Medical Research & Journals | Free Research Review Medical Studies Publications

ISSN 1178-6191

In this issue:

Mortality outcomes and inequities in rural Māori
Economic costs of Indigenous health inequities
Using an Indigenous rubric to interpret mortality data
Experiences of racism among adolescents
Postoperative mortality disparities in Indigenous patients
Māori elders’ perspectives of end-of-life family care
Diagnostic coding accuracy by emergency department clinicians
Publicly funded aged care service referral in Indigenous populations
Understanding the workforce supporting Indigenous people with diabetes
A decolonial relational vision of planetary health

Tēnā koutou katoa

Nau mai, haere mai ki a Māori Health Review. We aim to bring you top Māori and Indigenous health research
from Aotearoa and internationally. Ngā mihi nui ki Manatu Hauora Māori for sponsoring this review, which
comes to you every two months. Ko te manu e kai i te miro nōna te ngahere, Ko te manu kai i te mātauranga,
nōna te ao.

Welcome to the 100th issue of Māori Health Review.

In this landmark issue, being our 100th edition of Māori Health Review, we include important papers on
Indigenous health inequities in New Zealand, which have the potential to be addressed through the new health
reforms. We also feature a Lancet study of racism experiences among a multi-ethnic adolescent population in
New Zealand. Finally, we highlight Māori elders’ perspectives on end-of-life care, problematising the notion of
a single ‘primary caregiver’.

We hope you find this issue informative and of value in your daily practice. We welcome your comments and
feedback.

Ngā mihi
Associate Professor Matire

Mortality outcomes and inequities experienced by rural Māori in Aotearoa New Zealand

Authors: Crengle S et al

Summary: A population-level observational study has revealed that rural Māori have higher rates of allcause and amenable mortality than urban Māori. The study used deidentified, routinely collected mortality and census data. For all five levels of the Geographic Classification of Health, Māori had higher all-cause mortality (standardised incidence rate ratio [SIRR] 1.87 urban; 1.95 rural) and amenable mortality (SIRR 2.45 urban; 2.34 rural) than non-Māori. For rural Māori vs urban Māori, SIRR was 1.07 for all-cause mortality and 1.13 for amenable mortality. All-cause and amenable mortality rates increased for both Māori and non-Māori as rurality increased. The authors suggested that there are additional challenges for Māori associated with living rurally.

Comment: This paper received a lot of media attention given its important findings and the potential to address the issues with the new health reforms.

Reference: Lancet Reg Health West Pac. 2022;28:100570.

Abstract

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Estimating the economic costs of Indigenous health inequities in New Zealand

Authors: Reid P et al.

Summary: The significant economic costs of health inequities between Māori and non-Māori adults in New Zealand has been highlighted in an Indigenous-led study. The study used quantitative epidemiological methods and cost-of-illness methodology within a Kaupapa Māori theoretical framework. Deidentified data from national collections held in government agencies was reviewed for the period 2003-2014, including all hospitalisations, mortality, outpatient and primary care consultations, laboratory and pharmaceutical usage and accident claims for individuals aged ≥15 years. Health inequities between Māori and non-Māori adults were estimated to cost NZ$863.3 million per year. Direct costs of NZ$39.9 million per year included ambulatory sensitive hospitalisations and outpatient care, as well as cost savings from underutilisation of primary care. Indirect costs of NZ$823.4 million per year were calculated from years of life lost and lost wages. The study authors noted that the ‘cost of doing nothing’ is predominantly borne by Indigenous communities and society.

Comment: An important paper, which follows Papaarangi’s previous work ‘The Cost of Doing Nothing’ for tamariki Māori and health. Papaarangi spoke on these issues in a recent lecture, a summary of which can be found here: https://www.auckland. ac.nz/en/news/2022/11/01/papaarangi-reidopinion- health-inequities.html.

Reference: BMJ Open. 2022;12(10):e065430.

Abstract

Privacy Policy: Research Review will record your email details on a secure database and will not release them to anyone without your prior approval. Research Review and you have the right to inspect, update or delete your details at any time. The views expressed in this Publication are personal to the authors, and do not necessarily represent the views or policy of the Ministry of Health on the issues dealt with in the publication.

Disclaimer: This publication is not intended as a replacement for regular medical education but to assist in the process. The reviews are a summarised interpretation of the published study and reflect the opinion of the writer rather than those of the research group or scientific journal. It is suggested readers review the full trial data before forming a final conclusion on its merits.

Research Review publications are intended for New Zealand health professionals.

