Making Education Easy Issue 23 – 2009
Authors: Jaeger SR et al
Summary: Outcomes are reported from 99 door-to-door interviews conducted in 2007 in a high deprivation neighbourhood in Auckland investigating fruit consumption. On average, participants reported eating a serving of fresh fruit five to six times per week. At the time of the interview, 38% of respondents did not have any fresh fruit in the house and 60% reported that in the past month they had thrown out fruit between one to four times per week because it was considered to be past its best in terms of eating quality. Fruit juice was consumed on average one to two times per week. Self-efficacy for fruit consumption was positively associated with consumption. Relative to participants with lower levels of self-efficacy for fruit consumption, those with higher levels of self-efficacy were more likely to achieve the target of consuming ≥2 daily fruit servings. The study authors suggest that “strategies that aim to increase self-efficacy beliefs for fruit consumption may contribute to improving compliance with the recommended two or more servings daily”.
Comment: The results raise a number of questions – what would ‘strategies that increase self-efficacy for fruit consumption’ look like? And in order to increase fruit consumption, are these more effective and cheaper than say supplying low-cost/high-quality fruit? Many reported having fruit in the home, but the majority of respondents had thrown fruit out because it was rotten. This may reflect the fact that people want to buy fresh produce but can only afford the less expensive and unfortunately old fruit.
Reference: Aust N Z J Public Health. 2009;33(5):471-6.
Abstract
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Authors: Lee C et al
Summary: These researchers examined the extent to which perceived provider discrimination explains racial/ ethnic differences in healthcare utilisation and subsequently health status, in a sample of 5642 adults living in the USA, who participated in the 2001 Survey on Disparities in Quality of Health Care. The researchers applied structural equation modelling to evaluate the relationship between perceived provider discrimination, healthcare utilisation, and health status. Significantly higher levels of perceived provider discrimination and poorer health were reported by African Americans, Hispanics and Asians than by non- Hispanic whites. The model revealed poor health to be significantly mediated by two paths: (1) by perceived provider discrimination and (2) by perceived provider discrimination through unmet need for healthcare utilisation.
Comment: Although this confirms what many of us suspected/knew anyway, these studies are really useful in discussions with those who continue to argue that clinicians don’t treat people differently. The next step is to look at ways to address provider discrimination at the system level. Possibilities include training, ongoing audit, and workforce development to increase the number of Māori clinicians.
Reference: Reference: Ethn Dis. 2009;19(3): 330-7.
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Authors: Ong KS et al
Summary: This paper weighs up the efficiency-equity debate from the health economics perspective. It contends that as currently available qualitative and quantitative methods designed to incorporate equity into economic evaluation are beset by definitional uncertainties and other inherent limitations, no method has been universally adopted to date. The researchers propose a concept that may overcome some of those limitations; a cost-based equity weight for evaluating the cost side as opposed to the outcomes side of interventions delivered by primary health care programmes. As this concept focuses on achieving equity in processes rather than outcomes, it is sensitive to the context and health beliefs of target groups. The researchers evaluate primary health care delivery to the Australian Aboriginal and Torres Strait Islander (or Indigenous) population, as an illustrative case study. The ‘equity of access’ decision-making tool is a potentially important avenue for further health economics research, conclude the researchers.
Comment: Not being a health economist, many of the concepts discussed in this paper were new to me. However, there is increasing interest in the area of health, economy and equity. As Gareth Morgan argues in his new book ‘Health Cheque’, an investment in reducing health inequalities now will have long-term benefits for all new Zealanders (see his website and prescription at www.healthcheque.co.nz).
Reference: Int J Equity Health. 2009;8(1):34.
