Medical Research & Journals | Free Research Review Medical Studies Publications

ISSN 1178-6191

In this issue:

Indigenous inequalities in cancer care
Overview of ethnic inequities in cancer
Indigenous health workforce development
Web-based alcohol intervention reduces drinking
B4 School Check behaviour measures
Antenatal, labour, and delivery care for Māori
Explaining lung cancer diagnostic delay
Health performance of the C&CDHB
Taking community action on diabetes prevention
Ethnic differences in Caesarean section rates

Tēnā koutou katoa

Nau mai ki tenei Tirohanga hou Hauora Māori. He rangahau tuhi hou e paa ana ki nga hau ora a ki te oratanga o te Māori. No reira noho ora mai raa i o koutou waahi noho a waahi mahi hoki. Ngā mihi o te wā me te Tau Hou ki a koutou katoa. Noho ora mai.

Greetings

Welcome to this issue of the Māori Health Review. Each issue attempts to bring you research relevant to the health and wellbeing of Māori. I welcome feedback and suggestions for papers/research to include in future issues and I’m pleased to hear and read about the excellent work being undertaken in Hauora Māori.
Nga mihi

Matire
Dr Matire Harwood
matire@maorihealthreview.co.nz

Indigenous inequalities in cancer: what role for health care?

Authors: Hill S et al

Summary: This review of recent evidence of cancer treatment and outcomes among Māori and non-Māori New Zealanders explored possible factors contributing to poorer survival in Māori. The papers reports good evidence for poorer survival with most types of cancer among Māori compared with other ethnic groups, particularly European New Zealanders. In particular, two recent studies show that Māori patients receive poorer quality treatment for cancers of the lung and colon, even after adjusting for patient factors. The paper’s authors suggest that these findings indicate that at a population level, the health-care system as a whole may disadvantage Indigenous patients. The authors’ analysis proposes a framework that directs attention beyond individual patient factors towards system-level factors affecting cancer care, including the location, resourcing and cultural focus of services. By recognising the strengths and addressing the weakness of cancer services, we have an opportunity to improve the quality and equity of cancer services and optimise cancer survival in Indigenous populations, conclude the authors.

Comment: An extremely useful framework that has been well thought out. Importantly, the focus on system level factors provides impetus for services to not only consider and implement change but monitor impact.

Reference: ANZ J Surg 2013;83(1-2):36-41.

Abstract

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Cancer in Māori: lessons from prostate, colorectal and gastric cancer and progress in hereditary stomach cancer in New Zealand

Authors: Blair V et al

Summary: This discussion of colorectal, prostate and stomach cancer in Māori illustrates selected issues that impact on cancer care. Evidence relating to colorectal cancer illustrates the importance of accurate cancer statistics to focus management strategies. The paper details how prostate cancer in Māori is an area where cultural factors impact on care delivery. The focus on sporadic stomach cancer in New Zealand shows how subclassification of different types of cancer can be important and illustrates the breadth of putative causal factors. An overview of developments in hereditary gastric cancer in New Zealand in the last 15 years demonstrates how successful clinical and research partnerships can improve patient outcomes. For example, the marae-based Kimi Hauora Health Clinic in the Western Bay of Plenty provides support to cancer patients, mutation carriers and their families, helping them navigate the interface with the many healthcare professionals involved in the multidisciplinary care of cancer patients.

Comment: An interesting overview of ethnic inequities in cancer, with more detail around a few specific examples. The role of genetics, as well as the necessary support required for whānau with hereditary cancers, must inform Māori ethical and research frameworks

Reference: ANZ J Surg 2013;83(1-2):42-8

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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.

Indigenous Health Workforce Development: challenges and successes of the Vision 20:20 programme

Authors: Curtis E, Reid L

Summary: These researchers analysed outcomes data from the Vision 20:20 programme, an initiative that has been designed to improve Indigenous Māori and Pacific health workforce development in New Zealand via recruitment, bridging/foundation and tertiary retention support interventions within the University of Auckland’s Faculty of Medical and Health Sciences (FMHS). The paper details 7 years of student data (2005–2011) for undergraduate Student Pass Rate (SPR) by ethnicity and Certificate in Health Sciences (CertHSc) SPR, enrolments and completions by ethnicity. Four key areas of development are involved in this programme: (i) student selection and pathway planning; (ii) foundation programme refinement; (iii) academic/pastoral support; and (iv) re-development of the Indigenous recruitment model. All of these developments have had a positive impact on basic student data outcomes. The FMHS undergraduate SPR increased from 89% in 2005 to 94% in 2011 for Māori and from 81% in 2005 to 87% in 2011 for Pacific students. The CertHSc SPR increased from 52% in 2005 to 92% in 2011 with a greater proportion of Māori and Pacific enrolments achieving completion over time (18–76% for Māori and 29–74% for Pacific)

Comment: An excellent paper, particularly for those of us working in the ‘Indigenous health workforce development’ space. I was fortunate to hear the authors present the paper and talk to the rationale of changing the educational system, including medical schools, to support Māori students ‘not to fail’ along their chosen pathway.

