Medical Research & Journals | Free Research Review Medical Studies Publications

ISSN ISSN 1178-6191

In this issue:

Impact of HPV vaccine
Regional variations in cancer survival
Maternal morbidity and foetal/neonatal outcomes
Inequities in epilepsy outcomes
Rongoā Māori in public hospitals
Impact of unemployment on mortality
Reducing clinic non-attendance
Military post-traumatic stress
Work-related fatalities
Technology use by octogenarians

Abbreviations used in this issue

HPV = human papillomavirus

HR = hazard ratio

RR = relative risk

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.

Greetings

Welcome to the 85th issue of Māori Health Review
Several studies in this issue are particularly relevant as we continue to work together to eliminate COVID-19 and lessen restrictions in alert level 2 and level 1. We need to be mindful of our kaumatua who have relatively low use of technology, understand the obstacles for attendance at outpatient clinics, and be aware of the impact of unemployment on health.

Nga mihi
Matire
Dr Matire Harwood
matire@maorihealthreview.co.nz

Impact of human papillomavirus vaccination on rates of abnormal cervical cytology and histology in young New Zealand women

Authors: Innes CR, et al.

Summary: Receiving at least one dose of quadrivalent HPV vaccine prior to age 18 years significantly lowered the incidence of abnormal cervical cytology or histology in a retrospective cohort of 104,313 women born between 1990–1994. All had cervical cytology or histology recorded when aged 20–24. Vaccinated women had a 25% lower incidence of high-grade cytology (8.5 vs 11.3 per 1000 person years; p<0.001) and a 31% lower incidence of high-grade histology (6.0 vs 8.7 per 1000 person years; p<0.001) than unvaccinated women. No differences were evident between New Zealand European and Māori women in the incidence of high-grade cytology irrespective of vaccination status.

Comment: Great to have follow-up evidence demonstrating the impact of the HPV vaccine on ‘cancer’ (defined here in terms of cytology and histology) incidence rates, and by ethnicity.

Reference: N Z Med J. 2020;133(1508):72-84.

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The characteristics and outcomes of patients with colorectal cancer in New Zealand, analysed by Cancer Network

Authors: Blackmore T, et al.

Summary: Regional differences in cancerspecific survival outcomes were investigated in a retrospective analysis of 29,221 cases of colorectal cancer recorded in the New Zealand National Cancer Registry over a 10-year period between 2006–2015. 42% of the study population were aged >75 years, 52% were male and 88% were New Zealand European. Survival outcomes for patients with colorectal cancer aged <75 years did not vary by regional cancer network. A higher risk of dying from colorectal cancer was evident for atients aged >75 years living in the Central Cancer Network (1.12; 95% CI 1.03–1.22) and Midland Cancer Network (1.10; 95% CI 1.02–1.18) compared with those living in the Northern Cancer Network. Disparity in outcomes was also evident for patients of Māori and Pacific ethnicity; cancerspecific survival and all-cause survival were worse for Māori and Pacific patients than New Zealand European patients diagnosed with colorectal cancer.

Comment: A very important paper which is relevant as we move to level 2 and level 1 post lockdown, highlighting differences by age and ethnicity in cancer survival rates. The other clear message for me is that there may be differences in ‘network’ policies or practices that result in differences in outcomes for certain peoples.

Reference: N Z Med J. 2020;133(1513):42-52.

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Examining adverse fetal/neonatal outcomes associated with severe maternal morbidity

Authors: Lawton B, et al.

Summary: Severe maternal morbidity events were associated with high rates (49.4%) of adverse foetal and neonatal outcomes in a retrospective study of 400 women admitted to New Zealand intensive care units (ICUs) or high dependency units (HDUs) in 2014. Adverse foetal/neonatal outcomes were defined as foetal or early neonatal death, hypoxic ischaemic encephalopathy, Apgar score <7 at 5 minutes, or admission to neonatal intensive care unit (NICU) or special care baby unit (SCBU). Pre‐eclampsia was the most common condition associated with an adverse foetal/neonatal outcome (67%). The rate of adverse foetal/neonatal outcomes was 30% higher in Māori women compared with New Zealand European women (63.7% vs 48.9%; RR 1.30; 95% CI 1.04–1.64).www.uruta.maori.nz/hapu-mama

Comment: In addition to highlighting the results and discussion presented here, I would like to acknowledge the work of Bev Lawton, the first author, in advocating for women’s health during recent weeks of COVID-19 lockdown. I encourage readers to look at the advice Bev, Kasey Tawhara and others have written for whānau, available on the Urutā website.

