The Right to Equal Health: Best Practice Priorities for Māori with Bipolar Disorder from Staff Focus Groups

Bipolar disorder (BD) is a serious mental health condition that is clinically complex to monitor and manage. While best practice guidelines exist, they vary internationally lacking consensus. Indigenous peoples, including Māori in New Zealand, experience higher community rates of BD. While New Zealand practice guidelines recommend providing culturally responsive care to Māori, studies show that Māori do not receive best practice. This qualitative study aimed to share the evidence about patterns of health service use and Māori patient experiences with focus group participants involved in the design and delivery of BD services, to discuss and develop guidelines for best practice for Māori with BD and address areas of unmet need. Three focus groups were conducted with 22 participants involved in the delivery of services to Māori with BD across three sites. Willing participants were sent background information and three focus group questions framed to elicit priority solutions to improve clinical, structural and organisational features of mental health service delivery for Māori patients with BD and their whānau (family). The nominal group technique was used to synthesise responses, and then develop a prioritised list of proposed solutions. Results identified system-level changes required at the clinical, structural and organisational levels of healthcare. Findings further evidence the need for healthcare reform in New Zealand, to be responsive to Māori with BD.

'E koekoe te Tūī, e ketekete te Kākā, e kuku te Kererū, The Tūī chatters, the Kākā cackles, and the Kererū coos': Insights into explanatory factors, treatment experiences and recovery for Māori with eating disorders - A qualitative study

BACKGROUND

Eating disorders are as common in Māori, the Indigenous people of Aotearoa-New Zealand, as they are in non-Māori; however, research has focused on the experiences of non-Māori. This paper will describe explanatory factors, treatment experiences and what helps with recovery for Māori.

METHODS

Kaupapa Māori research methodology informed the methods and analysis. Fifteen semi-structured interviews comprised thirteen Māori participants with eating disorders (anorexia nervosa, bulimia nervosa and binge eating disorder) and two whānau (support network) members. A thematic analysis was undertaken by a first cycle of coding that used deductive structural coding to identify data describing participants' perceived causes of eating disorders, their experience of treatment and recovery. A second cycle of coding used inductive analysis with descriptive and pattern coding.

RESULTS

Three overarching themes were antecedents (cumulative exposure), treatment (a system of complexities) and recovery (resource empowerment). Antecedents comprised cumulative exposure to body and sporting ideals and adversity as causal factors of eating disorders. In the treatment theme, a system of complexities critiqued rural settings for generalised mental health services, allocation of Māori cultural support, the economic burden of treatment, culturally incongruent treatment (methods, values) and a weight-focused discharge criterion. Recovery (resource empowerment) found appropriate health information, self-determination and connection to Māori culture and whānau aspirations helped with recovery.

CONCLUSION

The diversity of birdcalls reminds us of the individuality of eating disorders. Health practitioners are reminded that just as the Tūī, Kākā and Kererū possess their own unique birdcalls, so do Māori with eating disorders and their whānau have their own experiences, needs and required treatment responses.

It's not special treatment… That's part of the Treaty of Waitangi! Organisational barriers to enhancing the Aged Residential Care environment for older Māori and Whānau in New Zealand

BACKGROUND

New Zealand's older Indigenous Māori people experience poorer health and reduced access to healthcare than their older non-Māori counterparts. Organisational factors (such as leadership or workforce) may influence the attitudes and perceptions of older Māori and their family (whānau) to use aged residential care services. Currently, there is a paucity of research surrounding the organisational barriers that impact the experiences of older Māori people who seek care in aged residential care (ARC) services.

METHODS

This study used a Kaupapa Māori qualitative research approach that legitimises Māori knowledge and critiques structures that subjugate Māori autonomy and control over their wellbeing. Interviews regarding their experiences of care were carried out with older Māori (n = 30) and whānau (family) members (n = 18) who had used, or declined to use an aged residential care facility. Narrative data were analysed inductively for themes that illustrated organisational barriers.

RESULTS

The key organisational theme was 'Culturally safe care', within which there were three barriers: 'Acceptability and Adequacy of Facility', 'Interface Between Aged Residential Care and Whānau Models of Care', and 'Workforce'. Collectively, these barriers emphasise the importance of an organisational approach to improving the quality of care delivered to older Māori and whānau in ARC.

CONCLUSION

Fostering a collective culture of equity within ARC provider services and equipping healthcare leaders and staff with the skills and knowledge to deliver culturally safe care is critical to addressing organisational barriers to ARC.

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

BACKGROUND

There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. Racism has been implicated as having an important role.

AIM

To use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis outcomes.

METHODS

Critical Race Theory informed the methodology used. Twenty-three Indigenous participants participated in four family focus group interviews and thirteen individual interviews, comprising of 9 Māori youth with early psychosis, 10 family members and 4 Māori mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding.

RESULTS

Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems pertaining to social responsiveness, risk discourse, and mental health service structures. This is described across three major themes: 1) selective responses based on racial stereotypes, 2) race related risk assessment bias and 3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased use of coercive practices and an under resourced Indigenous mental health workforce.

CONCLUSION

The study illustrated the inter-related nature of interpersonal, institutional and structural racism with examples of interpersonal racism in the form of negative stereotypes interacting with organizational, socio-cultural and political priorities. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Acute aortic syndrome: nationwide study of epidemiology, management, and outcomes

BACKGROUND

Epidemiological studies on acute aortic syndrome (AAS) have relied largely on unverified administrative coding, leading to wide-ranging estimates of incidence. This study aimed to evaluate the incidence, management, and outcomes of AAS in Aotearoa New Zealand.