Reference: ANZ J Surg 2013;83(1-2):49-54

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Web-based alcohol intervention for Māori university students

Authors: Kypri K et al

Summary: Outcomes are reported from this evaluation into the effectiveness of web-based alcohol screening and brief intervention (e-SBI) for reducing hazardous drinking among Māori university students in New Zealand. The study researchers emailed invitations in April 2010 to all 6697 17–24-year-old Māori university students to complete a brief web questionnaire including the Alcohol Use Disorders Identification Test (AUDIT)-C, a screening tool for hazardous and harmful drinking. Those screening positive (AUDIT-C score of ≥4) were randomised to either <10 minutes of web-based alcohol assessment and personalised feedback (intervention; n=939) or screening alone (controls; n=850). Follow-up assessments were completed at 5 months by 682 controls (80%) and 733 intervention group participants (78%). Relative to controls, participants receiving the intervention drank less often (RR 0.89), less per drinking occasion (RR 0.92), less overall (RR 0.78) and had fewer academic problems (RR 0.81).

Comment: This paper would be useful to services that may be developing web-based tools, particularly for rangatahi.

Reference: Addiction 2013;108(2):331-8

Abstract

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The B4 School Check behaviour measures: findings from the Hawke’s Bay evaluation

Authors: Hedley C et al

Summary: Using Health Hawke’s Bay records, these researchers analysed the number and demographics of 4-year-old children assessed with behaviour issues as determined by the Strengths and Difficulties Questionnaire (SDQ) at the health and development Before (B4) School Checks up to 31 August 2011, and the interventions to which they were referred. Thirty-six parents/caregivers of these children were interviewed by telephone and asked what difference did the B4 School Check make to children assessed with behaviour issues and what aspects of the B4 School Check delivery contributed to successful outcomes for these children. Child behaviour issues were identified in more boys than girls and concentrated in more deprived families. Māori children were over-represented in relation to the regional population. The majority of referrals for child behaviour directed parents/caregivers to non-governmental organisations for family support and parenting programmes. An analysis of the interview material indicated high levels of satisfaction with the B4 School Check for behaviour and the referred outcomes

Comment: Pleasing to see that the B4SC supports Māori parents to identify and report child behavioural problems to nurses; supports care pathways for tamariki via NGOs rather than clinical care when appropriate; and that parents/caregivers were generally positive about the programme.

Reference: Nurs Prax N Z 2012;28(3):13-23

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Antenatal, labour, and delivery care for Māori: experiences, location within a lifecourse approach, and knowledge gaps

Authors: Ratima M, Crengle S

Summary: These researchers reviewed the literature on antenatal care and care during labour and delivery for Māori, as well as accounts detailing Māori experiences, with particular reference to access and knowledge gaps. They also considered the links between access to care and health outcomes for Māori babies from a life course perspective. The paper reports that many gaps exist in our knowledge of antenatal, labour and delivery care, and birth outcomes for Māori. What is known is that, compared to other women, Māori women have much greater maternity care needs and that also, inequalities in birth outcomes between Māori and non-Māori persist. This review highlights the need to better understand the extent, causes of, and how to address ethnic inequalities in receipt of antenatal, labour, and delivery care. The reviewers go on to advise that research is also required to understand the causes of inequalities in birth outcomes for Māori, and what constitutes optimal antenatal care for Māori from a life course perspective.

Comment: Great follow-up to a couple of internationally-based papers in the previous issue of Māori Health Research Review on the acute and long-term impacts of antenatal and birth care. Here we see the issues for Māori mama, pepi and whānau.

Reference: Pimatisiwin: a journal of Aboriginal and Indigenous community health 2013;10(3):353-66

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Patient perceptions of barriers to the early diagnosis of lung cancer and advice for health service improvement

Authors: Walton L et al

Summary: This qualitative research project explored New Zealand service users’ experiences of the pathway to lung cancer diagnosis, in an attempt to identify factors contributing to delay and provide advice for service improvement. Two patient cohorts were involved: 19 patients who presented to a hospital emergency department with suspicious symptoms were interviewed individually; another 20 with confirmed lung cancer took part in a focus group. Patient delay was common, but most had seen a GP before referral. While none of the emergency department participants had seen a respiratory specialist prior to admission, most had a seamless pathway after admission, whereas long waits were common among outpatient participants. Two central themes, ‘access to health services’ and ‘processes of care’, described factors influencing delay. Issues relating to symptom interpretation, health beliefs, provider continuity, relationships and perceived expertise contributed to patient and GP delay. Barriers at the primary–secondary care interface and within secondary care included system complexity, information systems and resourcing issues. The study researchers recommend the following solutions: include community initiatives to educate and resource at-risk patients to seek help; support and resource primary care to increase timely referral and implement strategies to reduce system complexity for GPs and patients; and the employment of care coordinators.

