ISSN ISSN 1178-6191

Maori Health Review

Making Education Easy Issue 80 - 2019

Maori Health Review

Insiders’ insight: discrimination against Indigenous peoples through the eyes of health care professionals

Authors: Wylie L, McConkey S

Summary: This Canadian investigation invited healthcare providers and decisionmakers to identify any challenges that they see facing Indigenous patients and families when accessing health services in a large city in southern Ontario. The respondents identified widespread discrimination against Indigenous people as a major challenge for the healthcare system. Analyses of the interview data highlighted 3 key discrimination subthemes: (1) an unwelcoming environment; (2) stereotyping and stigma and; (3) practice informed by racism. The study researchers state that these findings highlight the importance of going beyond simply making health services more welcoming and inclusive, if healthcare access is to be meaningfully improved for Indigenous peoples. Moreover, they note that practice norms shaped by biases informed by discrimination against Indigenous people are widespread and compromise standards of care. The researchers call for a quality improvement strategy designed to address the problem throughout the healthcare system. As they note, addressing the problem in this way will require not only a significant shift in the attitudes, knowledge, and skills of healthcare providers, but also, healthcare organisations will need to establish accountabilities to ensure equitable health services for Indigenous peoples.

Comment: Please read the whole paper, especially the quotes from health professional participants, who were forthright, open and challenging.

Reference: J Racial Ethn Health Disparities 2019;6(1):37-45


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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.

Factors across life associated with remaining free from functional limitations despite lifelong exposure to socioeconomic adversity

Authors: Kok AAL et al.

Summary: These researchers sought to determine which specific factors across life may protect some older-aged individuals from developing functional limitations despite exposure to socioeconomic adversity. The study analysed data from 1,973 participants in the UK Medical Research Council National Survey of Health and Development, followed from birth until age 60–64 years. Functional limitations were defined as reporting difficulty with ≥1 of 16 activities at age 60–64 years. Lifetime socioeconomic adversity was based on socioeconomic trajectories, categorised into 3 adversity levels (low, intermediate and high). Functional limitations in the low, intermediate and high adversity groups affected 23%, 30% and 44% of men, respectively, and 49%, 55% and 61% of women, respectively. A ‘Resilient’ group was identified that consisted of 196 participants, all of whom had a high level of adversity but no functional limitations. Analyses compared psychosocial factors and health-related behaviours between the ‘Resilient’ group and 5 groups with other combinations of adversity and limitations. Compared with the ‘Resilient’ group, people with high adversity/ limitations were more likely to have childhood illness (19% vs 12%) and to be obese between the ages of 43 and 64 years (70% vs 55%). Other factors that were also associated with resilience included higher adolescent selfmanagement, lower neuroticism, engaging in volunteer work and physical activity (age 60–64 years) and not smoking. There was no evidence that marital status and contact frequency were associated with resilience.

Comment: I think we all agree that the prevention of childhood adversity is paramount. However, there are a couple of key points here. As clinicians, we must do what we can to prevent/manage childhood illness (immunisations, best practice) and support children into physical activity. As citizens, we need to acknowledge the cumulative impacts of stigma associated with chronic illness, obesity, poverty and adversity.

Reference: J Epidemiol Community Health 2019;73(6):529-36


Maori Health Review

Relationship between socioeconomic factors, distribution of public access defibrillators and incidence of out-of-hospital cardiac arrest

Authors: Dicker B et al.

