Medical Research & Journals | Free Research Review Medical Studies Publications

ISSN 1178-6191

In this issue:

Reproductive justice in Aotearoa New Zealand
Profiles of mental health need among adolescents
Continuous glucose monitoring in Māori children with type 1 diabetes
Continuous glucose monitoring in insulin requiring type 2 diabetes
Emergency department non-traumatic dental presentations
COVID-19 pandemic and perceptions of scheduled childhood vaccines
Does supporting cultural diversity benefit only Māori?
Provision of care for diabetic retinopathy
Altering medical students’ ethnic bias towards Māori
Blood cancer incidence, mortality and survival for Māori

Tēnā koutou katoa

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.

Welcome to the 111th issue of Māori Health Review.

We would like to acknowledge the sad passing of two important leaders in Māoridom: Kīngi Tūheitia, a key proponent of kotahitanga among Māori, and Wellington GP Dr Dougal Thorburn, a champion of equity for Māori.

In this issue, we include two studies highlighting the effectiveness of continuous glucose monitoring for glycaemic control in Māori with diabetes. We present a large analysis showing ethnic disparities in blood cancer incidence, mortality and survival for Māori. Finally, we feature a comprehensive review of reproductive justice in New Zealand, including the policy and practice changes needed to ensure reproductive autonomy for all New Zealanders. 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

Reproductive justice in Aotearoa New Zealand

Authors: Huria T et al.

Summary: Policies developed with a reproductive justice methodology are crucial for ensuring reproductive autonomy and safety of all people in New Zealand, according to a narrative review from Family Planning (now Sexual Wellbeing Aotearoa). Necessary changes include equity of access to contraception and abortion, reducing sexually transmitted and human papillomavirus infection rates in Māori and Pasifika women, improving access to gynaecological care, improving sexuality education, and ending intimate partner violence and sexual violence. Policies and practices aimed at facilitating reproductive autonomy must pay particular attention to tino rangatiratanga for Māori.

Comment: In this article, the authors explore the concept of reproductive justice for New Zealand, including ways it could be furthered. An excellent and comprehensive review of key issues are presented through a justice lens, highlighting the intersection of oppression and disadvantage in this space but also opportunities for transformation led by Māori in partnership with Sexual Welling Aotearoa.

Reference: Aotearoa New Zealand Social Work. 2023;35(4):136–143.

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Distinct profiles of mental health need and high need overall among New Zealand adolescents

Authors: Sutcliffe K et al.

Summary: An analysis of data from the Youth19 Rangatahi Smart Survey has shown that youth mental health is not “one size fits all”. The survey, conducted in 2019, included 7721 adolescents aged 13-18 years. Six variables from the survey were analysed: wellbeing; possible anxiety symptoms; depression symptoms; past-year self-harm; suicide ideation; and suicide attempt. Five clusters of mental health were identified. The healthy cluster (40.3% of adolescents) reported positive mental health; the anxious cluster (28.2%) reported high possible anxiety symptoms but otherwise generally positive mental health; the stressed and hurting cluster (9.4%) reported subclinical depression, possible anxiety symptoms and some self-harm; the distressed and ideating cluster (15.8%) reported clinical depression, possible anxiety symptoms and high suicide ideation; and the severe cluster (6.4%) reported the least positive mental health across all indicators. The higher severity clusters included an overrepresentation of female, rainbow, Māori and Pacific students, and those from higher deprivation areas. Exposure to sexual harm and discrimination were also associated with increasing cluster severity. Future research should consider how to best support the mental health of each cluster, concluded the study authors.

Comment: Youth mental health issues are increasing in prevalence and complexity for a variety of reasons – we see it in a variety of settings including education, justice and our own whare. Importantly, exposure to harm – including discrimination and feeling devalued by society and its ‘leaders’ – is associated with increased severity. I worry that funding cuts which target young Māori will grow the problems described here.

Reference: Aust N Z J Psychiatry. 2024;58(8):678-692.

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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.

Research Review publications are intended for New Zealand health professionals.

Emergent inequity of glycaemic metrics for Māori children with type 1 diabetes is negated by early use of continuous glucose monitoring

Authors: Stedman L et al.

