ISSN 1178-6191
Making Education Easy Issue 97– 2022
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.
In this issue, we feature three studies focusing on the impact of lockdowns for COVID-19 on whānau wellbeing and access to healthcare. We also include a review highlighting strategies needed to enhance ascertainment and quality of health register data for Indigenous peoples, as well as a study of persistent ethnic disparities in childhood middle ear ventilation tube insertions. Finally, we include a paper from the late Cat Pausé, exploring understandings of fatness and health from Kaupapa Māori and fat studies perspectives. 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
Authors: Wright K et al.
Summary: Indigenous-led research, meaningful collaboration, and a sharing of knowledge and experiences between registers is needed to enhance ascertainment and quality of health register data for Indigenous peoples, according to a Kaupapa Māori review. The review included 17 studies, published between 1992 and 2020, which focused on the reporting of research involving Indigenous peoples using the CONSIDER checklist domains, ascertainment, and data quality. Aspects of 4 of 8 CONSIDER domains were identified to be included in study reporting. Barriers to ascertainment were themed as relating to ‘ethnicity data collection and quality’, ‘systems and structures’, ‘health services/health professionals’, and ‘perceptions of individual and communitylevel barriers’. Strategies to support ascertainment were categorised as ‘collaboration’, ‘finding people’, and ‘recruitment processes’. Strategies to support data quality were ‘collaboration’, ‘ethnicity data collection and quality’, ‘systems-level strategies’, and ‘health service/health professional-level strategies’. The authors noted that poor-quality data for Indigenous peoples in health registers prevents the achievement of health equity and exemplifies inaction. They found visible gaps in the breadth of strategies, particularly relating to the inclusion of Indigenous peoples in health register and research governance, and actions to identify and address institutional racism.
Comment: Important information here, which will help inform the way health data is collected and used in the health system reforms, given the focus on localities and Iwi partnership. Two key messages for me were: (1) Indigenous governance and (2) being proactive when it comes to anti-racism.
Reference: Int J Equity Health. 2022;21(1):34.
Abstract
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Authors: Wilkinson A et al.
Summary: This study involved previous clients of a health and social care navigation service in a New Zealand metropolitan city. A total of 9 clients (7 women and 2 men, aged 30-80 years) were individually interviewed in their homes. Interviews were transcribed and then analysed thematically. Many clients reported social isolation and were without regular income. The overall theme to emerge from the interviews was that of restoration of essence of being and sense of belonging, through a regenerative approach developed in partnership between the navigator and the client. This enabled clients to feel renewed and validated as human beings. The study authors concluded that enabling a client to feel valued assists in the development of self-determination and thereby improves health and well-being.
Comment: The sad thing is that people felt invalidated and unvalued in the first place.
Reference: Chronic Illn. 2022;18(1):169-180.
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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.
Authors: Menzies O et al.
Summary: A Kaupapa Māori focus group study has identified themes that can be used to inform assessment of older Māori with cognitive impairment. A total of 241 older Māori were involved in 17 focus groups across New Zealand, including 8 families from one region. Data from audio-recorded interviews was transcribed and thematically analysed. Results identified two overarching themes, connection (Tūhononga) and self (Whaiaro). Eight subthemes were also identified: mind (hinengaro), spirit (wairua), body (tinana), family (whānau), social connection (whanaungatanga), identity and role (tuakiri), place (wāhi), and ancestors (tūpuna). Māori language (Te Reo Māori) was deemed important for cognitive health. The study authors noted that their findings improve understanding of dementia (mate wareware) in Māori, and that the Tūhononga Whaiaro framework suggests factors potentially crucial for healthy aging in Māori.
Comment: There are some powerful videos about a grandson caring for his Papa who has dementia on Tiktok right now – see @jaydenjaze_. You can also check out this site and its app for more information - https://www.matewareware.co.nz.
Reference: J Appl Gerontol. 2022 Apr;41(4):1066-1073.
Authors: Savila F et al.
