Medical Research & Journals | Free Research Review Medical Studies Publications

ISSN 1178-6191

In this issue:

Child health data storage, linkage and consent for use
Financial insecurity and cardiac event recovery in Māori men
The National Bariatric Prioritization Tool and health outcomes
Racism, early psychosis, and institutional contact
Reduced use of seclusion for Māori
Intimate partner violence against women
Socio-demographic profile of New Zealand medical students
Dental caries and body mass index in pre-school children
Primary health care enrolment during the COVID-19 pandemic
Virtual marae-based workshop for rural doctors

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 107th issue of Māori Health Review.

In this issue, we include two studies examining mental health services, the first highlighting experiences of racism among Māori youth with early psychosis, and the second showing reduced use of seclusion for Māori in a national quality improvement project. We also present studies showing impacts of the COVID-19 pandemic – the first examining disparities in primary health care enrolments, and the second reviewing experiences of a virtual adaptation of a marae-based workshop for rural doctors. Finally, we report a sobering study of intimate partner violence against women in New Zealand.

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

In safe hands: child health data storage, linkage and consent for use

Authors: Wild CEK et al.

Summary: A qualitative study of children, adolescents and their families in New Zealand has shown that consent processes for ongoing use of child health data require attention. The study included 24 Māori and non Māori across five focus groups, recruited from a community-based health service, and used a mixed Māori and non-Māori research team. Focus groups for children, adolescents and parents/caregivers were held separately. Three themes were identified: (1) I am more than a number: seeing patients as people; (2) In safe hands: data as power; and (3) What are your intentions with my data? Consent as an active relationship. The authors noted that a strong ethical and child rights-based approach to child health data management is needed to avoid the risk of exacerbating health inequities and experiences of breach of trust.

Comment: Really useful information here on what matters for Māori and non-Māori whānau and then how do we, as people collecting, holding and using data, uphold their views and aspirations in practice.

Reference: Health Promot Int. 2023;38(6):daad159.

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Reciprocal relations between cardiovascular disease, employment, financial insecurity, and post cardiac event recovery among Māori men

Authors: Lisipeki S et al.

Summary: Financial (in)security and personal income are key determinants of participant experiences and outcomes among Māori men undergoing cardiac investigation and treatment at Waikato Hospital, according to a case-comparative study. The study involved three 1- to 3-hour interviews with four Māori men, with the first interview taking place 5-16 weeks after surgery/ discharge. Kaupapa Māori Research practices were used. Rather than medical problems, major financial disruptions were at the forefront of concerns for participants with financial insecurity. Financial hardship impacted access to care, and access to funding contributed to psychological distress for several participants. Positive treatment experiences and recovery were facilitated by economic security and reciprocal relationships between employers and employees.

Comment: I’ve heard similar concerns from Māori after stroke – with return to work being a significant issue that is ignored or not considered by health providers. The researchers tease this out further here, with a key message being to ‘ask and not assume’.

Reference: J Med Case Rep. 2023;17(1):468.

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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.

Does the National Bariatric Prioritization Tool predict health outcomes?

Authors: Chung L et al.

Summary: A study of patients undergoing elective bariatric surgery at Middlemore Hospital found that while National Bariatric Prioritization Tool (NBPT) score is not correlated with percentage total weight loss after 18 months, it is associated with improvement of comorbidities. Correlation coefficients for the association of NBPT score with reduction in glycosylated haemoglobin, resolution of obstructive sleep apnoea and resolution of hypertension were 0.28 (p < 0.0001), 0.20 (p < 0.001) and 0.20 (p < 0.001), respectively. NBPT scores were significantly higher for Māori and Pacific than New Zealand European patients (p = 0.0023). The study authors concluded that the NBPT could be used to achieve equity of access, but that further modifications should be considered to optimise outcomes.

Comment: Interesting paper given the recent outcry of using prioritisation tools at Auckland-based hospitals last year. I’d add though that, in my experience: (1) GPs, the main referrers to surgery, don’t necessarily have access to the priority criteria and; (2) arbitrary exclusion criteria can undermine equity aspirations.

Reference: ANZ J Surg. 2023;93(12):2851-2856.