Summary: Use of continuous glucose monitoring (CGM) within 12 months of type 1 diabetes diagnosis ameliorates ethnic disparity in glycaemic control in children, according to an analysis of data from the KIWIDIAB network. Data were collected for 206 children aged <15 years diagnosed between 1 October 2020 and 1 October 2021. CGM use was 56.7% for Māori and 77.2% for European children. At 12 months post-diagnosis, glycosylated haemoglobin (HbA1c) was 10.8 mmol/mol (95% CI 2.3-19.4 mmol/mol; p = 0.013) higher in Māori vs European children without CGM, but was similar between ethnic groups in those using CGM.

Comment: Miharo to see these devices are now funded by Pharmac. Please check the website for more information - https://pharmac.govt.nz/news-and resources/cgms-and-insulin-pumps. Ka rawe!

Reference: N Z Med J. 2024;137(1598):14-21.

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Real time continuous glucose monitoring in high-risk people with insulin-requiring type 2 diabetes

Authors: Lever CS et al.

Summary: A randomised controlled trial found that real-time (rtCGM) improved glycaemia in a predominantly Māori population of adults with insulin-requiring type 2 diabetes. The trial assigned 67 participants with HbA1c ≥64 mmol/mol (8.0%), who were using insulin ≥0.2 U/kg/day, to rtCGM or self-monitoring blood glucose (SMBG). A total of 54% of participants were Māori. The primary endpoint was time in the target glucose range (TIR; 3.9-10 mmol/L) during weeks 10-12. Mean TIR increased by 13% (95% CI 4.2 to 22%; p = 0.007) in the rtCGM group but did not change in the SMBG group. Baseline-adjusted between-group difference in TIR was 10.4% (95% CI -0.9 to 21.7; p = 0.07). Mean HbA1c decreased from baseline in both groups (p < 0.001 for both). No severe hypoglycaemic or ketoacidosis events occurred in either group.

Comment: Can we have these funded for our pakeke with type 2 diabetes too please!

Reference: Diabet Med. 2024;41(8):e15348.

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Outcome measures for Māori with non-traumatic dental presentations: a retrospective observational study and Kaupapa Māori approach examining emergency department inequities

Authors: Cameron-Dunn S et al.

Summary: The first study using a Kaupapa Māori approach to examine emergency department non-traumatic dental presentations (NTDP) found barriers to accessing primary oral healthcare and a paucity of Kaupapa Māori initiatives. The study reviewed 2034 NTDP to the Christchurch emergency department between 2018 and 2020. Māori and Pacific peoples were over represented compared to local population estimates (27.0% and 6.9% vs 9.4% and 3.2%, respectively). Māori had the highest age-standardised incidence of hospital admission, but shorter length of stay compared with Pacific peoples and NZ Europeans (0.9 vs 3.8 and 2.0 days, respectively). Provision of high-quality, equitable care for Māori requires further action and accountability, concluded the study authors.

Comment: Important that we continue to monitor this important health issue, as we now know that poor dental health affects pregnancy outcomes, nutrition and related conditions (diabetes, cardiovascular disease) and mental health (through pain and financial stress). I found this paper – Undoing structural racism in dentistry: Advocacy for dental therapy – really useful to unpick these issues, and to see how an Indigenous-led programme is delivering change.

Reference: N Z Med J. 2024;137(1599):16-26.

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Exploring the impact of the COVID-19 pandemic on perceptions of national scheduled childhood vaccines among Māori and Pacific caregivers, whānau, and healthcare professionals in Aotearoa New Zealand

Authors: Charania NA et al.

Summary: Māori and Pacific-led vaccination strategies should be embedded in immunisation service delivery to improve uptake and immunisation experiences for whānau, according to a qualitative study. Interviews and discussions were undertaken with Māori and Pacific caregivers (n = 24) and healthcare professionals (n = 13) between November 2022 and May 2023 to understand perceptions of routine childhood vaccines through the COVID-19 pandemic. Four themes were constructed from gathered data. “We go with the norm” reflected how participants’ acceptance of routine vaccines before the pandemic were promoted by social norms, health personnel and institutions. “Everything became difficult” explains how challenges were added to the daily struggles of whānau and healthcare professionals by the pandemic. “It needed to have an ethnic-specific approach” highlighted the Western-centric strategies that dominated during the initial pandemic response, that did not meet the needs of Māori and Pacific communities. “People are now finding their voice” expressed renewed agency among whānau about vaccination following pressure to receive COVID-19 vaccines.

Comment: Really important information here, especially given the contribution that timely immunisation makes to addressing health inequities; the focus of the government in this area; and the importance of supporting whanau agency and informed consent.

Reference: Hum Vaccin Immunother. 2024;20(1):2301626.