Summary: These researchers sought to determine whether relationships exist between socioeconomic factors, geospatial distribution of public access defibrillators (PADs) and incidence of out-of-hospital cardiac arrest (OHCA) within New Zealand. The analyses revealed that cardiac arrest incidence increases with increasing sociodemographic deprivation. Between 1 October 2013 and 30 June 2016, the incidence of OHCA events per 100,000 person-years in the most deprived areas of the NZDep2013 decile was double that of the least deprived areas (156.5 vs 78.0). Analyses of the 2013 Census data revealed that for every 1% increase in the proportion of Māori within a specific census area unit (CAU), the OHCA rate increased significantly by 1.0% (p=0.001); similarly, OHCA rates within a CAU increased significantly with each 1% increase in the proportion of Pacific Peoples (an increase of 0.6%; p=0.005), over 65-year-olds (3.7%; p<0.001) and males (3.7%; p<0.001). An analysis of data obtained from a registry containing all registered PAD locations throughout New Zealand in 2018 revealed that NZDep decile 10 areas had the lowest coverage of PADs compared with less deprived areas (a median 81% of these areas contained PADs vs 65% of NZDep decile 10 areas).

Comment: The findings are consistent with institutionalised or systematic “processes, attitudes and behavior which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping” (see The Stephen Lawrence Inquiry). People are dying as a result. Please check on the availability of PADs in your communities. For example, there has been a push to have them at marae in Te Tai Tokerau, with St John staff providing the training.

Reference: Resuscitation 2019;138:53-8


Did New Zealand’s new alcohol legislation achieve its object of facilitating public input? Qualitative study of Māori communities

Authors: Kypri K et al.

Summary: The introduction of alcohol legislation in 2012 by the New Zealand government was proclaimed as being designed to facilitate community input on decisions concerning alcohol. These researchers investigated the experience of Māori communities with the new law, by obtaining submissions made to local governments and submitters from iwi (tribes), hapū (sub-tribes/clan groups) and Māori service providers who were invited to participate in semi-structured interviews with Māori researchers. Analyses of the interview transcripts revealed that the respondents had invested heavily in human resources to write submissions informed by technical knowledge of liquor licensing and relevant research. In their experience, local governments had not meaningfully engaged with the content of their submissions, and on multiple occasions had not updated participants on how the consultation was progressing. In the opinion of some respondents, the fact that the alcohol industry had easier access to local politicians was likely to mean that outcomes would reflect industry interests.

Comment: Disappointing, but perhaps not surprising.

Reference: Drug Alcohol Rev 2019;38(4):331-8


The impact of the introduction of a point-ofcare haematology analyser in a New Zealand rural hospital with no onsite laboratory

Authors: Blattner K et al.

Summary: This evaluation assessed the impact of introducing point-ofcare (POC) haematology testing in Hokianga Hospital, a small rural hospital in the far north of New Zealand serving a predominantly Māori population of 6,500 people. POC biochemistry has been available at the hospital since 2010, but it lacks an onsite laboratory. This 3-part investigation was conducted at Hokianga Hospital over 4 months in 2016. In Part 1, hospital doctors completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. In Part 2, focus group interviews were conducted with hospital doctors, nurses and a cultural advisor. Part 3 of the study involved an analysis of cost versus tangible benefits. Analysis of the 97 POC haematology tests (97% were performed during the acute clinical presentation; 72% were performed out of hours) revealed a significant reduction in the average number of differential diagnoses, from 2.43 pre-testing to 1.7 post-testing (p<0.05). Haematology POC testing was also associated with significant reductions in the number of patients transferred and significantly increased the number of patients discharged home (both p<0.05). Analyses of the interview transcripts revealed 3 key themes: impact on patient management, challenges, and the commitment to ‘make it work’. POC haematology positively impacted patient management and clinician confidence, mainly by increasing diagnostic certainty. Respondents cited challenges surrounding the testing as issues relating to the hidden costs of implementing the analyser and its associated quality assurance programme in a remote-from-laboratory setting. A cost– benefit analysis demonstrated savings in healthcare costs.

Comment: Useful for those of you considering, or arguing for, POC in your areas.

Reference: Rural Remote Health 2019;19(2):4934


Maori Health Review

Evolving threat of community acquired methicillin resistant Staphylococcus aureus upper extremity infections in the South Pacific: 2011–2015

Authors: Abeysekera N et al.

