ISSN 1178-6191
Making Education Easy Issue 105 – 2023
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 include three national population-based studies, highlighting disproportionate rates of noninvasive ventilation use, acute aortic syndrome, and hospitalisation for asthma exacerbations among Māori. We present a paper examining the health, wellbeing and nutritional impacts of the government-funded healthy school lunch programme. Finally, we describe support for key Smokefree 2025 strategies among Māori who smoke. 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: Maclennan B et al.
Summary: Findings from the POIS-10 Māori cohort have shown that the most common predictors of adverse health-related quality of life (HRQoL) outcomes 12 years after injury are pre-injury chronic conditions and pre-injury living arrangements. A total of 354 Māori individuals were interviewed, and outcomes of interest were responses to each of the five EQ-5D-5L dimensions. Pre-injury sociodemographic and health measures, as well as injury-related factors, were collected from earlier POIS interviews and administrative datasets. The study authors stated that longterm HRQoL outcomes for injured Māori may be improved by considering the broader aspects of patient health and wellbeing throughout the injury recovery process, and by coordinating patient care with other health and social services where necessary.
Comment: Context so important. It’s critical that we enquire about contexts to: (1) identify and manage factors that may impact negatively on long-term outcomes; (2) ensure people are heard/feel valued; and (3) recognise and integrate their strengths.
Reference: Qual Life Res. 2023;32(9):2653-2665.
Abstract
Authors: Cate L et al.
Summary: In a cross-sectional survey of patients who underwent total knee arthroplasty at publicly funded Bay of Plenty hospitals in 2021, Māori accessed more rehabilitation than non-Māori. Survey participants were asked to record demographic information, as well as the duration, type, and location of their pre- and post-operative rehabilitation. Mean total rehabilitation time was 9.75 hours for Māori patients and 8.34 hours for non-Māori patients. The difference was in large part driven by a significant home-based component of rehabilitation for Māori (42.9% of survey participants received at least some of their rehabilitation at home, compared with 16.4% of non-Māori).
Comment: My worry here is that the authors focus on ‘equal’ access which doesn’t necessarily lead to equitable outcomes (think of the picture of people standing on the boxes to watch the sports game). Hopefully the service will look at the quality of rehabilitation, including timeliness and safety.
Reference: N Z Med J. 2023;136(1581):44-50.
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Authors: McKelvie-Sebileau P et al.
Summary: The government-funded healthy school lunch programme has enhanced wellbeing and delivered financial benefits for students and families after two years of operation, according to a qualitative study. Five focus groups (two with secondary students and three with family members) were conducted across four schools, and the principals were also interviewed. A range of contexts were represented: primary and secondary, schools with onsite cooks and schools using external caterers. Family participants were 82% Māori with borderline (73.5%) or no (8.8%) financial security. Thematic analysis identified seven positive impacts: improved food security, enhanced equity, increased appreciation of healthy foods for students, enhanced wellbeing for all, reduced financial hardship/stress for families, opportunities for nutritional learning and recognition that appreciation and uptake happen over time. Negative impacts were low uptake that created food waste, perception that healthy food is not palatable for students, lack of knowledge of the programme and loss of agency for students. It is essential to involve students and family members in programme planning, the study authors concluded.
Comment: Love this study and seeing the wonderful results – hopefully the post-election government/funders will practice evidence-based policy!
Reference: Health Promot Int. 2023;38(4):daad093.
Authors: Neill A et al.
Summary: A national prevalence survey has found that use of noninvasive ventilation (NIV) doubled between 2011 and 2018. Prevalence rates were calculated using adult population data (aged ≥20 years) for each District Health Board region, and a subanalysis of individual-level data was used to calculate age-standardised rates by diagnostic category. In 2018, 1197 adults were receiving NIV, giving a national rate of 32.9 per 100 000 population, which compares with a rate of 16.7 per 100 000 population in 2011. However, the NIV rate varied significantly across regions, from 4.5 to 84.2 per 100 000 population. The most frequent indications for NIV were obesity hypoventilation syndrome (47%), obstructive pathologies (28%) and neuromuscular disorders (15%); all have significantly increased in prevalence since 2011. Māori and Pacific peoples were significantly overrepresented among NIV users, with agestandardised rate ratios of 2.24 (95% confidence interval [CI] 1.72-2.93) and 7.03 (95% CI 5.52-8.94), respectively, compared with non-Māori/non-Pacific peoples.
Comment: The regional variation is huge and not explained by rurality/demographics, with Tairawhiti having the highest rates and Taranaki the lowest. Te Whatu Ora presents a great opportunity here, in terms of national criteria, education, equipment provision and equity.
Reference: Intern Med J. 2023;53(8):1458-1468.
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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: Xu W et al.
Summary: Mortality after acute aortic syndrome (AAS) has remained high over the last decade, according to a national population-based study. A total of 1295 patients presenting to hospital with an index admission of AAS (61% type A and 38% type B) between 2010 and 2020 were retrospectively assessed. Hospital records were supplemented by information from the National Mortality Collection and the Australasian Vascular Audit. Between 2010 and 2018, 290 patients died out of hospital. The overall incidence of aortic dissection, including out-of-hospital cases, was 3.13 (95% confidence interval [CI] 2.96-3.30) per 100 000 person-years, and this increased by an average of 3% (95% CI 1-6%) per year after adjustment for age and sex, driven by increasing type A cases. Agestandardised disease rates were higher in men, and in Māori and Pacific populations. Overall rates of 30-day mortality were 31.9% in patients with type A disease and 9.7% in those with type B disease, and did not change significantly over the study period. Management strategies also remained constant over time. The study authors noted that work is needed to reduce ethnic disparities in rates of AAS.