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Does supporting cultural diversity benefit only Māori? A study of Māori and Pākehā employees

Authors: Haar J et al.

Summary: A study of New Zealand employees has shown that cultural diversity promise fulfilment (CDPF) is beneficial for both Māori and Pākehā. A total of 165 Māori and 729 Pākehā aged ≥18 years in paid employment and working ≥20 hours per week were surveyed for the study. There was strong support for CDPF influencing key work outcomes of turnover intentions and job satisfaction, as well as cultural wellbeing. While effects were stronger for Māori, there were similar beneficial effects for Pākehā. The study authors noted that their findings should encourage organisations to actively embrace cultural diversity.

Comment: There has been a lot of messaging about cultural diversity in the health workforce – hence my reasoning for including this paper here. We know cultural concordance is associated with better outcomes for patients. I think what is less well established, but demonstrated here, is the important contribution cultural diversity makes to the WHOLE workforce – with reports of better job satisfaction and less turnover for both Māori and New Zealand European workers when cultural diversity promises are fulfilled at the workplace.

Reference: Journal of the Royal Society of New Zealand. 2024;1-20.

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Provision of care for diabetic retinopathy in New Zealand: are there ethnic disparities?

Authors: Solanki J et al.

Summary: There is a need to reduce barriers faced by Māori in accessing GP, optometry and retinopathy screening referrals, according to a retrospective audit of first specialist diabetic retinopathy clinic appointments at the Department of Ophthalmology, Te Whatu Ora Te Toka Tumai Auckland. Data from 388 patients was analysed, of whom 42% were European, 9.5% were Māori, 13.2% were Pasifika, 32.7% were Asian and 2% were Middle Eastern/Latin American/African. Compared with patients of other ethnicities, Māori patients were eligible for a significantly greater number of treatments (p=0.001). Across ethnicities, the comprehensiveness of history taking, examination, investigations and proportion of eligible treatments provided was similar but did not reach the gold standard of care.

Comment: Although the evidence presented here is disheartening, I am pleased that we have non-Māori health researchers and providers working with Māori Hauora leaders to monitor ethnic inequities in Aotearoa and focus on the significant system/structural factors at play.

Reference: N Z Med J. 2024;137(1600):12-20.

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I have a dream: altering medical students’ ethnic bias towards Indigenous population (NZ Māori) using a digital training called cognitive bias modification

Authors: Hsu C-W & Akuhata-Huntington Z

Summary: A single training session using a tool designed to address interpretation bias in medical students was effective in reducing overall bias, suggesting potential applications in addressing health disparities. The tool, cognitive bias modification for stereotype (CBM-S), uses an implicit learning task to create a less biased interpretation of Māori patients in common health scenarios. Following CBM-S training, stereotype interpretation bias scores were reduced over time, as well as post-training stereotype bias scores after adjustment for baseline bias scores.

Comment: How interesting – a specific type of training to reduce unconscious bias in Aotearoa. Although developed for medical students in working with patients, I’d love to see it being used to reduce bias toward fellow Māori students/peers and for other health professions. In fact, I’m already creating the list for other occupations!

Reference: Stigma and Health. 2024; Advance online publication.

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Blood cancer incidence, mortality and survival for Māori in New Zealand

Authors: Clough S et al.

Summary: Ethnic disparities are apparent for incidence, mortality and survival of blood cancers, according to a study of the New Zealand Cancer Registry (2007 2019) and national mortality records. Blood cancers in 2653 Māori and 20,458 Europeans were identified. Incidence and mortality rates for leukaemia and myeloma were higher in Māori than Europeans. Cancer-specific survival outcomes were poorer for Māori vs Europeans across most blood cancer types, with age- and sex-adjusted hazard ratios of 1.77 (95% CI 1.57-2.00) for leukaemia, 1.18 (95% CI 0.65-2.16) for Hodgkin lymphoma,1.71 (95% CI 1.50-1.95) for non-Hodgkin lymphoma and 1.40 (95% CI 1.19-1.64) for myeloma.

Comment: The survival disparities between Māori and non-Māori observed here are consistent with other Indigenous peoples with blood cancer, and importantly for 23 of the 24 most common cancers in Aotearoa. Unequal detection and screening, and unequal treatment, are the most likely drivers, though others specific to blood cancers must be considered. Finally, although the results are disappointing, what is uplifting is the number of Māori and Pacific Admission Scheme graduates/Māori leaders heading this important research and contributing to healthcare in Aotearoa!

Reference: Cancer Epidemiol. 2024;93:102656.

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