Getting the story right: reflecting on an Indigenous rubric to guide the interpretation of mortality data

Authors: Cram F et al.

Summary: This article presents a reflection of how well the Family Violence Death Review Committee (FVDRC) embedded Te Pou in developing its Sixth Report “Men Who Use Violence”, published in 2020. Te Pou is a Māori responsiveness rubric published in 2019 by Ngā Pou Arawhenua. Authors of the current article reflect on how the FVDRC strove to get the story right (Tika-to be correct or true), be culturally and socially responsive (Manaakitanga-hospitability, kindness, support), advance equity, self-determination and social justice (Mana-prestige, authority, spiritual power), and establish relationships for positive change (Mahi Tahi-working together). Opportunities for improved responsiveness in FVDRC reporting are identified, as well as suggestions for extending the guidance in Te Pou. The authors recommend that other Mortality Review Committees also undertake reflective practice on responsiveness to Māori/Indigenous peoples.

Comment: This paper deconstructs the notion that ‘numbers don’t lie’ (spoiler alert – discrimination occurs in the interpretation and reporting of Māori data). Importantly, the authors go further to suggest and test opportunities to ‘getting the story right’. Research organisations/committees should look to develop, and reflect on, their own pou and practice.

Reference: J Interpers Violence. 2022;37(21-22):NP19599-NP19623.

Abstract

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Flexible resources and experiences of racism among a multi-ethnic adolescent population in Aotearoa, New Zealand

Authors: Simon-Kumar R et al.

Summary: Anti-racist interventions and policies in multi-ethnic western societies must address both structural deprivation and associated intergenerational mobility and colourism, according to an intersectional analysis of health and socioeconomic inequities in New Zealand. The analysis used data from 20,410 adolescents in school years 9-13 (median age 15 years) involved in the Youth2000 survey series undertaken in the Auckland, Tai Tokerau, and Waikato regions between 2001 and 2019. Findings showed that socioeconomic, interpersonal, and health inequities varied with access to flexible resources among Māori and racialised migrant youth. High levels of socioeconomic inequities were experienced by Māori and racialised migrants from low-income and middle-income countries. Socioeconomic inequalities for racialised migrant youth persisted over three generations, especially for Pasifika migrants. Compared with visibly racialised groups, minorities perceived as White experienced less discrimination and had more advantages. Modelling showed that embodiment resources, and to a lesser extent structural resources, mediated, but did not eliminate ethnic disparities in socioeconomic status and interpersonal discrimination. These resources did not strongly mediate ethnic disparities in health.

Comment: As the authors suggest, there are so many layers to discrimination. It is so important to test these as they have done here. I suspect that other ‘isms’ based on people’s perceptions of us (i.e. beyond colour to include tā moko or te reo use) will become increasingly prominent over time.

Reference: Lancet. 2022;400(10358):1130-1143.

Abstract

Understanding disparities in postoperative mortality for Indigenous patients

Authors: Gurney JK et al.

Summary: This article presents a framework for understanding the drivers of disparities in postoperative mortality for Māori compared with non-Māori. The article authors recently published a national audit of 4,000,000 procedures undertaken between 2005 and 2017, showing considerable disparities in postoperative mortality for Māori. In the framework presented in this article, disparity drivers are conceptualised as operating in layers, with each factor leading to the next. Layers include structural factors, care system factors, care process factors, care team factors and patient factors

Comment: A clear and comprehensive framework to understand Māori health inequities beyond the usual “it’s because of their co-morbidities” or “health service location”. Importantly, the authors hope to both inspire and rouse providers, funders and decision makers into appropriate action.

Reference: N Z Med J. 2022;135(1565):104-112.

Abstract

Māori elders’ perspectives of end-of-life family care: whānau carers as knowledge holders, weavers, and navigators

Authors: Simpson ML et al.

Summary: The notion of a single ‘primary caregiver’ has been problematised in a study of older Māori with experience of palliative care for a partner or family member. Māori-centred and community-based participatory research principles were used to examine 17 interviews with whānau carers, with thematic analysis using a cultural-discursive framework incorporating Māori principles of wellbeing and values. Findings centred on three roles for whānau carers in palliative care: (1) Holders and protectors of Māori knowledge; (2) Weavers of spiritual connection; and (3) Navigators in different worlds. Health professionals should be encouraged to recognise the cultural embeddedness of dominant approaches to palliative care.

Comment: Love this because it is so true. And not only for palliative care but for aged care, for whanau living with disabilities, maternity care, and long term conditions. I’ve been a member of a research group looking at whanau consent in clinical research too, particularly when the research could have impact on whakapapa.