Summary: This analysis examined data from 1,252 patients with upper extremity infections requiring operative management between 2011 and 2015 at the Auckland Regional Hand Unit; culture-positive communityacquired methicillin-resistant Staphylococcus aureus (CA-MRSA) upper extremity infections were identified in 150 (12%) patients. An increasing annual trend was observed. Notably, in 2014 and 2015, CA-MRSA rates in Māori and Pacific Islander populations exceeded 15%, satisfying the US Center for Disease Control (CDC) threshold for empiric antimicrobial cover.

Comment: I think more work needs to be done in this area. Our clinic is seeing higher than anticipated numbers of children and adults with MRSA. A small audit showed that at least half had been treated in hospital only, that is, they had not been seen in primary care. As the authors suggest, a review against best practice is warranted.

Reference: J Hand Surg Asian Pac 2019;24(2):129-37


Factors supporting retention of Aboriginal Health and Wellbeing staff in Aboriginal health services: a comprehensive review of the literature

Authors: Deroy S, Schütze H

Summary: This Australian research identified 26 English-language papers published between 2002 and 2017 that focused on retention of Aboriginal Health and Wellbeing staff, or health staff in comparable roles working in Aboriginal health services. The work of Aboriginal Health and Wellbeing staff is essential for successful primary healthcare for Aboriginal communities, but is often compromised by high rates of stress, burnout, and staff turnover, impacting on primary healthcare delivery to Aboriginal peoples. This investigation explored organisational factors that help support the retention of Aboriginal Health and Wellbeing staff in Aboriginal Health services. Five key themes were found to contribute to the retention of Aboriginal Health and Wellbeing staff in Aboriginal Health Services: (1) feeling culturally safe and secure within the workplace; (2) teamwork and collaboration; (3) supervision (internal or external supervision with a counsellor outside the organisation), with strong managerial leadership and support from peers (to debrief, reflect, receive emotional support and strengthen coping mechanisms); (4) professional development (the opportunity for skill development and role progression), and; (5) recognition (of work load, quality of work performed, being trusted to work autonomously, with financial remuneration reflecting the high pressure of the role).

Comment: Being well aware of the issues recruiting and retaining Māori and Pacific staff at clinics serving Māori and Pacific communities, I thought this paper provided an excellent review of the potential solutions. I was particularly interested in two points made by the authors to reduce turnover – formal peer support (as staff/management may think that informal is enough) and recognition (both fiscal and other forms of ‘sponsorship’).

Reference: Int J Equity Health 2019;18:70


Bringing a health equity perspective to the prevention of child abuse and neglect

Authors: Klevens J, Metzler M

Summary: These researchers contend that it is possible to reduce persistent inequities in risk for child abuse and neglect (CAN) by using a health equity perspective, giving all children the opportunity to reach their full health and life potential. The chapter describes how the World Health Organization’s Commission on the Social Determinants of Health framework supports this goal. The researchers use the framework to explore possible mechanisms and pathways that contribute to current inequities in risk for CAN, within their US-based experience. They then discuss how this framework has been used to guide and monitor activities in the Centers for Disease Control and Prevention’s Essentials for Childhood Initiative. The chapter concludes with suggestions as to how this work can successfully prevent child abuse and neglect, and other childhood adversities by assuring safe, stable, nurturing environments for all children and families.

Comment: I recently attended the hui for the Māori Inquiry into Oranga Tamariki and was asked by a reporter why health professionals had been invited. I recalled this paper, which is just one chapter of a book called Re-visioning public health approaches for protecting children. The entire book is excellent, but I found this chapter a useful reminder for clinicians on why and how we are part of the problem, and the solution. It is not Kaupapa Māori, but I think much of it aligns with the recommendations John Rangihau and others made some 30+ years ago (https://www. publications-resources/archive/1988- puaoteatatu.pdf).

Reference: In Lonne, B., Scott, D., Higgins, D., & Herrenkohl, T. (Eds.) Re-visioning public health approaches for protecting children. Springer, 2019: pp. 197-220.