primary school classes. The final evaluation phase involved a pilot study of HQthrive at six Victorian primary schools, including 20 classes, 20 classroom teachers, and paired data from 131 students. Evaluation included examination of the adoption and implementation process, and examination of indicators of success, including participant feedback, researcher observations, emotional vocabulary data, subjective survey data of hedonic and eudaimonic wellbeing, and objective physiological data. Overall pedagogy, implementation and learning processes, and alternative outcome measures for PPIs are highlighted as important consideration for future research.