Medical Research & Journals | Free Research Review Medical Studies Publications

ISSN ISSN 1178-6191

In this issue:

Experiences of a Māori-led diabetes programme
Acceptability of HPV self-sampling for minority women
Racial differences in diabetes mortality and complications
Māori women talk about HPV self-testing
Socioeconomic equity in the NZ health workforce
Co-designing health promotion interventions
Experiences of senior Māori public health practitioners
Prehospital barriers for rural NZ parents in paediatric appendicitis
Māori health workers’ perspectives on Māori pain management
A wellbeing app for young people in NZ
Ethnic disparities in NZ postoperative mortality

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 94th issue of Māori Health Review.

In this issue, we feature a Kaupapa Māori qualitative study investigating success factors and barriers to senior Māori public health practitioners working in mainstream public health units in New Zealand. This study was submitted as a thesis to the Auckland University of Technology in fulfilment of the requirements for the degree of Master of Philosophy. We also report two studies of human papillomavirus (HPV) self-testing in Aotearoa, a randomised controlled trial and a Kaupapa Māori qualitative analysis. Finally, we highlight the promising results of a pilot study investigating a wellbeing app designed to support New Zealand young people 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.

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

Māori and Pacific peoples’ experiences of a Māori-led diabetes programme

Authors: Tane T et al.

Summary: Analysis of a Māori-led diabetes support programme, Mana Tū, has identified barriers, facilitators and motivators for Māori and Pacific peoples with type 2 diabetes. The study used a Kaupapa Māori approach to conduct 22 semi-structured interviews with participants of Mana Tū and their whanau living in Auckland and Northland. Key themes identified were: (1) whānau experience of type 2 diabetes, (2) cultural safety in healthcare interactions, (3) whānau ora (collective family wellbeing) and (4) Kaupapa Māori approaches to health interventions. Themes were consistent across Māori and Pacific participants. The study authors concluded that Māori-led health interventions are needed to ensure that Māori and Pacific peoples with type 2 diabetes receive appropriate, responsive and equitable healthcare.

Comment: This could also apply to the community management of whānau living with COVID-19; based on my experience these past few weeks. We need a workforce who will coordinate both healthcare and welfare.

Reference: N Z Med J. 2021;134(1543):79-89.

Abstract

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Acceptability of human papillomavirus (HPV) self-sampling among never- and under-screened Indigenous and other minority women

Authors: Brewer N et al.

Summary: A community-based trial has demonstrated that HPV self-sampling increases screening amongst groups of Māori, Pacific and Asian women in New Zealand. The study included 3553 never- and markedly under-screened (≥5 years overdue) women aged 30-69 years. Women were randomised to clinic-based self-sampling (n = 1574), home-based self-sampling (n = 1467), or usual care (invited to attend a clinic for collection of a standard cytology sample; n = 512). Participation was highest for home-based self-sampling (14.6% in Māori, 8.8% in Pacific, and 18.5% in Asian women). Corresponding rates for clinic-based self-sampling were 7.0%, 5.3% and 6.9%, respectively. Participation rates for usual care were only 2.0%, 1.7% and 4.5%, respectively. The adjusted odds ratio for participation in home-based self-sampling vs usual care was 9.7 (95% CI 3.0-31.5) for Māori women, 6.0 (95% CI 1.8-19.5) for Pacific women, and 5.1 (95% CI 2.4-10.9) for Asian women. No adverse outcomes were reported. Non-responding women were invited to participate in a follow-on substudy after 3 months. Of these women, 192/2780 (6.9%) had taken an HPV self-sample by 6 months.

Reference: Lancet Reg Health West Pac. 2021;16:100265.

Abstract

Under-screened Māori women talk about HPV self-testing cervical screening clinical pathways

Authors: Adcock A et al.

Summary: While HPV self-testing has the potential to improve access to cervical screening and reduce inequities for Māori, care must be taken in the delivery of screening and colposcopy results, according to a Kaupapa Māori qualitative study. The study enrolled 28 Māori women aged 25-69 years who had not been screened for HPV in more than 4 years. After HPV self-testing, 22 women returned a negative test, while 6 had a positive test and underwent colposcopy. Women felt the HPV self-test was empowering and promoted bodily autonomy, although some were concerned about the use of new technology. The women who returned a positive test had many fears, which were compounded by seeking out information on the internet. The importance of support and responsive care when attending colposcopy was emphasised.

Comment: Important that we keep this in mind as I understand the number of women needing cervical smears continues to climb throughout lockdown and community COVID-19 transmission

Reference: Int J Gynaecol Obstet. 2021;155(2):275-281.

Abstract

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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.

Racial differences in all-cause mortality and future complications among people with diabetes

Authors: Ezzatvar Y et al.