METHODS

This was a national population-based retrospective study of patients presenting with an index admission of AAS from 2010 to 2020. Cases from the Ministry of Health National Minimum Dataset, National Mortality Collection, and the Australasian Vascular Audit were cross-verified with hospital notes. Poisson regression adjusted for sex and age was used to investigate trends over time.

RESULTS

During the study interval, 1295 patients presented to hospital with confirmed AAS, including 790 with type A (61.0 per cent) and 505 with type B (39.0 per cent) AAS. A total of 290 patients died out of hospital between 2010 and 2018. The overall incidence of aortic dissection including out-of-hospital cases was 3.13 (95 per cent c.i. 2.96 to 3.30) per 100 000 person-years, and this increased by an average of 3 (95 per cent c.i. 1 to 6) per cent per year after adjustment for age and sex adjustment on Poisson regression, driven by increasing type A cases. Age-standardized rates of disease were higher in men, and in Māori and Pacific populations. The management strategies used, and 30-day mortality rates among patients with type A (31.9 per cent) and B (9.7 per cent) disease have remained constant over time.

CONCLUSION

Mortality after AAS remains high despite advances over the past decade. The disease incidence and burden are likely to continue to increase with an ageing population. There is impetus now for further work on disease prevention and the reduction of ethnic disparities.

Informed consent for medical student involvement in patient care: an updated consensus statement

Enabling patients to consent to or decline involvement of medical students in their care is an essential aspect of ethically sound, patient-centred, mana-enhancing healthcare. It is required by Aotearoa New Zealand law and Te Kaunihera Rata o Aotearoa Medical Council of New Zealand policy. This requirement was affirmed and explored in a 2015 Consensus Statement jointly authored by the Auckland and Otago Medical Schools. Student reporting through published studies, reflective assignments and anecdotal experiences of students and teachers indicate procedures for obtaining patient consent to student involvement in care remain substandard at times. Between 2020 and 2023 senior leaders of Aotearoa New Zealand's two medical schools, and faculty involved with teaching ethics and professionalism, met to discuss these challenges and reflect on ways they could be addressed. Key stakeholders were engaged to inform proposed responses. This updated consensus statement is the result. It does not establish new standards but outlines Aotearoa New Zealand's existing cultural, ethical, legal and regulatory requirements, and considers how these may be reasonably and feasibly met using some examples.

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

There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. racism has an important role. This study aimed to use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis. Critical Race Theory informed the methods used. Twenty-three Indigenous participants participated in 4 family focus group interviews and 13 individual interviews, comprising of 9 youth, 10 family members and 4 mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding. Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems. This is described across three themes: (1) selective responses based on racial stereotypes, (2) race related risk assessment bias and (3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased coercion and an under resourced Indigenous workforce. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Interviews with Indigenous Māori with type 1 diabetes using open-source automated insulin delivery in the CREATE randomised trial

Purpose

Open-source automated insulin delivery (AID) is used by thousands of people with type 1 diabetes (T1D), but has unknown generalisability to marginalised ethnic groups. This study explored experiences of Indigenous Māori participants in the CREATE trial with use of an open-source AID system to identify enablers/barriers to health equity.

Methods

The CREATE randomised trial compared open-source AID (OpenAPS algorithm on an Android phone with a Bluetooth-connected pump) to sensor-augmented pump therapy. Kaupapa Māori Research methodology was used in this sub-study. Ten semi-structured interviews with Māori participants (5 children, 5 adults) and whānau (extended family) were completed. Interviews were recorded and transcribed, and data were analysed thematically. NVivo was used for descriptive and pattern coding.

Results

Enablers/barriers to equity aligned with four themes: access (to diabetes technologies), training/support, operation (of open-source AID), and outcomes. Participants described a sense of empowerment, and improved quality of life, wellbeing, and glycaemia. Parents felt reassured by the system’s ability to control glucose, and children were granted greater independence. Participants were able to use the open-source AID system with ease to suit whānau needs, and technical problems were manageable with healthcare professional support. All participants identified structures in the health system precluding equitable utilisation of diabetes technologies for Māori.

Conclusion

Māori experienced open-source AID positively, and aspired to use this therapy; however, structural and socio-economic barriers to equity were identified. This research proposes strength-based solutions which should be considered in the redesign of diabetes services to improve health outcomes for Māori with T1D.

Trial Registration: The CREATE trial, encompassing this qualitative sub-study, was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000034932p) on the 20^th January 2020.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01215-3.

Evolution of first episode psychosis diagnoses and health service use among young Māori and non-Māori-A New Zealand national cohort study

AIMS

The validity of diagnostic classification in early psychosis has important implications for early intervention; however, it is unknown if previously found disparities between Māori (Indigenous people of New Zealand) and non-Māori in first episode diagnoses persist over time, or how these differences impact service use.

METHODS

We used anonymized routine mental health service data and a previously established cohort of over 2400 13-25-year-old youth diagnosed with FEP between 2009 and 2012, to explore differences in diagnostic stability of psychosis diagnoses, comorbid (non-psychosis) diagnoses, and mental health service contacts between Māori and non-Māori in the five-year period following diagnosis.

RESULTS

Differences in schizophrenia and affective psychosis diagnoses between Māori and non-Māori were maintained in the five-year period, with Māori being more likely to be diagnosed with schizophrenia (51% vs. 35%), and non-Māori with bipolar disorder (28% vs. 18%). Stability of diagnosis was similar (schizophrenia 75% Māori vs. 67% non-Maori; bipolar disorder 55% Māori vs. 48% non-Māori) and those with no stable diagnosis at FEP were most likely to move towards a schizophrenia disorder diagnosis in both groups. Māori had a lower rate of diagnosed co-morbid affective and anxiety symptoms and higher rates of continued face to face contact and inpatient admission across all diagnoses.