Authors: Zorc JJ et al
Summary: These US-based researchers evaluated the effect of an emergency department (ED)-based intervention addressing beliefs and barriers to follow-up asthma care among inner-city families. The study recruited 433 children aged 1 to 18 years who were discharged after asthma treatment in an urban paediatric ED. Controls received instructions to followup with a primary care provider (PCP) within 3 to 5 days. Intervention subjects additionally underwent asthma symptom screening, viewed a video addressing beliefs about asthma control and they were mailed a reminder to follow-up with a PCP. All subjects were contacted by telephone 1, 3, and 6 months after the ED visit. After the intervention and before ED discharge, intervention subjects were more likely to endorse beliefs about the benefits of follow-up than controls. However, rates of PCP follow-up during the month after the ED visit (44.5%) were similar to control subjects (43.8%) as were asthma-related quality of life, medication use, and ED visits.
Comment: One important ‘confounder’ may be the fact that the intervention was delivered in the ED. Community-based studies, including the Wairarapa Asthma study in which education was delivered on marae, have had very different results. And given the disparities in asthma management between Māori and non Māori, this should continue to be an area for improvement. For example, the Asthma and Respiratory Foundation of NZ is looking to develop an asthma education programme for HealthTV, to be delivered in waiting rooms
Reference: Pediatrics. 2009;124(4):1135-42.
Authors: Hart LM et al
Summary: This paper describes the development of culturally appropriate guidelines for providing first aid to an Australian Aboriginal or Torres Strait Islander experiencing a mental health crisis or developing a mental illness. A panel of Aboriginal mental health experts participated in six independent Delphi studies investigating depression, psychosis, suicidal thoughts and behaviours, deliberate selfinjury, trauma and loss, and cultural considerations. The panellists reached consensus about culturally appropriate first aid for mental illness. A total of 536 statements about first aid actions were accepted for inclusion in a guideline (94 for depression, 151 for psychosis, 52 for suicidal thoughts and behaviours, 53 for deliberate self-injury, 155 for trauma and loss, and 31 for cultural considerations). The panellists affirmed the methodology and the guidelines themselves as useful and appropriate.
Comment: An interesting paper, particularly for those people involved in the development of guidelines. Importantly, it describes the way in which a health need was identified by the indigenous community; how they’ve utilised evidence that is validated by cultural expertise, and in working with indigenous experts, have also increased their knowledge about an important health issue. The methodology may be useful for similar activities in Aotearoa.
Reference: BMC Psychiatry. 2009;9:47.
Authors: Malcolm L, Barnett R
Summary: Māori and non-Māori rates of utilisation of cardiology inpatient services were analysed by linking the enrolled population of Partnership Health with hospital discharge data from the New Zealand Health Information Service. Rates of discharges for the 2 years ending June 2007 (n=127,246) were analysed in relation to age, gender, ethnicity (19,712 Māori), deprivation score and other variables. Rates of utilisation including cardiology in patient services were analysed by diagnosis-related groups (DRGs). Standardised Māori rates of utilisation for almost all major cardiology DRG categories were substantially higher than the non-Māori population. Overall rates for cardiology DRGs were 1.47 times higher for Māori. Standardised Māori rates were higher than the non-Māori population for higher deprivation scores. Māori cardiology inpatients had almost twice the level of Care Plus levels than the non-Māori population. The researchers stress that the higher rate of hospital utilisation suggests that higher quality data rather than increased access is the explanation.
Comment: As the authors have indicated, the results may in fact reflect better data quality and not actual improvements. It would be useful to also know confidence levels and statistical significance of results. Finally, the authors haven’t stated if utilisation reflects health need, or is associated with equitable outcome. A follow-up study is required.
Reference: N Z Med J. 2009;122(1304):63-71.
Authors: Priest P et al
Summary: To assess whether ethnic inequalities in cervical cancer mortality are due to differences in survival independent of stage and age at diagnosis, and to assess the contribution of screening to stage at diagnosis, this investigation examined demographic data and cervical screening history for 402 women with histologically proven primary invasive cervical cancer, diagnosed in New Zealand between 1 January 2000 and 30 September 2002. Date of death was available for women who died up to 30 September 2004. In an age-adjusted Cox proportional hazard model, the Māori mortality rate was 1.80 times that of non-Māori. This reduced to 1.25 after adjusting for stage at diagnosis. Among determinants of late stage at diagnosis, older age and being Māori significantly increased the risk, while screening was protective.