Summary: A systematic review and meta-analysis of data from more than 2.4 million individuals has revealed that Māori people with diabetes have a higher risk of all-cause mortality than White people with diabetes. The analysis included 23 prospective cohort studies that reported risks for diabetic complications and all-cause mortality according to racial/ethnic group, published up until May 2021. Hazard ratio (HR) estimates were pooled using a random-effects inverse-variance model. Racial/ethnic groups were White (59.3%), Black (11.2%), Asian (1.3%), Hispanic-American (2.4%), Native American (0.2%), East Asian (1.9%), South Asian (0.8%), Pacific Islander (2.3%), Māori (2.4%) and Other (18.2%). Compared with White people, the HR for allcause mortality in Māori people was 1.88 (95% CI 1.61- 2.21). Hispanic-American people had a significantly lower risk for cardiovascular disease (HR 0.66; 95% CI 0.53-0.81) and Black people had a higher risk for end-stage renal disease (HR 1.54; 95% CI 1.05-2.24) compared with White people.

Comment: I think we’ve known this for Aotearoa, hence the introduction of equity-based criteria for new diabetic medications. I know script numbers and diabetes/ cardiovascular disease outcomes are being collected since the introduction of these new treatments, hoping to see the numbers soon.

Reference: Diabetologia. 2021;64(11):2389-2401.

Abstract

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Empowering equity: Striving for socioeconomic equity in the Aotearoa New Zealand health workforce

Authors: Thomson R et al.

Summary: The Socioeconomic Equity (EQ) support programme at the University of Otago is helping to build a health workforce that fairly reflects people from all communities. The EQ programme includes group workshops on study skills, guidance from peer mentors, subject-specific academic support, one-onone course advice and pastoral support and activities. Students who attended secondary school in a low socioeconomic area are invited to take part in the EQ programme at the start of the university academic year. Comparing the first two years of the EQ programme with the previous year, a higher proportion of students from schools in low socioeconomic areas passed the Health Sciences First Year, and the proportion of students from low socioeconomic backgrounds entering health professional programmes doubled.

Comment: Love this programme and the results. As the authors say, the programme cannot directly influence the wider determinants for inequities. However, by improving the retention rates for students in health programmes and giving them the ‘skills for life’ there are clearly long-term impacts.

Reference: Clin Teach. 2021;18(5):565-569.

Abstract

Perceptions of co-designing health promotion interventions with Indigenous communities in New Zealand

Authors: Harding T et al.

Summary: This Kaupapa Māori study identified facilitators and barriers of codesigning a health promotion intervention with Māori communities. The study considered a specific Māori co-design framework, He Pikinga Waiora (HPW), which is a participatory approach to creating interventions emphasising community engagement, systems thinking and Kaupapa Māori. Study participants (n = 19) were stakeholders in the New Zealand health sector, and were interviewed using an in-depth, semi-structured protocol. Collaboration and community voice were found to be facilitators for co-designing health promotion interventions with Māori communities. Mismanaged expectations and research constraints were barriers. In terms of the HPW framework, facilitators included providing clear guidelines and being grounded in Māori perspectives, while barriers included limited concrete case studies, jargon and questions about sustainability. The study authors concluded that collaboration and inclusion of community voice supports the development of more effective co-design health promotion interventions within Māori communities, and

Comment: Really useful for Health New Zealand and the Māori Health Authority as both commence work on co-design, whānau engagement and commissioning new programmes.

Reference: Health Promot Int. 2021;36(4):964-975.

Abstract

Experiences of senior Māori public health practitioners working in public health units in Aotearoa New Zealand

Authors: Rawson E

Summary: This Kaupapa Māori qualitative study investigated success factors and barriers to Māori public health practitioners who have worked in mainstream public health units for at least 5 years. The study found that all participants were experiencing and/or had observed restrictions on Kaupapa Māori practice and cultural freedom in the workplace. Lack of value was placed on mātauranga Māori, Kaupapa Māori practice and te ao Māori worldview. Inconsistent practice was observed in relation to hiring for positions requiring te ao Māori knowledge. Resourcing for professional development or for Māori projects has generally not been prioritised, and institutional barriers or institutional racism has been present within these decisions. The study author concluded that solutions mitigating the perpetuation of environments less suitable to Māori success are needed, ideally solutions that prevent damaging situations or environments from existing in the first place.

Comment: Based on my experience, and particularly over the past 18 months, I really think our public health units would be strengthened with more Māori and Pacific consultants/leaders. Emma and her supervisors have really hit the nail on the head here with their description of barriers to working in New Zealand’s public health organisations – and very timely as we develop New Zealand’s Health Plan and Charter.

Reference: Auckland University of Technology 2021.

Abstract

Prehospital barriers for rural New Zealand parents in paediatric appendicitis

Authors: Elliot BM et al.