CONCLUSIONS

Indigenous differences in schizophrenia and affective psychosis diagnoses could be related to differential exposure to socio-environmental risk or assessor bias. The lower rate of co-morbid affective and anxiety disorders indicates a potential under-appreciation of affective symptoms in Māori youth with first episode psychosis.

Reimagining eating disorder spaces: a qualitative study exploring Māori experiences of accessing treatment for eating disorders in Aotearoa New Zealand

BACKGROUND

Health, illness, and the body are conceptualized within the cultural context of a society. The values and belief systems of a society, including media portrayals, shape how health and illness present. Traditionally, Western portrayals of eating disorders have been prioritized over and above Indigenous realities. This paper explores the lived experiences of Māori with eating disorders and their whānau (family/support system) to identify the enablers and barriers to accessing specialist services for eating disorders in New Zealand.

METHOD

Kaupapa Māori research methodology was used to ensure the research supported Māori health advancement. Fifteen semi-structured interviews were completed with Māori participants including; those with an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, and binge eating disorder), and/or their whānau. Structural, descriptive, and pattern coding was undertaken within the thematic analysis. Low's spatializing culture framework was used to interpret the findings.

RESULTS

Two overarching themes identified systemic and social barriers to accessing treatment for Māori with eating disorders. The first theme, was space, that described the material culture within eating disorder settings. This theme critiqued eating disorder services, including idiosyncratic use of assessment methods, inaccessible service locations, and the limited number of beds available in specialist mental health services. The second theme, place, referred to the meaning given to social interactions created within space. Participants critiqued the privileging of non-Māori experiences, and how this makes a place and space of exclusion for Māori and their whānau in eating disorder services in New Zealand. Other barriers included shame and stigma, while enablers included family support and self-advocacy.

CONCLUSION

More education is needed for those working in the space of primary health settings about the diversity of those with eating disorders to enable them to look beyond the stereotype of what an eating disorder looks like, and to take seriously the concerns of whaiora and whānau who present with disordered eating concerns. There is also a need for thorough assessment and early referral for eating disorder treatment to ensure the benefits of early intervention are enabled for Māori. Attention given to these findings will ensure a place for Māori in specialist eating disorder services in New Zealand.

'It absolutely needs to move out of that structure': Māori with bipolar disorder identify structural barriers and propose solutions to reform the New Zealand mental health system

OBJECTIVES

This paper synthesises critique from Māori patients with Bipolar Disorder (BD) and their whānau to identify barriers and propose changes to improve the structure and function of the New Zealand mental health system.

DESIGN

A qualitative Kaupapa Māori Research methodology was used. Twenty-four semi-structured interviews were completed with Māori patients with BD and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data.

RESULTS

Three key themes identified the impact of structural features of the New Zealand mental health system on health equity for Māori with BD. Themes involved the accessibility, delivery and scope of the current health system, and described how structural features influenced the quality, utility and availability of BD services for Māori patients and whānau. Structural barriers in the existing design, and potential changes to improve the accessibility, delivery and scope of BD services for Māori, were proposed including a redesign of operational, environmental, staffing, and navigation points (information, transition, fatigue) to better meet the needs of Māori with BD.

CONCLUSION

A commitment to equity when implementing structural change is needed, including ongoing evaluation and refinement. This paper provides specific recommendations that should be considered in health service redesign to ensure the New Zealand mental health system meets the needs of Māori patients with BD and their whānau.

Dying in hospital-staff perceptions on providing quality care

AIM

To understand what healthcare staff perceive contributes to the quality of patient and family/whānau experiences of dying and death on a hospital inpatient ward.

METHOD

A survey was created, piloted and sent to all staff members who had cared for a deceased patient within two working days of their death, at Christchurch Hospital (CH), New Zealand. The survey comprised questions evaluating whether the patients physical, emotional, social or family/whānau needs were met, using both a Likert scale and free-text options. The survey was sent over a three-month period in 2016/2017.

RESULTS

A total of 169 staff responded to the deaths of 51 patients. The majority (71.3%) of staff agreed that "end-of-life care was of a high standard", with the physical symptoms domain holding the highest score for both agreement (68%) and disagreement (13%) that "physical symptoms were well managed". Qualitative analysis of free-text responses revealed three themes: coordinated care (service delivery, complex case or communication needs, teamwork); culture of practice (dignity, trust, respect and relationships); and complexity of care (encompassing complex physical symptoms or patient or family/whānau interpersonal dynamics).

CONCLUSION

Evaluation of quality of death in hospitals can be enhanced by routine use of surveys of staff who cared for the deceased person. Such surveys could comprise part of a suite of tools to provide a holistic view of dying and death, complementing methods such as retrospective audits and family/whānau interviews.

Medical students and informed consent-response to "Consent for Teaching"

Nil.

An evaluation of a New Zealand "vape to quit smoking" programme

AIM

To compare the use of smoking cessation aids across different ethnic groups and age groups within a large New Zealand cohort and to assess the uptake and effectiveness of e-cigarettes for smoking cessation via a "vape to quit" initiative.

METHODS

Retrospective analysis of Te Hā - Waitaha smoking cessation service, including a telephone interview of a subgroup, who opted into the "vape to quit" programme. The uptake of different smoking cessation aids, including the use of medications and other products, was evaluated and the self-reported quit rate in a "vape to quit" cohort was evaluated.