Reference: Aust N Z J Obstet Gynaecol. 2020 Apr 21. doi: 10.1111/ajo.13163. [Epub ahead of print]

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Mortality and morbidity of patients with treated and untreated epilepsy in New Zealand

Authors: Hamilton KJ, et al.

Summary: Māori patients with newly diagnosed epilepsy had lower treatment rates and worse health outcomes in an analysis of hospital admissions and prescription data for 3366 patients diagnosed with epilepsy between 2007–2015. After diagnosis with epilepsy, 92.8% of patients received immediate treatment, 3.7% received delayed treatment and 3.5% were untreated. Māori patients were less likely to receive treatment, had higher mortality (HR 1.41; 95% CI 1.08–1.83) and were more likely to develop liver disease (HR 4.67; 95% CI 1.32–16.4) and alcohol or drug dependence (HR 2.55; 95% CI 1.44–4.51). An increased risk of acute myocardial infarction was evident in patients who received delayed treatment or were untreated (HR 9.64; 95% CI 1.83–50.8).

Comment: I had no idea that there were such significant inequities in epilepsy outcomes and treatments for Māori. In trying to better understand this, I plan to audit my care as a first step but will also look at current research in this area, and Māori specific resources (e.g. http://epilepsy.org.nz/files/Brochure_ Maori.pdf).

Reference: Epilepsia. 2020;61(3):519-527.

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Is there a role for Rongoā Māori in public hospitals?

Authors: Koea J, Mark G.

Summary: Knowledge of Rongoā Māori, the traditional form of healing for Māori, was investigated in an internet-based survey of staff at Waitemata District Health Board. The survey response rate was 19.6% (1181 responses from approximately 6000 staff) and responders were predominantly female (80%), medical practitioners or nurses (66%) and of European ethnicity (67%); 18% of responders were Māori. Familiarity with Rongoā Māori was reported by 46% of responders and 16% had used Rongoā Māori on themselves or whānau. Availability of Rongoā Māori within the hospital system was supported by 32% of responders.

Comment: It would be great to consider the place of Rongoā in our hospitals when we ‘re-start’ the health system. The recommendations made here would be a good place to start.

Reference: N Z Med J. 2020;133(1513):73-80.

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Association between employment status and risk of all-cause and cause-specific mortality

Authors: Nie J, Wang J, et al.

Summary: Retirement, temporary unemployment and never being employed were associated with higher mortality in a population-based prospective cohort study of 282,364 participants aged 18–65 years in the US National Health Interview Survey from 2001–2013. A total of 12,645 participants died during a mean follow-up of 8.2 years. An increased all-cause mortality risk was evident for participants who were retired (HR 1.27; 95% CI 1.17–1.37), temporarily unemployed (HR 1.76; 95% CI 1.67–1.86), or never employed (HR 1.63; 95% CI 1.47–1.81) compared with employed participants. Conditions associated with increased mortality risk included cancer, cardiovascular disease, chronic lower respiratory disease, diabetes and kidney disease.

Comment: Research about the impact of unemployment on health always reminds me of Vera Keefe- Ormsby and her seminal study ( https://www.otago.ac.nz/wellington/departments/publichealth/research/erupomare/research/otago019495.html ) on health following the closure of the meat works in Hawkes Bay. Obviously there are reasons outside of peoples’ control for them to be unemployed. As health professionals, our role is to ensure excellent access to care including the management of risk factors

Reference: J Epidemiol Community Health. 2020;74(5):428-436.

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‘Getting to clinic study’: A mixed methods study of families who fail to attend hospital outpatient clinics

Authors: Christie-Johnston CA, et al.