Summary: Delayed presentation to hospital for paediatric appendicitis in rural families is most frequently due to extended decision-making around the costs and benefits of accessing hospital-level care, according to a qualitative study. The study involved semi-structured interviews with the parents of 11 rural children presenting to hospital with acute appendicitis between June 2019 and January 2020. The mean distance travelled to hospital was 50.4 km, and the median duration of prehospital symptoms was 42 hours. Families more likely to ‘watch and wait’ were those with reduced financial or social resources. Travel, organising childcare and parental income loss were key considerations. Prompt access and engagement with healthcare was further discouraged by structural barriers including poor cultural safety, maldistribution of rural health services, and contradictory public health messages. Earlier presentation to hospital was evident for families who sought informal community-based health advice.

Comment: Again, relevant to our current health predicament – managing COVID-19 in the community. The issues of rurality, in addition to costs and cultural safety of services when whānau attempt to engage, as identified here, must be taken into consideration – and quickly!

Reference: ANZ J Surg. 2021;91(10):2130-2138.

Abstract

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Kaiāwhina Māori health workers’ perspectives on pain management for Māori

Authors: Devan H et al.

Summary: A Māori-centred, qualitative study used focus groups to explore kaiāwhina (Māori community health workers) perspectives on supporting whānau Māori with chronic pain. Kaiāwhina (n = 13) from the greater Wellington region participated in the study. Key themes identified were: (1) chronic pain treatment in primary health relies solely on medication, (2) there is an urgent need for health literacy approaches to pain management, (3) Māori have significant unmet need for culturally responsive pain management, and (4) in Māori communities, the availability of, and referral practices to, specialist pain services are inadequate. The authors stated that developing new initiatives to address management of chronic pain in Māori must be Māori-led and codesigned with whānau if they are to result in holistic solutions.

Comment: I’ll admit that I’m guilty of this – treating pain in a biomedical way. I’d love to have Māori-developed, whānau-centred resources in my kete for people living with chronic pain.

Reference: N Z Med J. 2021;134(1543):19-29.

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Pilot study of a well-being app to support New Zealand young people during the COVID-19 pandemic

Authors: Serlachius A et al.

Summary: The acceptability, usability, and preliminary efficacy of a newly developed wellbeing app, Whitu, has been examined in a study of New Zealand young adults. Whitu has 7 modules that support young people to learn and practice evidence-based coping skills, including relaxation, mindfulness, self-compassion, and goal-setting. Participants aged 16-25 years (n = 20) were recruited via social media to test the first prototype of Whitu over 6 weeks. At 2 weeks post-intervention, statistically significant improvements in anxiety (p = 0.024) and stress (p = 0.017) were evident vs baseline. At 6 weeks post-intervention, there were significant improvements in wellbeing (p = 0.021), depression (p = 0.031), anxiety (p = 0.005), and stress (p = 0.004) vs baseline. There were no statistically significant changes in self-compassion, optimism, or sleep quality. A further 21 participants aged 16-30 years participated in 4 focus groups to give feedback on the app’s usability and cultural acceptability. Based on this feedback, modifications to the look and feel, cultural content, and onboarding have been undertaken, and a randomised controlled trial of Whitu is currently underway.

Comment: I’m sure we are all seeing high levels of anxiety and stress this year, and in the lead up to Christmas and 2022. With all the busyness in peoples’ lives and in health services, it’s good to know that tools like this are being developed with consumer input. Looking forward to seeing the results from the randomised controlled trial.

Reference: Internet Interv. 2021;26:100464.

Abstract

Disparities in post-operative mortality between Māori and non-Indigenous ethnic groups in New Zealand

Authors: Gurney J et al.

Summary: A study of nearly 3.9 million surgical procedures conducted in New Zealand between 2005 and 2017 has revealed higher rates of postoperative mortality for Māori vs European patients. The study assessed 30-day and 90-day postoperative mortality rates for all surgical specialties and by common procedures. Hazard ratios for mortality risk according to ethnicity were adjusted for age, sex, deprivation, rurality, comorbidity, American Society of Anesthesiology score, anaesthetic type, procedure risk and procedure specialty. Māori had higher rates of 30- and 90-day postoperative mortality across most procedure categories, in particular for elective/waiting list procedures. For example, the adjusted hazard ratio for 30-day mortality after an elective/ waiting list musculoskeletal procedure was 1.93 (95% CI 1.56-2.39) for Māori vs European patients. The authors stated that the disparities were likely driven by a combination of healthcare system, process and clinical team factors.

Comment: Auē, the outcomes described here are no good. However, I’m impressed with the description of mechanisms – we can use these to start developing and implementing solutions.

Reference: N Z Med J. 2021;134(1542):15-28.

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