RESULTS

The final dataset analysed consisted of 1,118 participants: 66.6% NZ European; 28.1% Māori; 3.1% Pacific; and 2.2% Asian. Māori participants were younger on average and had increasing vaping use. Māori were less likely to receive varenicline to assist with smoking cessation. Vaping use increased over time in all groups. Nicotine containing e-cigarettes were the most common smoking cessation products used, with >65% of each ethnic cohort utilising these products. Of the 100 participants in the "vape to quit" cohort 16% were smokefree and vapefree, 31% were smokefree and vaping, 31% were smoking and not vaping, and 22% were smoking and vaping.

CONCLUSIONS

The Te Hā - Waitaha service was successful in engaging Māori in their smoking cessation programme. Nicotine containing e-cigarette products were popular in all cohorts. Nicotine containing e-cigarettes are showing potential in smoking cessation programmes in support of the Smokefree Aotearoa 2025; however, 22% of those in the "vape to quit" programme became dual users.

Patient, carer and health professional experiences of end-of-life care services in chronic obstructive pulmonary disease: an interpretive synthesis of qualitative studies

The objective of this systematic literature review is to identify patients’, carers’ and health professionals’ reported perspectives of end-of-life care services for severe chronic obstructive pulmonary diseases (COPD) and explore whether services are person-centred and integrated according to WHO definitions. The systematic review was qualitative with interpretive synthesis. The data sources included MEDLINE, CINAHL, Emcare, Embase, Cochrane (CENTRAL), Joanna Briggs Institute and PsycINFO databases from inception to 23 May 2022 limited to the English language. Qualitative studies were eligible if they reported open-ended patients,’ carers’ or healthcare professionals’ experiences of end-of-life care for severe COPD. Qualitative data were categorised according to healthcare stakeholder groups and conceptualised within a health services network using the Actor-Network Theory. Eighty-seven studies proved eligible. Eleven stakeholder groups constituted the healthcare services network for severe COPD (in order of frequency of interactions with other stakeholders): secondary care, primary care, community services, acute care, palliative care, carer, healthcare environment, patient, government, social supports and research. When evaluating the network for evidence of patient-centred care, patients and carers received input from all stakeholder groups. The relationship between stakeholder groups and patients was largely unidirectional (stakeholders towards patients) with low influence of patients towards all stakeholder groups. There was limited interaction between specific healthcare services, suggesting low network integration. Government services, research and social supports had few connections with other services in the healthcare network. Multiple intersecting health, community and government services acted on patients, rather than providing patient-informed care. Health services provided poorly integrated services for end-of-life care for severe COPD.

PROSPERO registration number

CRD42020168733.

Non-Indigenous privilege in health, justice and social services preceding first episode psychosis: A population-based cohort study

BACKGROUND

There is evidence of disparities between non-Indigenous and Indigenous incidence of psychotic disorders. Despite these disparities being a clear signpost of the impact of structural racism, there remains a lack of evidence to target institutional factors. We aimed to investigate non-Indigenous and Indigenous differences in government service use prior to first episode diagnosis as a means of identifying points of intervention to improve institutional responses.

METHODS

We used a previously established national New Zealand cohort of 2385 13 to 25-year-old youth diagnosed with psychosis between 2009 and 2012 and a linked database of individual-level multiple government agency administration data, to investigate the differences in health, education, employment, child protection and criminal-justice service use between non-Indigenous (60%) and Indigenous youth (40%) in the year preceding first episode diagnosis. Further comparisons were made with the general population.

RESULTS

A high rate of health service contact did not differ between non-Indigenous and Indigenous youth (adjusted rate ratio 1.0, 95% confidence interval [0.9, 1.1]). Non-Indigenous youth had higher rates of educational enrolment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and employment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and were 40% less likely to have contact with child protection services (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.8]) and the criminal-justice system (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.7]). Both first episode cohorts had a higher risk of criminal justice contact compared to the general population, but the difference was greater for non-Indigenous youth (risk ratio 3.0, 95% confidence interval [2.7, 3.4] vs risk ratio 2.0, 95% confidence interval [1.8, 2.2]), explained by the lower background risk.

INTERPRETATION

The results indicate non-Indigenous privilege in multiple sectors prior to first episode diagnosis. Indigenous-based social disparities prior to first episode psychosis are likely to cause further inequities in recovery and will require a response of health, education, employment, justice and political systems.

Culturally competent, safe and equitable clinical care for Ma¯ori with bipolar disorder in New Zealand: The expert critique of Ma¯ori patients and Wha¯nau

OBJECTIVE

Research designed to increase knowledge about Māori with bipolar disorder is required to understand how health services support wellbeing and respond to identified levels of community need. This paper synthesises the expert critique of Māori patients with bipolar disorder and their whānau regarding the nuances of cultural competence and safety in clinical encounters with the health system.

METHODS

A qualitative Kaupapa Māori Research methodology was used. A total of 24 semi-structured interviews were completed with Māori patients with bipolar disorder and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data.

RESULTS

Three themes were evident from participants' critique of clinical components of the health system. Theme 1 established that the efficacy of clinical care for bipolar disorder was dependent on Māori patients and whānau having clear pathways through care, and being able to access timely, consistent care from clinically and culturally competent staff. Theme 2 identified the influence of clinical culture in bipolar disorder services, embedded into care settings, expressed by staff, affecting the safety of clinical care for Māori. Theme 3 focused on the need for bipolar disorder services to prioritise clinical work with whānau, equip staff with skills to facilitate engagement and tailor care with resources to enhance whānau as well as patient wellbeing.