Reference: Palliat Care Soc Pract. 2022;16:26323524221118590.

Abstract

Accuracy of real-time SNOMED-CT coding by clinicians in an urban tertiary emergency department

Authors: Jones P et al.

Summary: An analysis of Auckland City Hospital Adult Emergency Department (ED) data has shown that Māori are less likely to have a diagnosis recorded at discharge than non-Māori, due to systemic bias in how diagnoses are captured electronically. A total of 5788 visits to the ED (n = 594 Māori, 5194 non-Māori) were audited in February 2021. In a random sample of case notes (n = 114), diagnoses recorded by clinicians were compared with diagnoses derived from clinical notes by auditors blinded to the actual diagnosis, patient name, and ethnicity. The New Zealand Emergency Department SNOMED-CT reference set was used to code diagnoses. Māori were less likely to have a diagnosis recorded at ED discharge compared with non-Māori (relative risk 1.48, 95% confidence interval 1.08-2.04, p = 0.016). Failure to record diagnoses was the result of a system flaw in extracting diagnoses from electronic notes, rather than failure to make a diagnosis. There was agreement in diagnoses recorded by clinicians and auditors for 94.6% of cases in Māori and 100% of those in non-Māori.

Comment: Although this may seem a trivial issue, there is evidence that health inequities can compounded through systemic biases in clinical algorithms and technologies (https://www2.deloitte.com/us/en/insights/industry/health-care/ racial-bias-health-care-algorithms.html). Regular audits such as the one reported here, in addition to standardised practice, quality data collection and analysis and ongoing evaluation of algorithms, are four ways health services can identify and address systemic bias.

Reference: Int J Med Inform. 2022;165:104813.

Abstract

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Referral for publicly funded aged care services in Indigenous populations

Authors: Hikaka J et al.

Summary: Ethnicity is not a factor in aged care service assessment access, according to an exploratory cohort study of new referrals received by the Waitematā District Health Board (WDHB) in 2018. Referrals for those aged ≥55 years (n = 3263) were ethnically representative of the general older adult population within the WDHB. Compared with non-Māori, non-Pasifika individuals, Māori were younger and were more likely to be referred for higher-level care needs (p = 0.03). There were no significant differences between ethnicities in referral outcome, time to assessment or mortality.

Comment: Great that this service can demonstrate equity in access, care and outcomes, despite differences in context/wellbeing which have the potential to affect timeliness and quality of care.

Reference: Australas J Ageing. 2022;41(3):473-478.

Abstract

Understanding the workforce that supports Māori and Pacific peoples with type 2 diabetes to achieve better health outcomes

Authors: Mullane T et al.

Summary: Supporting community-based, non-clinical workers to build meaningful and culturally safe relationships with Māori and Pacific people with type 2 diabetes has the potential to improve health outcomes, according to a qualitative study underpinned by the Tangata Hourua research framework. Focus groups with dietitians, community health workers and kai manaaki were held in South Auckland to gather information, and thematic analysis of transcripts was used to identify key themes. Themes common across all groups were whakawhanaungatanga (actively building relationships), cultural safety (mana enhancing) and cultural alignment to role. When compared with dietitians, kai manaaki and community health workers both strongly associated a multidisciplinary approach to experiences of feeling un/valued in their roles. All groups generally agreed that their roles required good relationships and understanding of the people they were working with.

Comment: With the recent health reforms in Aotearoa, including the development of a health charter and its focus on a relevant health workforce for communities, this paper provides useful information on ways to develop and support a diabetes workforce. Importantly, the authors note that non-clinical roles bring critical cultural, local and interpersonal skills and expertise that are integral to building relationships and trust with the whānau and communities they work within.

Reference: BMC Health Serv Res. 2022;22(1):672.

Abstract

Navigating fundamental tensions towards a decolonial relational vision of planetary health

Authors: Jones R et al.

Summary: This article argues the need for a vision of planetary health grounded in Indigenous epistemologies, centering relational ecocentric norms and values. Key tensions are identified that planetary health scholars, practitioners and advocates must engage with to inform action. Suggestions are made for working progressively towards a decolonial vision of planetary health that recognises obligations to all relations, human and more-than-human.

Comment: Although the article is a ‘Personal View’, Rhys is considered a leader in this field and therefore his opinion is highly valued. This piece cleverly centres Indigenous knowledge and understandings but also references ideas and positions emerging from a relational space between Indigenous and non-Indigenous scholars.

Reference: Lancet Planet Health. 2022;6(10): e834-e841.

Abstract

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