Summary: A holistic approach and responsiveness to perceived community needs may contribute to the sustained success of Brown Buttabean Motivation (BBM), a Pacific-led health programme with the primary aim of weight-loss motivation. In a qualitative study, 22 BBM members were interviewed in South Auckland, New Zealand. Study participants were 50% female, aged 24-60 years and of mixed Pacific and Māori ethnicities. They consisted of regular BBM members, attendees of the programme for those morbidly obese, and trainers. Analysis of data was guided by Pacific Fonofale and Māori Te Whare Tapa Whā health models. Participants in the study identified the interactive holistic nature of health and wellbeing. As well as physical, mental and spiritual benefits, BBM helped many reconnect with both their family and their culture. The study authors noted that while many weight programmes focus on improving physical exercise and nutrition, they seldom address sustainability and other core factors such as mental health.
Comment: Okay I need to ‘declare’ that I was part of the evaluation team for this project! And yes, we did demonstrate important results for individuals, whānau and the community. However, another key point is the weaving together of Māori and Pacific methodologies for research undertaken with both peoples. I think we’ll see more of this given our shared whakapapa and contexts.
Reference: BMJ Open. 2022;12(4):e059854.
Authors: Gillon A & Pausé C
Summary: A theoretical paper has explored the dual understandings of fatness and health from Kaupapa Māori and fat studies perspectives. Māori understandings of bodies and fatness that reflect whakapapa and culture are often excluded from health contexts and discourses. Fat studies have highlighted the cultural constraints against fat people and fat bodies and the structural oppression that prevents fat people from accessing public services, including evidence-based healthcare. The authors suggest a shift away from public health approaches to fatness that can often be oppressive and perpetuate healthism, in favour of Kaupapa Māori and fat studies pathways that promote self-determination and agency, supporting the community and collective, and body sovereignty.
Comment: As the authors say, ‘fatness for Indigenous peoples can be complex and an entanglement of multiple oppressions’. The authors carefully and safely navigate this space, always considering the rights of Indigenous and fat peoples to have excellent health care and outcomes. I want to especially acknowledge Cat Pausé for her courage and advocacy in fat studies. For those of you not aware, Cat passed away in March. Ka tangi te ngakau e hoa, moe mai, moe mai, moe mai ra.
Reference: Fat Studies. 2022;11(1):8-21.
Authors: Seo JY et al.
Summary: A study of childhood middle ear ventilation tube (VT) insertions in Auckland over the period 2009- 2018 has highlighted persistent ethnic disparities, with greatest impact on Pacific children. The overall rate of publicly funded VT insertions in children aged 0-4 years declined over the study period. In 2018, Asian and Pacific ethnic groups had the lowest rates of VT insertions in both the Counties Manukau District Health Board (CMDHB) and Auckland District Health Board (ADHB) areas, as well as nationally. VT insertion rates for Māori, Pacific and Asian children in CMDHB areas were less than half that of respective groups in ADHB areas. Children classified as NZ European/Other had the highest rates of VT insertions in CMDHB and nationally, but their rate was similar to that for Māori in ADHB areas. The study authors state that there may be a need for targeted middle ear screening for preschool children earlier than the 4-year-old Before School Check.
Comment: Gosh I remember inequities in rates and treatment for middle ear disease being reported 30 years ago. We must continue to monitor care and outcomes, but with time and more information these researchers have been able ‘drill down’ to expose the major gaps. I hope that their recommendations are implemented asap.
Reference: NZ Med J. 2022;135(1553):83-90.
Authors: Donnelly S et al.