CONCLUSION

The standard of clinical care for Māori with bipolar disorder in New Zealand does not align with practice guidelines, Māori models of health or clinical frameworks designed to inform treatment and address systemic barriers to equity. Research also needs to explore the role of structural and organisational features of the health system on Māori patient and whānau experiences of care.

"If we can just dream…" Māori talk about healthcare for bipolar disorder in New Zealand: A qualitative study privileging Indigenous voices on organisational transformation for health equity

Objectives

This paper identifies barriers to equity and proposes changes to improve the organisation of healthcare in New Zealand for Māori with bipolar disorder (BD) and their families.

Design

A qualitative Kaupapa Māori methodology was used. Twenty‐four semi‐structured interviews were completed with Māori with BD and members of their family. Structural and descriptive coding was used to organise and analyse the data, including an analytic frame that explored participants' critique of attributes of the organisation of healthcare and alignment with Māori health policy.

Results

Transformation to the organisation of healthcare is needed to achieve health equity. Executive management must lead changes to organisational culture, deliver an equity partnership model with Māori, embed cultural safety and redesign the organisation of healthcare to improve wellbeing. Healthcare incentive structures must diversify, develop and retain a culturally competent health workforce. Information management and technology systems must guide continued whole system improvements.

Conclusion

This paper provides recommendations that should be considered in planned reforms to the organisation of healthcare in New Zealand. The challenge remains whether resourcing for an equitable healthcare organisation will be implemented in partial fulfilment of promises of equity in policy.

Indigenous health equity requires the organisation of healthcare to transform.

Executive management must lead changes to organisational culture.

Change to healthcare culture will then support organisational re‐design.

Evaluation, technologies, and incentives will support continued equity gains.

On pandemics and pivots: a COVID-19 reflection on envisioning the future of medical education

The required adjustments precipitated by the coronavirus disease 2019 crisis have been challenging, but also represent a critical opportunity for the evolution and potential disruptive and constructive change of medical education. Given that the format of medical education is not fixed, but malleable and in fact must be adaptable to societal needs through ongoing reflexivity, we find ourselves in a potentially transformative learning phase for the field. An Association for Medical Education in Europe ASPIRE Academy group of 18 medical educators from seven countries was formed to consider this opportunity, and identified critical questions for collective reflection on current medical education practices and assumptions, with the attendant challenge to envision the future of medical education. This was achieved through online discussion as well as asynchronous collective reflections by group members. Four major themes and related conclusions arose from this conversation: Why we teach: the humanitarian mission of medicine should be reinforced; what we teach: disaster management, social accountability and embracing an environment of complexity and uncertainty should be the core; how we teach: open pathways to lean medical education and learning by developing learners embedded in a community context; and whom we teach: those willing to take professional responsibility. These collective reflections provide neither fully matured digests of the challenges of our field, nor comprehensive solutions; rather they are offered as a starting point for medical schools to consider as we seek to harness the learning opportunities stimulated by the pandemic.

Eating disorders in New Zealand: Implications for Māori and health service delivery

OBJECTIVE

Lifetime prevalence rates in Te Rau Hinengaro (The New Zealand Mental Health Survey) suggest eating disorders are at least as common in the Māori population as the non-Māori population, yet little is known at a population level about those accessing specialist mental health treatment for eating disorders in New Zealand. The aim of this study was to describe the population undergoing specialist mental health treatment for eating disorders and compare Māori and non-Māori clinical characteristics and service use.

METHOD

This study uses the Programme for the Integration of Mental Health Data data set, managed by the New Zealand Ministry of Health to describe the characteristics of people with eating disorders and their use of specialist mental health services from 2009 to 2016.

RESULTS

There were 3,835 individuals with a diagnosed eating disorder who had contact with specialist mental health services in this time period, 7% of whom were Māori. Within the cohort, Māori had a higher prevalence for a bulimia nervosa diagnosis, fewer diagnosed with anorexia nervosa, and a higher prevalence of other psychiatric comorbidity than non-Māori.

DISCUSSION

There is discrepancy between the proportion of service users accessing specialist mental health services who are Māori and the assessed crude prevalence of eating disorders for Māori in national estimates. Once Māori are in specialist services; however, their use of services is comparable to non-Māori. Further research is needed to highlight the experiences of those Māori with eating disorders and address barriers to accessing services for Māori with eating disorders.

Gender and mental health service use in bipolar disorder: national cohort study

BACKGROUND

Despite evidence of gender differences in bipolar disorder characteristics and comorbidity, there is little research on the differences in treatment and service use between men and women with bipolar disorder.

AIMS

To use routine data to describe specialist mental health service contact for bipolar disorder, including in-patient, community and support service contacts; to compare clinical characteristics and mental health service use between men and women in contact with secondary services for bipolar disorder.

METHOD

Cross-sectional analysis of mental health patients with bipolar disorder in New Zealand, based on complete national routine health data.

RESULTS

A total of 3639 individuals were in contact with specialist mental health services with a current diagnosis of bipolar disorder in 2015. Of these 58% were women and 46% were aged 45 and over. The 1-year prevalence rate of bipolar disorder leading to contact with specialist mental health services was 1.56 (95% CI 1.50-1.63) per 100 000 women and 1.20 (95% CI 1.14-1.26) per 100 000 men. Rates of bipolar disorder leading to service contact were 30% higher in women than men (rate ratio 1.30, 95% CI 1.22-1.39). The majority (68%) had a diagnosis of bipolar I disorder. Women were more likely to receive only out-patient treatment and have comorbid anxiety whereas more men had substance use disorder, were convicted for crimes when unwell, received compulsory treatment orders and received in-patient treatment.

