ISSN 1178-6191
Making Education Easy Issue 110 – 2024
Nau mai, haere mai ki a Arotake Hauora Māori. 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.
Mānawatia a Matariki. We hope you had time over Matariki to come together, reflect on the past year, remember loved ones, celebrate the present and plan for the year ahead. In this issue, we feature two studies highlighting the need for more attention towards developing a culturally safe healthcare workforce. We present a feasibility trial indicating unanimous support for combining Rongoā Māori and Western medicine in a surgical outpatient setting. Finally, we include two studies outlining the difficulties faced by Māori health providers during the COVID-19 pandemic. 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 Harwood matire@maorihealthreview.co.nz
Authors: Fisher C et al.
Summary: An analysis of Surgical Education and Training (SET) selection criteria for the proposed 2024 intake has revealed that some surgical specialties fail to recognise or credit Māori identification and cultural competency. As a proportion of total SET selection scores, criteria related to Māori identification and/or cultural competency made up 6%, 2%, and 1.5%, respectively, for Otolaryngology and Head & Neck, General, and Vascular Surgery specialties. As a proportion of rank scores for interview eligibility, criteria related to Māori identification and/or cultural competency made up 9% and 0.1%, respectively, for Orthopaedic and Plastics & Reconstructive Surgery specialties. No criteria pertaining to Māori were incorporated for Cardiothoracic Surgery, Paediatric Surgery, Neurosurgery and Urology specialties. The study authors noted that allocation of research-related points according to authorship may disincentivise Māori trainees.
Reference: ANZ J Surg. 2024;94(6):1039-1044.
Abstract
Authors: Penney S et al.
Summary: Māori experience culturally unsafe pre-hospital care, according to a Kaupapa Māori study. Semi structured interviews were conducted with ten Māori patients and/or whānau who had received acute care from paramedics for cardiac symptoms. Key themes identified were interpersonal workforce skills, access and service factors, and active protection of Māori. Paramedics’ clinical knowledge and interpersonal skills were described by participants, including appropriate communication and ability to connect. Limited personal and community resources, as well as workforce issues, were described as barriers to accessing ambulance services. Despite there being fewer reports of interpersonal discrimination than in previous research, systemic and structural barriers were found to be harmful to Māori. Efforts to address paramedic workforce representation, resource disparities and cultural safety education are needed, the study authors concluded.
Comment: It’s important to recognise that there is a pipeline for developing a culturally safe and concordant health workforce. As demonstrated here, post-university workforce training organisations, and whānau/health users, now demand more attention to Māori selection and appointments in these pipelines in order to achieve better care and outcomes.
Reference: J Prim Health Care. 2024;16(2):180-189.
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Authors: Oetzel JG et al.
Summary: A case study has described how one community used co-design and culturally-centred principles when developing a housing project to meet the health and social wellbeing needs of kaumātua. The study included interviews (n = 4), focus groups (4 groups; 16 participants in total) and survey questionnaires (n = 56) with kaumātua and organisation members. Enabling kaumātua to be connected to the marae was the primary purpose of the housing project, as part of a larger vision of developing intergenerational housing. Te Ao Māori was used in visioning, development of a collaborative team and funding, leadership, fit-for-purpose design, and tenancy management for the project.
Comment: With an ageing population, and increasing desire to care, connect and support kaumātua through papakāinga and other housing initiatives, we need research like this to make sure that we get it right.
Reference: BMC Public Health. 2024;24(1):1313.
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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.
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Authors: Blattner K et al.
Summary: Successful delivery of health services in New Zealand must incorporate rural contexts and be capable of meeting the needs of diverse communities, according to a qualitative study of the COVID-19 vaccination rollout in rural Māori and Pasifika communities. Semi-structured interviews were conducted with 42 participants at four rural health providers in individual or focus groups settings, to examine views of the COVID-19 vaccination rollout. Key themes identified were: 1) A fragile yet resilient pre-COVID-19 rural health setting; 2) An urban-centric and Pakehā-focused health system; 3) Multiple logistical challenges with poor/no consideration of rural context leading to wasted resource and time; 4) Rural providers finding geographically tailored, culturally anchored and locally driven solutions; 5) A need for sustained investment in rural health services, including funding long-term integrated (rather than ‘by activity’) health services.
