ISSN ISSN 1178-6191

Maori Health Review

Making Education Easy Issue 79 - 2019

Maori Health Review

Upholding Te Tiriti, ending institutional racism and Crown inaction on health equity

Authors: Came H et al.

Summary: This article acknowledges the institutional racism that pervades the New Zealand health system and proposes ways in which this problem can be effectively addressed and eradicated. The authors emphasise that institutional racism is a key determinant of health inequalities. They appeal to the Crown, which has the power to uphold the responsibilities of te Tiriti o Waitangi within the health sector and they call for the government to take action to end racism in New Zealand’s health system. This action can be undertaken in the form of planned, systems-based approaches, such as those that are currently being applied to child poverty and gender pay inequity. The authors believe that such action will end institutional racism against Māori and contribute to health equity.

Comment: It is wonderful to see that ‘equity’ is a priority in Aotearoa’s health strategies, and the re-establishment of the Māori Health Directorate within the Ministry. However, further action is required, as these authors suggest. A couple of great resources that may be of interest to readers working in this area include a critique of our government’s performance in racial discrimination reported by a UN Committee in 2017 and an overview of the evidence linking the primary domains of racism – structural racism, cultural racism, and individual-level discrimination – to mental and physical health outcomes.

Reference: N Z Med J 2019;132(1492):61-6


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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.

The health of older New Zealanders in relation to housing tenure: analysis of pooled data from three consecutive, annual New Zealand Health Surveys

Authors: Pledger M et al.

Summary: These researchers pooled data from a total of 15,626 older adults (aged ≥55 years) who participated in the 2013/14, 2014/15 and 2015/16 rounds of the New Zealand Health Survey (NZHS), for this investigation into relationships between the housing tenure of this cohort and their health-related behaviours, physical and mental health. The study researchers compared owner-occupiers, private renters and public renters. The majority of the study sample were owner-occupiers (83.2%); private and public renters comprised 12.4% and 4.5% of the study sample, respectively. Compared with owner-occupiers, renters were more likely to be living alone and living on lower annual incomes. Moreover, the study researchers identified a health gradient for overall measures of physical and mental health, with public renters in the poorest health and owner-occupiers in the best health. Rates of renting were higher amongst females aged ≥75 years, Māori and Pacific people. The paper points out that these groups are particularly vulnerable to any negative impact of renting on health. It also notes that over time, the proportion of older renters has been increasing, which will have important implications for future health and housing policy.

Comment: Possible reasons for these findings include unstable tenure, with a high turnover of rentals in Aotearoa compared with other nations, and limited ability to make changes for health reasons (such as ramp installation, adequate heating/cooling, which are more likely to impact on independence and wellbeing as we age). Māori are also more likely to experience racism when looking for housing, creating further disadvantage when renting.

Reference: Aust N Z J Public Health 2019;43(2):182-9


Efficacy of an incentive intervention on secondary prophylaxis for young people with rheumatic fever: a multiple baseline study

Authors: Oetzel JG et al.

Summary: This investigation used a multiple baseline design that followed the 77 participants (aged 14–21 years) with RF for a period of 15 months (3 months prior to intervention and 12 months afterwards). The study researchers sought to determine whether an incentive programme consisting of a mobile phone and monthly “top-up” (for data/calls) increased the number of secondary prophylaxis injections, increased texts/calls with nurses, reduced the number of visits to get a successful injection, less medicine wasted, and increased nurse satisfaction, compared to the baseline period prior to the intervention. All study participants were enrolled in an acute RF registry in the Waikato region and were classified by the number of injections at baseline as either fully adherent (all injections received and ≤1 late) or partially adherent. Following the intervention, injections were markedly increased and slightly decreased over time in the partially adherent cohort (p=0.003), while those classified as fully adherent maintained their high rate of injections. There was a similar pattern for satisfaction among the district nurses, who expressed higher rates of satisfaction with fully adherent patients than with those in the partially adherent cohort and, while nurses’ satisfaction for fully adherent patients fell slightly over time, satisfaction with partially adherent patients increased sharply post-intervention and then fell slightly over time (p=0.001). There was a significant increase throughout the intervention in the number of calls/texts placed by nurses to the partially adherent patients (p=0.003). The number of visits made by nurses fell over time with partially adherent patients and increased over time with fully adherent patients (p=0.012). The overall incremental cost-effectiveness for the 12-month study period was $NZ989 per extra successful injection.

Comment: Great to see a health delivery intervention being tested. The importance of supporting a good relationship between the clinical team and patient/whānau is also highlighted here.

Reference: BMC Public Health 2019;19:385


Maori Health Review

How universal are universal preschool health checks? An observational study using routine data from New Zealand’s B4 School Check

Authors: Gibb S et al.