CONCLUSIONS

Although the prevalence of bipolar disorder is equal between men and women in the population, women were more likely to have contact with specialist services for bipolar disorder but had a lower intensity of service interaction.

The physical health of Māori with bipolar disorder

AIMS

There is very little empirical evidence about the relationship between severe mental illness and the physical health of Indigenous peoples. This paper aims to compare the physical health of Māori and non-Māori with a diagnosis of bipolar disorder in contact with NZ mental health services.

METHODS

A cohort of Māori and non-Māori with a current bipolar disorder diagnosis at 1 January 2010 were identified from routine mental health services data and followed up for non-psychiatric hospital admissions and deaths over the subsequent 5 years.

RESULTS

Māori with bipolar disorder had a higher level of morbidity and a higher risk of death from natural causes compared to non-Māori with the same diagnosis, indicating higher levels of physical health need. The rate of medical and surgical hospitalisation was not higher among Māori compared to non-Māori (as might be expected given increased health needs) which suggests under-treatment of physical health conditions in this group may be a factor in the observed higher risk of mortality from natural causes for Māori.

CONCLUSION

This study provides the first indication that systemic factors which cause health inequities between Māori and non-Māori are compounded for Māori living with severe mental illness. Further exploration of other diagnostic groups and subgroups is needed to understand the best approach to reducing these inequalities.

Exploring indigenous ethnic inequities in first episode psychosis in New Zealand - A national cohort study

INTRODUCTION

First episode psychosis (FEP) disproportionately affects rangatahi (young) Māori, the Indigenous people of New Zealand, but little is known about factors contributing to this inequity. This study describes a cohort of rangatahi Māori and young non-Māori with FEP, and explores ethnic differences in incidence rates, and the contribution of deprivation, urbanicity and substance use.

METHODS

Māori and young non-Māori, aged 13-25 at the time of the first recorded psychosis-related diagnoses, were identified from within Statistics NZ's Integrated Data Infrastructure (IDI), between 2009 and 2012. To estimate age-standardised FEP incidence rates, the population-at-risk was estimated using IDI-based usual resident population estimates for 2009-2012, stratified by ethnicity and single year of age. Poisson regression models were used to estimate ethnic differences in FEP incidence adjusted for age, gender, deprivation, and urban-rural area classification.

RESULTS

A total of 2412 young people with FEP (40% Māori, 60% non-Māori) were identified. Māori were younger, and more likely to live in deprived and rural communities and be diagnosed with schizophrenia. Substance induced psychosis was uncommon. The unadjusted age-standardised FEP incidence rate ratio was 2.48 (95% CI: 2.29-2.69) for rangatahi Māori compared with young non-Māori. While adjusting for age, sex, deprivation and urban rural area classification reduced ethnic differences in incidence, rangatahi Māori were still more than twice as likely to have been diagnosed with FEP compared to young non-Māori.

CONCLUSIONS

This study confirms previous findings of elevated rates of psychosis among rangatahi Māori. The difference in rates between Māori and non-Māori were attenuated but remained after adjustment for deprivation and urbanicity.

Is there systemic bias for Māori with eating disorders? A need for greater awareness in the healthcare system

The New Zealand Mental Health Survey, Te Rau Hinengaro, indicated that eating disorders are at least as common in Māori as non-Māori, which is consistent with international findings that eating disorders exist in other indigenous and ethnic minority groups. Specific factors may be relevant to the development and treatment of eating disorders in the Māori population. We suggest this may include differential exposure to risk factors, the impact of acculturation, changing body image ideals and systemic bias reducing access to treatment and research participation. However, an absence of high-quality research regarding eating disorders in Māori makes it difficult to be certain about this. We suspect that Māori do not receive treatment in specialist eating disorders services at a level commensurate with comparable prevalence data in New Zealand and that a significant contributory factor to the apparent unmet need for Māori with eating disorders is likely to be systemic bias. Urgent attention to this area of research is required.

Consolidated criteria for strengthening reporting of health research involving indigenous peoples: the CONSIDER statement

BACKGROUND

Research reporting guidelines are increasingly commonplace and shown to improve the quality of published health research and health outcomes. Despite severe health inequities among Indigenous Peoples and the potential for research to address the causes, there is an extended legacy of health research exploiting Indigenous Peoples. This paper describes the development of the CONSolIDated critERtia for strengthening the reporting of health research involving Indigenous Peoples (CONSIDER) statement.

METHODS

A collaborative prioritization process was conducted based on national and international statements and guidelines about Indigenous health research from the following nations (Peoples): Australia (Aboriginal and Torres Strait Islanders), Canada (First Nations Peoples, Métis), Hawaii (Native Hawaiian), New Zealand (Māori), Taiwan (Taiwan Indigenous Tribes), United States of America (First Nations Peoples) and Northern Scandinavian countries (Sami). A review of seven research guidelines was completed, and meta-synthesis was used to construct a reporting guideline checklist for transparent and comprehensive reporting of research involving Indigenous Peoples.

RESULTS

A list of 88 possible checklist items was generated, reconciled, and categorized. Eight research domains and 17 criteria for the reporting of research involving Indigenous Peoples were identified. The research reporting domains were: (i) governance; (ii) relationships; (iii) prioritization; (iv) methodologies; (v) participation; (vi) capacity; (vii) analysis and findings; and (viii) dissemination.

CONCLUSIONS

The CONSIDER statement is a collaborative synthesis and prioritization of national and international research statements and guidelines. The CONSIDER statement provides a checklist for the reporting of health research involving Indigenous peoples to strengthen research praxis and advance Indigenous health outcomes.