Reference: J Prim Health Care. 2024;16(2):170-179.
Authors: Sharma S et al.
Summary: A systems thinking case study has provided insights on systemic traps, their interactions and delays, contributing to a relatively less effective COVID-19 pandemic response for Māori whānau. The study was a collaboration between Tākiri Mai Te Ata Whānau Ora Collective (a large urban Māori health and social service provider) and public health researchers. Two online workshops were held with Tākiri Mai staff, and these highlighted the systemic barriers and opportunities for an effective COVID-19 response to Māori whānau. The medical model of health service delivery was found to cause difficulties for kaupapa Māori. As COVID-19 cases increased, these difficulties increased the risk of negative impacts on Māori whānau, along with pre-existing vulnerability and health system gaps. Better support for Māori whānau during future pandemics will require creation of equal power in health perspectives, reducing dominance of the individual-focused medical model.
Comment: We’ve talked a lot about the ways Māori providers “stepped-up” during COVID-19 and its lockdowns. These studies highlight ways in which these efforts were potentially undermined. Important we look at both sides in order to be better prepared for the next national emergency.
Reference: BMC Health Serv Res. 2024;24(1):717.
Authors: Koea J et al.
Summary: Collaboration between Rongoā Māori healing and Western health professionals in public hospitals is possible and meets the need for patient-centred care, according to a recent feasibility trial. The trial involved six patients who met with both a Rongoā Māori practitioner and a Western trained surgeon during three 45-minute appointments over a 6-month period. Patient whānau were welcome and kai was provided. Qualitative interviews were conducted with patients, whānau and practitioners after the final appointment. Benefits to participants were identified, and a high value was placed on healer/doctor relationships. There was unanimous support for Rongoā/ medical collaboration to be implemented in the health system, and suggestions for improvement of the collaboration were made.
Comment: The number of Rongoā practitioners working alongside clinicians is increasing across Aotearoa; these findings should inform and strengthen these important collaborations.
Reference: N Z Med J. 2024;137(1597):25-35.
Authors: Weaver A et al.
Summary: A retrospective cohort study has found that Māori individuals experienced worse survival outcomes and greater mortality rates from head and neck cancer (HNC) in New Zealand, and present with more advanced disease at a younger age. Anonymised data were obtained from the New Zealand Cancer Registry for 6593 patients diagnosed with HNC between 2010 and 2020. The study population was comprised of 10.7% Māori and 89.3% other ethnicities, predominantly New Zealand European (65.6%). At 5 years after diagnosis, the mortality rate was 39.3% for Māori compared with 35.1% for individuals of other ethnicity (p = 0.03) and 33.3% for New Zealand European individuals (p = 0.002). Mean age of HNC diagnosis was 58.0 years for Māori individuals compared with 64.3 years for individuals of other ethnicity, and mean ages of death were 63.5 vs 72.3 years, respectively. Māori individuals were less likely to have only localised disease at presentation compared with individuals of other ethnicity (14.5% vs 24.0%; p < 0.001), and were more likely to have regional lymph node involvement at diagnosis (39.1% vs 30.5% of patients; p < 0.001).
Comment: Important that researchers continue to monitor for and report on ethnic inequities along health and healthcare pathways, as we have here for head and neck cancers.
Reference: JAMA Netw Open. 2024;7(6):e2413004.
Authors: Singh S & Jelleyman T
Summary: The COVID-19 lockdown has had an immediate impact on obesity rates among 4-year-old children, according to study utilising growth data from the B4 School Check information system. Data were reviewed from 1 July 2012 to 30 June 2022, with 25 March 2020 used as the index date for comparison of pre- and post-COVID periods. The overall rate of obesity increased by 1.8% after COVID-19, and by 2% among males. When analysed by ethnic group, Pasifika individuals had the greatest increase in obesity rate (4.3%), followed by Māori (2.2%). Increases in obesity rates were greater in children from the most deprived areas (3%) and in those from the Auckland region (2.5%).