Summary: These researchers analysed data from 252,273 New Zealand children who completed a B4 School Check over 4 years, from 1 July 2011 to 30 June 2015. The study aimed to determine characteristics associated with non-participation in this universal preschool health screen. The study grouped the B4 School Check into 3 components: vision and hearing test (VHT) checks; nurse checks (height, weight, oral health, Strengths and Difficulties Questionnaire [SDQ] and parental evaluation of development status); and SDQ-Teacher check. Participation rates varied for each component of the B4 School Check (in 2014/2015, completion was highest at 91.8% for vision and hearing tests, followed by 87.2% for nurse checks and 62.1% for the SDQ-T), although participation rates for all components increased over time. The checks were less likely to be completed by Māori and Pacific children than by non-Māori and non-Pacific children (for VHTs: Māori: OR 0.60; 95% CI, 0.61 to 0.58; Pacific: 0.58; 0.60 to 0.56; for nurse checks: Māori: 0.63; 0.64 to 0.61; Pacific: 0.67; 0.69 to 0.65; and for SDQ-T: Māori: OR 0.76; 0.78 to 0.75; Pacific: 0.37; 0.38 to 0.36). Other characteristics that predicted a lower likelihood of participation in the B4 School Check included living in socioeconomically deprived areas, having younger mothers, living in rented homes and in larger households, having worse health status and living with higher rates of residential mobility, compared with children who completed the B4 School Check.

Comment: I agree with the authors in the respect that screening is an important part of the pathway from diagnosis to management to better outcomes, and that strategies to support health services to engage whanau in B4SCs is required. However, I’d also like to see a review of those two steps beyond ‘diagnosis’, i.e. appropriate referral to investigate and manage issues. Anecdotally, parents tell me that their concerns were often raised before or at the B4SC, but not actioned until much later.

Reference: BMJ Open 2019;9:e025535


Acceptability of self-taken vaginal HPV sample for cervical screening among an under-screened Indigenous population

Authors: Adcock A et al.

Summary: These researchers used Kaupapa Māori (by Māori, for Māori) mixed methodology, involving hui (focus groups/interviews) and a survey, to assess the potential acceptability of HPV self-testing for never/ under-screened (self-reported no cervical screen in ≥4 years) among Māori women aged ≥25 years living in 4 regions throughout New Zealand. Community-based researchers ran hui with 106 women and the survey was completed by 397 women. Seventeen healthcare providers (HCPs) were interviewed. Although the majority (87.15%) of survey participants were enrolled with a primary health organisation (PHO) and 71.9% attended regularly, they did not attend regular cervical screening. The most frequently cited barrier to screening was a desire for bodily autonomy (retaining privacy, control over one’s body), including whakamā (embarrassment/ shyness/reticence). Around 75% of the survey participants reported being likely/very likely to do an HPV selftest and 90% indicated that they would be likely/very likely to attend follow-up if they receive a positive HPV test result. Women and HCPs in the hui emphasised the need for health literacy, cultural competence and empathetic support.

Comment: I’ve nothing more to say except please sign my clinic up!

Reference: Aust N Z J Obstet Gynaecol 2019;59(2):301-7


An affront to her Mana: young Māori mothers’ experiences of intimate partner violence

Authors: Dhunna S et al.

Summary: This Kaupapa Māori (by Māori, for Māori) investigation used a thematic and interpretive phenomenological analysis to explore and understand the lived realities of 6 young Māori mothers (aged 14–19 years) who have experienced intimate partner violence (IPV) and to examine the extent to which service responsiveness has been culturally safe. These mothers were participating in the E Hine longitudinal maternal healthcare study and consented to narrative interviews for this research. Their stories revealed ways in which young Māori women resist violence, reclaim their Māori identities, and experience personal transformation during their motherhood journeys despite abuse. The stories also showed that whānau (extended family) can both perpetuate violence and be extremely protective. The analysis demonstrated that structural and institutional barriers prevent culturally safe service responsiveness for young Māori women. For example, they described racism at the frontlines of government agencies and pervasive victim-blaming. The researchers identified a lack of earnest decolonial structural change at the institutional level.

Comment: A really difficult and challenging issue to confront or address in a manaenhancing way. I read this and found that the womens’ narratives were presented in ways that were sensitive and strong, sad yet uplifting. Nga mihi nui to Dr Fiona Cram, one of the authors recently recognised in the NZ Honours list.

Reference: Interpers Violence 2018 December 17. [Epub ahead of print]


Maori Health Review

Noho Taiao: reclaiming Māori science with young people

Authors: Moewaka BH et al.

Summary: This article explores the educational and health promotion effects of Te Rārawa Noho Taiao projects, which have been operating in the Far North of New Zealand for almost a decade. These projects are designed to provide young Māori with place-based learning approaches that use Indigenous pedagogy, promoting Māori science, science leadership and learning, helping the students connect with and access positive relationships with customary environments. As this article describes, these projects are producing a range of benefits in health and well-being. Analyses of data from interviews with organisers and teachers of Noho Taiao, as well as a survey of student participants, reveal that the students in these projects are increasingly engaged with education, becoming more capable, increasing their sense of participation/belonging, establishing stronger relationships, and engaging in constructive peer processes and positive intergenerational interactions, all within Māori values and praxis. As the article notes, health-promoting frameworks recognise the importance of engaging with knowledge, science and understandings of the natural world, for creating and maintaining health and well-being among individuals, communities and populations.