Sociodemographic, environmental characteristics and comorbidities of older adults with schizophrenia who access community health service support: A national cross-sectional study

OBJECTIVES

Schizophrenia is a serious and chronic mental illness known to have broad ranging impacts for individuals across the lifespan, yet research on the disease in older adults is sparse. This study provides a profile of the sociodemographic, environmental and diagnostic characteristics of older community residents with schizophrenia using a national database.

METHODS

A cross-sectional sample of individuals who underwent community needs assessment using the standardised Home Care International Residential Assessment Instrument between 1 September 2012 and 31 January 2016 was utilised. Sociodemographic, diagnostic, and social and environmental variables were measured for individuals with a diagnosis of schizophrenia and compared to those without a diagnosis of schizophrenia. Statistical investigations employed bivariable and multivariable logistic regression models.

RESULTS

A total sample of 71,859 was eligible and 517 (0.7%) had a diagnosis of schizophrenia. The majority of the sociodemographic variables were statistically associated with schizophrenia in the adjusted analysis, except for ethnicity ( p = 0.35). Nearly all the measured social and environmental variables were adversely associated with having a diagnosis of schizophrenia, such as living in squalid conditions (adjusted odds ratio = 2.16; 95% confidence interval = [1.42, 3.28]). Participants with schizophrenia were significantly more likely to be diagnosed with all assessed psychiatric comorbidities ( p < 0.001) and diabetes mellitus ( p  = 0.002), whereas coronary heart disease ( p = 0.001) and other physical comorbidities ( p = 0.001) were found at significantly lower rates.

CONCLUSION

The profile of schizophrenia found here suggests some subtle differences in the demographic profile and distribution of medical comorbidities in the older population with schizophrenia. The results also suggest that this group continues to experience social disadvantage into old age. This requires the attention of policy-makers to ensure that services are tailored to the high social needs of these individuals.

Educating for Indigenous Health Equity: An International Consensus Statement

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education's influence-for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities.This article seeks to examine the factors underpinning medical education's role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity.The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions' responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

Māori Indigenous Health Framework in action: addressing ethnic disparities in healthcare

There has been a steady increase in cultural competency training in medical education programmes worldwide. To provide high-quality culturally competent care and reduce health disparities between Māori and non-Māori in New Zealand, several health models have been devised. The Indigenous Health Framework (IHF), currently taught at the University of Otago, Christchurch undergraduate medical programme, is a tool developed to assist health professionals to broaden their range of clinical assessment and communicate effectively with Māori patients and whānau, thereby improving health outcomes and reducing disparities. The authors of this article present a Māori health case study written from the observations of a trainee intern (first author) using components from the IHF to address health disparities between Māori and non-Māori.

Putting action into the revised Australian Medical Council standards on Aboriginal and Torres Strait Islander and Māori health

Since 2006 the Australian Medical Council (AMC) accreditation standards have required medical schools to comprehensively address issues related to the health of Aboriginal and Torres Strait Islander peoples in Australia, and Māori in New Zealand. This has spanned areas of staff expertise, staff and student recruitment, curriculum and institutional leadership. These Indigenous specific standards have, until now, been absent for specialist medical college accreditation. The AMC revised its accreditation standards for specialist medical colleges in 2015, and for the first time included Indigenous specific standards. This commentary presents a guideline to support Australasian medical colleges' responsiveness to these Indigenous specific standards.

Inequity in dialysis related practices and outcomes in Aotearoa/New Zealand: a Kaupapa Māori analysis

BACKGROUND

In Aotearoa/New Zealand, Māori, as the indigenous people, experience chronic kidney disease at three times the rate of non-Māori, non-Pacific New Zealanders. Māori commence dialysis treatment for end-stage kidney disease at three times the rate of New Zealand European adults. To examine for evidence of inequity in dialysis-related incidence, treatment practices, and survival according to indigeneity in Aotearoa/New Zealand, utilising a Kaupapa Māori approach.

METHODS

We conducted a retrospective cohort study involving adults who commenced treatment for end-stage kidney disease in Aotearoa/New Zealand between 2002 and 2011. We extracted data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) linked to the New Zealand National Health Index (NHI). Propensity score methods were used to assemble a cohort of 1039 Māori patients matched 1:1 on clinical and socio-demographic characteristics with a cohort of 1026 non-Māori patients. We compared incidence of end-stage kidney disease and treatment practices. Differences in the risks of all-cause mortality during treatment between propensity-matched cohorts were estimated using Cox proportional hazards and generalised linear models.

RESULTS

Non-Māori patients were older, more frequently lived in urban areas (83% versus 67% [standardised difference 0.38]) and bore less socioeconomic deprivation (36% living in highest decile areas versus 14% [0.53]). Fewer non-Māori patients had diabetes (35% versus 69%, [- 0.72]) as a cause of kidney failure. Non-Māori patients were more frequently treated with peritoneal dialysis (34% versus 29% [0.11]), received a pre-emptive kidney transplant (4% vs 1% [0.19]), and were referred to specialist care < 3 months before treatment (25% vs 19% [0.15]) than Māori patients. Fewer non-Māori started dialysis with a non-tunnelled dialysis vascular catheter (43% versus 47% [- 0.08]). The indigenous-age standardised incidence rate ratio for non-Māori commencing renal replacement therapy in 2011 was 0.50 (95% CI, 0.40-0.61) compared with Māori. Propensity score matching generated cohorts with similar characteristics, although non-Māori less frequently started dialysis with a non-tunnelled venous catheter (30% versus 47% [- 0.35]) or lived remotely (3% versus 14% [- 0.50]). In matched cohorts, non-Māori experienced lower all-cause mortality at 5 yr. after commencement of treatment (risk ratio 0.78, 95% CI 0.72-0.84). New Zealand European patients experienced lower mortality than Māori patients in indigenous age-standardised analyses (age-standardised mortality rate ratio 0.58, 95% CI 0.51-0.67).