Comment: As with other cardiovascular diseases, there are significant inequities in AAS and other aortic diseases between Māori and non-Māori. A recent pilot has tested the effectiveness of screening for aortic disease in older Māori. This is a promising area because, as the authors conclude, a focus on reducing risk and early management appears to be the best way to reduce disparities.
Reference: Br J Surg. 2023;110(9):1197-1205.
Authors: Chan AHY et al.
Summary: A national population-based study has shown that asthma exacerbation rates have increased over the period 2010 to 2019, but hospitalisation rates have decreased. The study retrospectively examined de-identified data from five national healthcare datasets. Exacerbations were defined based on hospital discharge diagnoses or oral corticosteroid dispensing. The total number of patients with asthma was 447,797 in 2010 and 512,627 in 2019, equating to approximately 10% of the population. The asthma exacerbation rate was 19.4% (376.2 per 1000 patientyears) in 2010 and 25.1% (438.3 per 1000 patient-years) in 2019. Exacerbations rates were consistently higher in females, Pacific peoples and Māori. Hospital admissions decreased from 1.4% in 2010 to 0.9% in 2019, however over 50% of admissions were in Māori and Pacific peoples. The study authors concluded that their findings suggest a move away from secondary to primary care management of asthma exacerbations.
Comment: Much of the work to improve asthma outcomes in Aotearoa has focussed on community management, including the introduction of healthy homes legislation, asthma guidelines and PHARMAC funding of combination therapy. Importantly, these three activities aligned with the principle of Te Tiriti, particularly tino rangatiratanga (Māori leaders), equity and active protection. Wonderful to see these contributing to better outcomes.
Reference: Respir Med. 2023;217:107365.
Authors: Waa A et al.
Summary: The Smokefree 2025 goal of reducing smoking prevalence to below 5% is supported by 42% of Māori who smoke, according to Wave 1 (2017-2019) of the Te Ara Auahi Kore longitudinal study. The study was conducted in partnership with five primary health organisations serving Māori communities, and included 701 Māori who smoked. Of the three key strategies now set out in the Smokefree Action Plan, support was greatest for mandating very low nicotine cigarettes (VLNCs). Participants believed that use of VLNCs would lead to high rates of smoking cessation. The most support for VLNCs came from participants who had made more quit attempts or reported less control over their life. As part of developing and implementing Smokefree Action Plan measures, it is important to engage with Māori who smoke and their communities, the study authors concluded.
Comment: Really useful to see who supports what, e.g. people with more quit attempts and less control over life preferred VLNCs. I’ll need to tailor discussion and cessation management to meet their needs and help them quit.
Reference: N Z Med J. 2023;136(1579):49-61.
Authors: Black R et al.
Summary: A study of submissions made to the Pae Ora (Healthy Futures) Bill has suggested that identifying Pākehā “standard story” discourses will enable the development of tools and procedures to eliminate institutional racism. A total of 3,000 individual submissions made in late 2021 were reviewed, of which 2,536 contained explicit references to race. Five longer submissions inferring that the Pae Ora bill was “racist” were analysed in detail. Many “standard story” race discourses were identified in the submissions. The study author described three derived discourses: Pākehā as norm (monoculturalism or not seeing Pākehā as a culture), equality and the “Treaty” (equality for all to access healthcare), and one people (we are all New Zealanders). Alternative discourses were provided using sources such as the Waitangi Tribunal Wai 2575 Hauora report.
Comment: This would be a great resource for professional training, from undergrad to specialist, clinical to management and policy. Not only do the authors highlight the usual anti-Māori narratives, but they also provide great responses to these. Other common ‘Māori’ myths, and clever retorts, can be found here - https://www.trc.org.nz/mediaand-te-tiriti/.
Reference: N Z Med J. 2023;136(1579):62-69.
Authors: Glassey R et al.
Summary: The mainstream curriculum can be a challenge for schools wishing to promote Māori ways of being, according to a qualitative study of five low advantage schools with high Māori student populations. Semi-structured interviews with school principals identified the following themes based on creating a curriculum around Te Ao Māori (Māori worldview): mainstream curriculum not fit for purpose for Māori learners; blending of mātauranga Māori and western knowledge; mātauranga Māori as learning and educational experiences; mātauranga ā-iwi (local Māori knowledge) and achievement fit for tamariki (children). Some schools supported a He Awa Whiria (braided rivers) approach to education, the interweaving of both western practices and mātauranga Māori.
Comment: Fantastic to see public and community health doctors in this team, promoting the importance of mātauranga Māori in kura/primary schools. This strengths-based research was as much about demonstrating how mātauranga supports success for Māori learners as it was about the potential benefits for all.
Reference: AlterNative. Epub 2023 Sep 6.
Authors: Agarwal S et al.
Summary: A Series paper published in The Lancet demonstrates how structural inequity (structural racism and geographical inequity) has accelerated diabetes prevalence, morbidity, and mortality rates globally. The paper discusses how structural inequity leads to large, fixed differences in key, upstream social determinants of health. In a cascade of widening inequity, these differences influence downstream social determinants of health and resultant diabetes outcomes. Categories of social determinants of health with known effects on diabetes outcomes are reviewed, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. Regional perspectives are also provided by the authors, to highlight prominent, real-world challenges.
Comment: A great resource for the national Diabetes Plan currently being updated here in Aotearoa! And useful reference for journal reviewers who argue that there is no evidence that racism contributes to health disparities.
Reference: Lancet. 2023;402(10397):235-249.