Comment: As a mum living in Auckland who also worked over COVID-19 lockdowns, I can relate to this. I remember watching my daughter doing some bursts of physical activity with her teacher and classmates online but it’s not the same as running around a playground over recess or playing sports outside of school. Something for us to consider in future pandemic planning.
Reference: N Z Med J. 2024;137(1597):13-24.
Authors: Cooper J et al.
Summary: Participants of a phase 2 study of high dose subcutaneous injections of benzathine penicillin G (SCIP) for prevention of rheumatic heart disease reported a preference for SCIP over their usual regimen. The study involved 20 young people who received 2% lignocaine followed by 13.8-20.7 mL of benzathine penicillin G (according to body weight) into the abdominal subcutaneous tissue at a Wellington clinic. Participant experiences were obtained via semi-structured interviews, using a Kaupapa Māori consistent methodology, and observations made during/after the injection, and on days 28 and 70. Low-level pain was reported on needle insertion, during injection and following injection. Discomfort and bruising on days 1 and 2 post dose was reported by some participants; however, pain was reported as less severe than with intramuscular benzathine penicillin G. Participants were relieved that injections were only required quarterly, and almost all (95%) reported a preference for SCIP over intramuscular benzathine penicillin G. Recommending SCIP as standard of care for most patients could transform secondary prophylaxis of acute rheumatic fever/rheumatic heart disease in New Zealand and internationally, concluded the study authors.
Comment: Great example of Kaupapa Māori health research which should inform clinical practice not only here in Aotearoa but worldwide.
Reference: PLoS One. 2024;19(5):e0302493.
Authors: Underwood L et al.
Summary: A longitudinal study of 6114 preschool children in New Zealand found a lower rate of injuries among Māori or Asian compared with European participants. Between birth and 4.5 years of age, 8% of studied children experienced 1-3 injuries with ≥1 hospitalisation, or ≥4 injuries (high injury group). Compared with European children, the odds of being in the high injury group was 0.7 (95% CI 0.5-0.97) for Māori children and 0.5 (95% CI 0.3-0.7) for Asian children, after accounting for antenatal, sociodemographic and psychosocial variables. Injury category was associated with maternal factors, family factors, social factors and service use, after adjustment for ethnicity and child variables (gender, temperament, level of activity and behaviour difficulties).
Comment: I think the authors say it best in their conclusion: “Our findings in relation to ethnicity go against the standard public rhetoric and provide support for shifting the apportioning of blame for child injury from individuals to wider environmental exposures for which public health and societal solutions are required.”
Reference: Inj Prev. 2024;30(3):233-238.
Authors: Richling S et al.
Summary: Food insecurity was prevalent in a cross-sectional study of patients presenting to the Whangarei Hospital emergency department, as assessed using the validated two-item Hunger Vital Sign screening tool. Out of a total of 300 participants, 37% were food insecure. Factors associated with food insecurity included Māori ethnicity (odds ratio [OR] 2.12; 95% CI 1.19-3.80; p = 0.011), household crowding (OR 1.19; 95% CI 1.02-1.39; p = 0.024) and lower socioeconomic status (OR 1.13; 95% CI 1.00-1.27; p = 0.048). The primary reason for emergency department attendance or the number of comorbidities were not significantly associated with food insecurity. Only half of participants who were food insecure reported being aware of (50.5%) or had used (54.1%) food resources. Food insecurity was associated with interest in social worker follow-up (OR 16.95; 95% CI 5.81-49.42; p < 0.001). The study authors concluded that an emergency department-based food insecurity screening programme with voluntary social worker follow-up was feasible and acceptable to patients.
Comment: Sad that this is an issue but an excellent example of how the social determinants are assessed and managed (using strengths-based approaches) in an incredibly busy clinical setting. Will look at introducing this in my clinic.
Reference: Emerg Med Australas. 2024;36(3):421-428.