Summary: Common reasons for non-attendance at a Melbourne-based paediatric hospital outpatient clinic were identified in interviews with 50 parents of children aged 0–18 years. Administrative factors, such as not receiving an appointment letter (26%) or text reminder (32%) and difficulties in re-scheduling appointments (22%), were commonly cited. Suggestions to reduce non-attendance included flexible clinic times, reduced waiting periods and cheaper parking. In addition to receiving text reminders of upcoming appointments, parents wanted to use text services to reschedule appointments and thereby remove the need to phone the hospital.

Comment: As many of you know, I become easily annoyed with the discourse around ‘Did Not Attend’ (DNA) as I find it very ‘victim-blaming’. Audits in adult services in Aotearoa have revealed similar findings to those described in this paper. Other issues included double booking, lack of transport and car parking. As the authors suggest, these are often administrative. Anecdotal evidence suggests that virtual (mostly telephone) follow-ups during the recent lockdown have been well liked by both patient and clinician, at least for some specialties.

Reference: J Paediatr Child Health. 2020;56(4):506-511.

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Risk and protective factors for post-traumatic stress among New Zealand military personnel

Authors: Richardson A, et al.

Summary: Post-traumatic stress was found to be prevalent among New Zealand military personnel in a cross-sectional study of 1817 currently serving and retired military personnel. Experience of significant post-traumatic stress symptoms, defined as scores ≥30 on the Military Post-traumatic Stress Disorder Checklist, were evident for 30% of participants. A further 10% of participants had scores ≥45 indicating a presumptive clinical diagnosis of posttraumatic stress. Lower scores were associated with longer duration of service, ability to adapt to changes in circumstances and good sleep. Higher scores were associated with experience of trauma and were more likely in older males and Māori.

Comment: This is timely given the recent ANZAC Day commemorations. It speaks to the long-term, and wider, impact of trauma when experienced by our military personnel. In addition to the recommendations made here regarding protective factors, I think more work, to understand the differences by ethnicity, is also required.

Reference: PLoS One. 2020;15(4):e0231460.

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Decade of fatal injuries in workers in New Zealand

Authors: Lilley R, et al.

Summary: Insights from a comprehensive 10-year national observational study of worker fatalities using coronial records from 2005–2014 found high fatality rates for workers aged 70–84 years, males and Māori. A total of 955 workers were fatally injured over the 10-year period translating to a rate of 4.8 per 100,000 worker-years. Mining occupations had the highest fatality rate in the workplace setting. Transport, postal and warehousing occupations had the highest fatality rate in the work-traffic setting, categorised as motor vehicle incidents in the course of their work on public roads.

Comment: Last year we lost one of our patients to an accident at his workplace. It made me think about whether there were inequities in fatal workplace injuries, so I tried to find data but couldn’t. This paper has done the work for me, although unfortunately it has also confirmed my assumptions.

Reference: Inj Prev. 2020 Mar 24. doi: 10.1136/injuryprev-2020-043643. [Epub ahead of print]

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Cell phone and technology use by octogenarians

Authors: Atlas A, et al.

Summary: Cell phone and technology use by octogenarians in New Zealand was relatively low, particularly for Māori octogenarians, in Te Puawaitanga O Nga Tapuwae Kia Ora Tonu – Life and Living in Advanced Age (LILACs) cohort study. Cell phone use was 16% in Māori octogenarians and 30% in non-Māori octogenarians; cell phone use was less likely in Māori supported only by a pension than Māori with more income. Internet use was associated with higher cognition scores and was 6% in Māori octogenarians and 19% in non-Māori octogenarians. Watching pay-per-view television (e.g. SKY) was less likely in women, octogenarians who lived alone, and non-Māori supported only by a pension. The authors commented that ‘Relatively low use of technology may limit potential for health technology innovation for people of advanced age.’

Comment: Although telephone consultations during lockdown (levels 3 and 4) may be liked by some, it won’t work for all without focused effort, as this article describes. In the same way the Ministry of Education and schools provided tablets and other support to tamariki so that they could access ‘virtual’ schooling, we should think about supporting our kaumatua to access technology so that they have equitable access to healthcare and other support services.

Reference: J Prim Health Care. 2020;12(1):35-40.

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