Comment: What a fantastic programme! And wonderful to see the wider benefits of it including the promotion of Mātauranga Māori and Hauora Māori for Rangatahi in Te Tai Tokerau.

Reference: Glob Health Promot 2019;26(3_suppl):35-43


The role of Māori community gardens in health promotion: a land-based community development response by Tangata Whenua, people of their land

Authors: Hond R et al.

Summary: This research explored the motivations for developing Māori community gardens (māra) and their role in Māori health promotion. Using a Kaupapa methodology (by Māori, for Māori), the researchers conducted interviews with 7 leaders of māra initiatives and analysed the data for key themes. The transcripts revealed that these people are motivated to develop māra as a means of empowering Māori collectives towards a vision of vital communities thriving as Māori. In particular, using ancestral lands for māra encourages people to feel inspired by a deep sense of shared cultural identity with those lands and to develop intergenerational links. The interviews described how the activities involved with māra link people with ancestral knowledge, customary practices and tribal connection. As land-centred community development initiatives, māra provide opportunities to practice Māori language and cultural processes within daily life, and thus help people to feel more committed to protecting cultural heritage as a resource for community life. The article notes that the underlying characteristic of māra, hands-on collective activity with shared decision-making, fosters social cohesion and collective efficacy. Such activity fits within the parameters of Māori health promotion and can help to achieve Māori health promotion outcomes.

Comment: Another fabulous piece of kaupapa Māori research demonstrating the potential depth and breadth of impact for Māori traditional practices. Importantly, the authors describe those key elements that made it work!

Reference: Glob Health Promot 2019;26(3_suppl): 44-53


Climate change and Indigenous health promotion

Authors: Jones R

Summary: Around the world, Indigenous peoples face enormous challenges to their health and well-being as a result of climate change. While they live in diverse contexts, they are subject to conditions that disproportionately increase their vulnerability to climate change and barriers to adaptation. These barriers include their unique relationships with the natural environment, socioeconomic deprivation, a greater existing burden of disease, poorer access to resources to respond, poorer quality of health care, as well as social and political marginalisation. Moreover, the rights of Indigenous peoples are threatened by responses to climate change at global, national, and local levels. This article notes that while climate action presents many opportunities to improve health and reduce inequities, climate mitigation and adaptation policies pose a significant risk for inflicting harm on Indigenous peoples by exacerbating inequities and eroding their rights still further. This article examines how Indigenous health is interwoven with climate change and seeks to identify Indigenous health promotion solutions that will ensure equitable responses to climate change. The author adopts a Kaupapa Māori positioning in this analysis of health impacts of climate change, and critiques Western knowledges and structures that undermine Indigenous rights and development. The article explains that the broader context of colonial oppression, marginalisation and dispossession must be examined before we can understand and address climate-related health impacts for Indigenous peoples. It argues that health promotion must engage in a process of decolonisation by deconstructing its own systems and practices to avoid reinforcing colonialism and perpetuating inequities. Health promotion has to support Indigenous selfdetermination and allow Indigenous knowledges to provide solutions for climate change and health.

Comment: Okay, so he’s an old classmate of mine and works three offices down from me, but despite these flaws, Rhys is a great writer and advocate for our environment. He’s also pretty sharp on Twitter too – check it out here:

Reference: Glob Health Promot 2019;26(3_suppl): 73-81


Trends in myeloma incidence, mortality and survival in New Zealand (1985–2016)

Authors: Sneyd MJ et al.

Summary: This analysis included all new registrations of and deaths from myeloma recorded by the Ministry of Health, New Zealand, between 1985 and 2016. A total of 7,826 New Zealanders were registered with myeloma during the study period. Since 1985, the incidence of myeloma has significantly increased since 1985; the age-specific incidence of myeloma increased significantly for men. The incidence of myeloma is higher among Māori and in non-Māori, and higher in men than in women. Overall mortality rates have fallen since the late 1990s. Throughout the study period, mortality rates were uniformly higher among men compared with women. Mortality has fallen since 1995–1999 for women, and since about 2000–2004 for men. Myeloma mortality was highest in Māori men. While survival has improved significantly since 1990, the risk of death remains higher among Māori than among non-Maori.

Comment: Having lost a whānau member to myeloma last year – haere, haere, haere atu ra e te rangatira e Quyen – this is a health issue close to my heart. A similar pattern to that of other cancers – higher incidence, poor survival rates – so further research is recommended.

Reference: Cancer Epidemiol 2019;60:55-9