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Racism, early psychosis, and institutional contact: A qualitative study of Indigenous experiences

Authors: Manuel J et al.

Summary: A qualitative study informed by Critical Race Theory has illustrated the inter-related nature of interpersonal, institutional and structural racism experienced by young Māori within the mental health sector. Focus groups and individual interviews were conducted with nine Māori youth with early psychosis, ten family members and four Māori mental health professionals. Three major themes were identified: (1) selective responses based on racial stereotypes; (2) race-related risk assessment bias; and (3) institutional racism in the mental health workforce. Reported impacts of racism were inaction in the face of social need, increased use of coercive practices and an under-resourced Māori mental health workforce. Social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts, concluded the study authors.

Comment: Well written and considered paper demonstrating the levels of racism in mental health, and how they play out for people within its ecosystem.

Reference: Int J Soc Psychiatry. 2023;69(8):2121-2127.

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Closing the equity gap as we move to the elimination of seclusion: Early results from a national quality improvement project

Authors: Bensemann C et al.

Summary: A national programme to eliminate seclusion in mental health services in New Zealand, with a focus on reducing inequity for Māori, has been associated with a reduction in seclusion for Māori. A bicultural change package, combining Māori cultural and Western clinical interventions, was developed, and incorporated quality improvement methodologies. National seclusion rates for Māori decreased from a baseline of 7.5% per month in August 2019 to 6.8% per month after implementation of the programme (sustained from late 2020 to September 2022). In addition, the duration of seclusion for Māori decreased from 4.5 hours at baseline to 3.0 hours after programme implementation, a 33% reduction.

Comment: A fantastic paper demonstrating the positive impact of a Māori- and equity-focused approach to health. I suspect that the programme had wider benefits including a drop in rates for all ethnicities, in line with gold standards and human rights.

Reference: Australas Psychiatry. 2023;31(6):786-790.

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Ethnic-specific prevalence rates of intimate partner violence against women in New Zealand

Authors: Fanslow JL et al.

Summary: A high lifetime prevalence of intimate partner violence is present across all ethnic groups in New Zealand, but is highest in Māori women, according to data from the 2019 New Zealand Family Violence Study. A total of 1431 ever partnered women were studied, of whom 55.8% reported intimate partner violence. Prevalence was 64.6% among Māori women, and was next highest in NZ European women, at 61.6%. Prevention and intervention services are needed at the population level, noted the study authors, and should be culturally responsive and attuned to the needs of communities that bear the greatest burden.

Comment: It’s always a challenge to report these statistics, given the potential to be highlighted by those who wish to perpetuate negative stereotypes. However, I felt some reassurance that Tracey MacIntosh was a lead researcher on the team. More than half of women reported intimate partner violence – it’s unacceptable. For those wanting to learn more I highly recommend a session with Dr Gabrielle Moss (https://www.nzdoctor.co.nz/sites/default/ f iles/2019-09/Recognition%20%26%20Response%20to%20Intimate.pdf).

Reference: Aust N Z J Public Health. 2023;47(6):100105.

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Socio-demographic profile of medical students in Aotearoa, New Zealand

Authors: Bagg W et al.

Summary: A national cross-sectional study has found that medical students do not reflect the diverse communities they will serve, with under-representation of Māori and Pacific students and those from low socioeconomic and rural backgrounds. A total of 2858 students enrolled to study medicine at the Universities of Auckland or Otago during 2016-2020 were included in the study. More women than men were enrolled in medicine (59.1% vs 40.9%), and almost all (96.5%) were in the 18-29 years age range. Rate ratios for enrolment of Māori and Pacific students were 0.92 (95% confidence interval [CI] 0.84-1.0) and 0.85 (95% CI 0.73-0.98), respectively. Enrolment rates had a nearly log-linear negative relationship with increasing socioeconomic deprivation for all ethnic groups, irrespective of rural or urban origin. The rate ratio for enrolment of students from rural areas was 0.53 (95% CI 0.46-0.61) compared with those from urban areas. The study authors suggested several policy changes to address these issues.