Comment: I was fortunate to be a member of the Equity Team for this research project. Many of the findings from this research are being incorporated into cancer care pathways of the DHB regions where the study took place.

Reference: Fam Pract 2013 Feb 1. [Epub ahead of print]

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www.maorihealthreview.co.nz a Research Review Publication

From Great to Good; how a leading New Zealand DHB lost its ability to focus on equity during a period of economic constraint

Authors: Matheson D

Summary: This report is a review of the Capital and Coast District Health Board (C&CDHB) decision-making processes and frameworks around primary health care and health equity between 2009 and 2012, based on the release of relevant papers requested under the Official Information Act. The review describes a lack of control by the Board over decentralised functions such as primary health care, as well as its losing battle to maintain equity as a high-level goal in the face of operational decisions inconsistent with this goal, as the Board attempts to live within a period of economic restraint. The Board is embarking on a new strategy, Integrated Care Collaboratives, in an attempt to reverse the current trends of increased hospital admissions and decreased support for the primary care sector. However, “this approach will struggle while the national signals remain tightly focused on the hospital sector, and whole system performance and complexity is not seriously considered in the way the system is led”, concludes the review.

Comment: Although this report was commissioned by stakeholders and may be seen as having particular bias, the author provides clear evidence on the need to have ‘equity’ as a driver for health planning and funding decisions. I was particularly interested in the statement that “New Zealand does not have an equitable health system, despite its policy framework. A recent Treasury report 1 shows an upper middle class household receives on average almost $11,000 of health services a year, whereas the households with the lowest income receive on average $6,000 of health services – despite their greater need.” 1. Treasury. Budget 2012 Information Release Release Document June 2012. In: Treasury T, editor.; 2012

Reference: Wellington: Centre for Public Health Research. 2013.

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Ngāti and healthy: translating diabetes prevention evidence into community action

Authors: Tipene-Leach DC et al

Summary: This paper describes the planning and design of an intervention intended to translate clinical trial evidence on the prevention of type 2 diabetes mellitus into a community-wide population health intervention in a high-risk predominantly Māori community. Key steps comprised consulting with communities, validating community concerns and prioritising cultural and ethical issues. An important finding was that time spent developing good relationships amongst the health provider and academic research team members at the outset proved invaluable, as the team was united in addressing the project planning and implementation challenges, such as funding obstacles that arose because of the intervention’s ethically and culturally appropriate non-randomised control trial evaluation design. The authors conclude that while community-wide lifestyle interventions have the potential to reduce rates of type 2 diabetes and other chronic diseases in high-risk communities, such initiatives require a high level of commitment from the health sector and buy-in from the community. Finally, they stress that adequate commitment, leadership, planning and resources are essential.

Comment: Great to read this paper which updates what was an innovative and iwi-led programme.

Reference: Ethn Health 2013 Jan 29. [Epub ahead of print]

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Ethnicity and risk of Caesarean section in a term, nulliparous New Zealand obstetric cohort

Authors: Anderson NH et al

Summary: These researchers examined ethnicity as an independent risk factor for elective and emergency Caesarean section in nulliparous women at term, in this retrospective analysis of maternity data comprising 11,848 singleton, nulliparous, term births at National Women’s Health, Auckland, from 2006 to 2009. The overall Caesarean section rate was 31.2% (elective 7.8%, n=923 and emergency 23.4%, n=2770). In multivariable logistic regression analysis, comparisons with European women revealed a lower likelihood of elective Caesarean section among Pacific and Chinese women (adjusted odds ratios of 0.42 and 0.68, respectively) and a higher likelihood of emergency Caesarean section among Indian women (aOR 1.54). Rates of elective or emergency Caesarean section for other ethnicities were similar to rates in Europeans.

Comment: I’d also be interested to see the outcomes associated with ‘equal rates’ of this particular intervention. Many have raised concerns that the higher perinatal and maternal mortality rates for Māori compared with non-Māori may be associated with an inadequate number or quality of surgical intervention.

Reference: Aust N Z J Obstet Gynaecol 2013 Jan 24. [Epub ahead of print]

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