Comment: PHO Performance Programme (PPP) data for cervical screening rates in primary care, when analysed by ethnicity, show that Māori are not receiving cervical screening at the same rate as non Māori, non-Pacific women. Some PHOs (including the one I work for) have introduced specific programmes that aim to reduce inequalities in cervical screening; major improvements have resulted. I’d be interested to hear from others who have implemented successful interventions for Māori cervical screening.
Reference: Cancer Causes Control. 2009 Oct 22. [Epub ahead of print]
Authors: Wiley A
Summary: Findings are reported from a year-long qualitative outcome evaluation of the implementation of Objective 11 of the New Zealand Disability Strategy (NZDS): promote the participation of disabled Māori. Semi-structured interviews conducted with ministry officials, service provider organisations, Māori consumers with disabilities and caregivers to Māori consumers, uncovered common themes that included issues surrounding the effectiveness of the NZDS and the conflict between indigenous worldviews framed within a mainstream service paradigm. Themes unique to specific interview groups covered areas such as accountability structure design, perceived levels of cultural competency, collaboration across sectors and information exchange. The paper concludes that the NZDS provides several pertinent lessons regarding the development of culturally comprehensive disability policy.
Comment: This paper presents the findings from an evaluation of a high-level strategy with input to the assessment from all stakeholders. Chapter 12 of Hauora: Māori Standards of Health IV provides a more in-depth description of Māori understandings of disability and disability support. Together, the two references provide an important focus on a critical issue – support for Māori with impairment and their whānau – and should inform the development of a Whānau Ora Framework.
Reference: Disabil Rehabil. 2009;31(14):1205-14.
Authors: Morgan J, Haar J
Summary: This study sought to determine whether the introduction of free GP sexual health consultations for registered under-25-year-olds in rural and low socioeconomic areas of the Waikato region, New Zealand, in late 2003–2004 improved provision of primary sexual health care, using testing and detection rates of Chlamydia trachomatis as a measurable outcome. Chlamydia testing among under-25 year olds at the 20 intervention practices increased over time, but not among the 29 non-intervention practices; coverage of females aged 18–24 years within the intervention increased from 13.9% in 2003 to 15.5% during the roll-out phase and to 16.8% in 2005. Intervention practices had higher test positivity rates than non-intervention practices (8.7% vs 5.9%; p<0.01), increasing from 7.7% in 2003 to 10% in 2005, relating mainly to increases in positive tests among females aged <25 years. In contrast, no increases occurred in testing or detection among those aged ≥25 years at intervention practices.
Comment: A great example of how easy it is to evaluate an intervention in primary care. Practice staff must be supported to ‘normalise’ the Chlamydia screening questions and introduce them opportunistically. Importantly, with free, targeted health care, disease detection and hopefully also management increase.
Reference: Sexual Health. 2009;6(3) 203-7.
Authors: Gracey M, King M
Summary: This paper describes the disparities in health and disease statistics among Indigenous people worldwide. It focuses on Indigenous Australians as an example of health gaps between Indigenous and non-Indigenous peoples. Simple, affordable, and effective ways to improve Indigenous health are discussed. The authors advocate that increased awareness, political commitment, and recognition is needed to correct these inequalities and they urge that Indigenous people be encouraged, trained, and enabled to become increasingly involved in overcoming these challenges.
Comment: I’ve included this paper as an extremely useful reference for those needing health statistics for indigenous peoples across many nations. The fact that it, and its sequel Part 2, appear in one of the top medical journals should also speak volumes.
Reference: Lancet. 2009;374(9683):65-75.