Comment: Many will have seen this in the news at the end of 2023, and the excellent commentary from authors when interviewed. A couple of examples are provided here https://www.teaonews.co.nz/2023/12/11/maori and-pasifika-medical-numbers-up-but-still-underrepresented-study/ and https://www.1news.co.nz/2023/12/11/govt-review-of-maori-pacific-doctor pathway-disappointing/.

Reference: BMJ Open. 2023;13(12):e073996.

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The pattern of association between early childhood caries and body mass index in pre-school children within Aotearoa | New Zealand

Authors: Schluter PJ et al.

Summary: Sex, ethnicity and area-level deprivation have a greater impact on dental caries than body mass index (BMI), according to a near whole population cross-sectional study. Data for 582, 820 children were extracted from the national B4 School Check screening programme between July 2010 and June 2021, of whom 98.2% had valid BMI and oral health records. Median age of the children was 4.3 years, 48.7% were female, 23.4% and 12.8% were identified as Māori and Pacific, respectively, and 24.4% lived in the most deprived areas of New Zealand. Overall, 14.2% had dental caries identified. After adjustment for age, sex, ethnicity and area level deprivation, a significant flattened S-shaped association was found between dental caries and BMI; those with lower sex-specific BMI-for-age z-scores had lower predicted probabilities of dental caries. However, large differences in predicted probabilities were observed between different sex, ethnicity and area-level deprivation groups.

Comment: Another complex set of results to get your head around but still important in the sense that it bunked assumptions about BMI and oral health. Given significant associations with demographic variables (including ethnicity and deprivation), population-level strategies (end poverty for example) are paramount.

Reference: Community Dent Oral Epidemiol. 2023;51(6):1109-1117.

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The enrolment gap and the COVID-19 pandemic: an exploration of routinely collected primary care enrolment data from 2016 to 2023 in Aotearoa New Zealand

Authors: Pledger M et al.

Summary: An observational study has found that the COVID-19 pandemic was associated with changed patterns of primary health care (PHC) enrolment in New Zealand. The study analysed enrolments at PHCs between 2016 and 2023, with Poisson regression models used to determine whether changes in enrolment were due to the COVID-19 pandemic. In 2016, enrolment was lower for Māori, young people and the most deprived compared with their peers. Enrolment rates decreased over time for Māori and Pacific people, as well as for those who were the most deprived. Enrolment rates increased for young people, those with the lowest levels of socioeconomic deprivation and those in the “other” ethnic category, mainly European New Zealanders.

Comment: Agree that COVID-19 and the lockdowns had an impact on PHO enrolments but there have also been major workforce issues across the sector including primary care which will have played a role also. Planning to understand these results better and address the inequities is required. International studies suggest marketing (‘Just do it – enrol now!’) and opportunistic enrollments are effective.

Reference: J Prim Health Care. 2023;15(4):316-323.

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Te Paatu o Te Ao Hurihuri - pandemic-related virtual adaptation of an established marae-based workshop for rural doctors

Authors: Blattner K et al.

Summary: Replacing an in-person remote marae-based workshop with a virtual workshop is achievable and has value when strong established relationships exist, according to medical student and teacher experiences. Experiences of a virtual marae-based workshop adaptation during the COVID-19 pandemic were analysed via document review and semi-structured interviews. Students found the virtual workshop valuable in furthering their knowledge of Māori culture, cross-cultural communication skills and health inequities in rural clinical practice. They felt some sense of connection with the remote locality and its people. Teachers were able to impart knowledge, connect and keep everyone culturally safe. However, the cultural experience for students was compromised, and the ability to share learning was lost. The authors noted that caution is needed when urban tertiary institutions partner with remote Māori communities to deliver virtual teaching, to ensure transparency in priorities and expectations and to avoid exacerbations of power imbalance and resulting loss of value.

Comment: It’s interesting that this has been implemented, and importantly evaluated, in a rural Māori community. My first virtual tangi was in Te Tai Rawhiti for Paratene Ngata, at his request, to overcome any travel or financial barriers for whānau. As the authors say, virtual marae-based experiences have a place – having tikanga and kawa in place first is key.

Reference: J Prim Health Care. 2023;15(4):343-349.

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