Summary: The experiences of whānau whose relatives died in an acute hospital setting during the 2020 level 3 & 4 lockdowns for COVID-19 have been explored in a qualitative study. Next of kin for 22 patients who died in Wellington Hospital, including 16 patients from General Medicine and 6 who identified as Māori, were interviewed by phone in August 2020. Thematic analysis revealed the main factors contributing to positive experiences for whānau were excellence in nursing and medical care. Hospital staff understanding of tikanga Māori as it relates to dying and death practices was of benefit to Māori whānau. Factors contributing to negative experiences for whānau included separation from loved ones at the time of death, not having time to say goodbye, and insufficient communication with medical personnel. The study authors recommended that pandemic policies prioritise the needs of whānau and hospitalised patients who are dying of any illness, by way of daily updates to whānau, use of a bereavement whānau coordinator, prioritisation of rapid COVID-19 testing, ensuring availability of Māori healthcare staff, and observing Māori tikanga around dying and death.
Comment: Our whānau recently attempted to see a loved one in hospital who had sustained life-threatening injuries. We followed the hospital’s guidelines in making a request to visit, and were willing to undergo rapid antigen testing (knowing that COVID-19 transmission risk was very low as both patient and visitor were triple vaccinated and had recovered from COVID-19 three weeks prior). However, we were told that visits ‘were for the person recovering and not the whānau grieving’. As the authors suggest here, we can care for both when open to it.
Reference: NZ Med J. 2022;135(1552):16-26.
Authors: Wikaire E et al.
Summary: A scoping study has shown that telehealth is a viable long-term option for supporting Māori whanau access to healthcare. In the study, semi-structured interviews were completed with 5 Māori health professionals, 6 Māori telehealth patients, and 6 Māori in-clinic patients, about healthcare consultation experiences during the March 2020 COVID-19 lockdown in New Zealand. Key benefits were identified by all participants and included time and economic saving, enabling of tino rangatiratanga and improved safety. A number of challenges were highlighted, including access to the necessary resources and unmet health needs due to prioritisation of COVID-focused care. Suggested improvements to telehealth provision included systems that were more user-friendly and included language options, real-time sharing of information between and across health system organisations, education for healthcare service staff around communication and delivery of information digitally, as well as building rapport online, and patient access to technology, devices and knowledge around their use.
Comment: Telehealth is here to stay but it should be implemented in ways that eliminate, and not increase or even sustain inequities. Some fantastic suggestions here on how to ‘make it work’!
Reference: NZ Med J. 2022;135(1552):112-119.
Authors: Ng L et al.
Summary: A clinical audit has shown that presentation patterns to a South Auckland acute mental health service changed during New Zealand’s first level 4 lockdown for COVID-19, and patients faced a unique set of stressors. A sample of patients presenting during the lockdown period was compared with a sample of patients presenting during 2019. Factors analysed included demographics, living situation, mode of referral, mode of assessment, diagnosis, substance use, risks, stressors, use of mental health act legislation and follow-up. Over the lockdown period, fewer Māori were assessed at the acute mental health service, police referrals increased, specific stressors related to confinement were identified and there was an increase in risks relating to self-harm and harm to others. To respond to the changing needs of patients during a pandemic, the study authors recommended optimising telehealth, enhancing connections with other essential services, developing digital interventions and providing care for frontline staff.
Comment: There were various narratives about mental health issues over the lockdowns – many of them reported in the media. Therefore, an audit like this is invaluable, providing real-life information and solutions.
Reference: Australas Psychiatry. 2022;30(2):223-228.
Authors: Fushida-Hardy N et al.
Summary: A review of the New Zealand National Stroke Register has revealed an increased rate of reperfusion therapy between 2015 and 2020, driven by an increase in the use of stroke clot retrieval (from 0.5 to 5.5% of patients). The rate of intravenous thrombolysis was 6.5% in 2015 and 11.3% in 2020. In 2019, females were less likely to receive intravenous thrombolysis than males. Ethnicity had no impact on overall reperfusion rates. However, median door-to-needle time over the period 2018-2020 was significantly longer for Māori patients compared with NZ Europeans.
Comment: This paper demonstrates how the introduction of a new health pathway can both increase overall intervention rates (in this case stroke clot retrieval pathways resulting in rising reperfusion rates) AND inequities.
Reference: NZ Med J. 2022;135(1551):68-80.