CONCLUSIONS

Non-Māori patients are treated with temporary dialysis vascular access less often than Māori, and experience longer life expectancy with dialysis, even when socioeconomic, demographic, and geographical factors are equivalent. Based on these disparities, health services should monitor and address inequitable treatment practices and outcomes in end-stage kidney disease care.

Improving gout education from patients’ perspectives: a focus group study of Māori and Pākehā people with gout

ABSTRACT INTRODUCTION Gout is a common form of arthritis that is typically managed in primary care. Gout management guidelines emphasise patient education for successful treatment outcomes, but there is limited literature about the educational experiences of people living with gout in New Zealand, particularly for Māori, who have higher gout prevalence and worse gout outcomes than Pākehā. AIM To explore gout patient education in primary care from the perspectives of Māori and Pākehā people with gout. METHODS In total, 69 people with gout were recruited through primary care providers in three locations across New Zealand. Nine semi-structured focus groups were run with Māori and Pākehā participants in separate groups. RESULTS Thematic analysis yielded two themes in relation to gout education: (i) ‘Multiple sources of gout education’; and (ii) ‘Gaps in gout knowledge’. Participants received education from general practitioners, educational resources, family and friends, and their own experiences. Māori participants preferred information to be kanohi-ki-te-kanohi (face-to-face) and with significant others present where necessary. Participants disclosed gaps in gout’s epidemiology and management. Pākehā and Māori participants reported limited understanding of the genetic basis of gout or the biological underpinnings of the condition and its treatments, but learned treatment adherence through experience. DISCUSSION Despite improved gout patient education, knowledge gaps remain and may contribute to poor medication adherence. Gout patient education interventions need to be tailored to culture and incorporate suitable methods of disseminating information about gout management.

Socioeconomic Position and Picky Eating Behavior Predict Disparate Weight Trajectories in Infancy

Infant weight gain has long-term implications for the establishment of overall health. We examined whether socioeconomic position (SEP), the use of pressure as a feeding practice, and picky eating relate to changes infant in weight-for-length (WFL). A modified developmental design was used to examine whether current levels of child picky eating, parental use of pressure, and SEP were associated with changes in WFL during infancy. Health providers distributed survey packets during routine well-child visits made in the homes of families with young children in New Zealand (n = 193). Primary caregivers of young children provided their child's current level of picky eating, their use of pressure, and their SEP. They also reported their child's professionally-measured WFL from birth, 8, 15, and 21 months of age. A multi-level modeling analysis yielded an interaction between SEP and picky eating in predicting infant weight change over time. Children who had a low SEP and were not picky eaters were on the highest WFL trajectory and children who had a low SEP and were picky eaters were lowest on the WFL trajectory. A main effect revealed that higher levels of parental pressure predicted lower WFL in infants at each age, but did not interact with SEP or picky eating. Findings from this study indicate that the combination of eating behavior and SEP are associated with differential infant growth patterns. These results suggest that eating behavior and SEP should be included in the development of interventions designed to achieve healthy weight during childhood.

Severe COPD and the transition to a palliative approach

Patients with severe chronic obstructive pulmonary disease (COPD) have a chaotic trajectory towards death. Research has focused on identifying a "transition point" that would allow identification of those patients who may benefit from a palliative approach to their care, or referral to a specialist palliative care service. This article aims to outline difficulties in identifying this transition point, summarise current literature on this topic and suggests a model based on clinical milestones.

EDUCATIONAL AIMS

To outline the difficulties associated with identifying patients with severe COPD who are at risk of dying.To summarise current research on this topic.

KEY POINTS

A specific transition point is difficult to identify in severe COPD.Tools are available that may assist the physician in identifying those at risk of dying.It is essential that the patient voice is heard, patients can describe specific events that may be used as a "trigger" for a palliative approach.Specialist palliative care services may only be required for a subgroup of patients whose needs cannot be managed by the primary care team.

Indigenous health: designing a clinical orientation program valued by learners

BACKGROUND

Indigenous health programs are seen as a curriculum response to addressing health disparities and social accountability. Several interrelated teaching approaches to cultural competency curricula have been recommended, however evidence of the impact of these on learner outcomes including engagement and self-reported competencies is limited. We aimed to explore undergraduate medical student perspectives of an indigenous health orientation program to inform curriculum strategies that promote learning and development of clinical skills.

METHODS

We analyzed quantitative and qualitative student evaluations (n = 602) of a three-day immersed indigenous health orientation program between 2006 and 2014 based on Likert-scale responses and open-text comments. We conducted a thematic analysis of narrative student experiences (n = 426).

RESULTS

Overall, 509 of 551 respondents (92%) rated the indigenous health orientation program as extremely or highly valuable and most (87%) reported that the course strongly increased their interest in indigenous health. The features of the clinical course that enhanced value for learners included situated learning (learning environment; learning context); teaching qualities (enthusiasm and passion for Māori health; role-modelling); curriculum content (re-presenting Māori history; exploring Māori beliefs, values and practices; using a Māori health framework in clinical practice); teaching methodologies (multiple teaching methods; simulated patient interview); and building relationships with peers (getting to know the student cohort; developing professional working relationships).

CONCLUSIONS

Undergraduate medical students valued an indigenous health program delivered in an authentic indigenous environment and that explicitly reframed historical notions of indigenous health to contextualize learning. Content relevant to clinical practice, faculty knowledge, and strengthened peer interactions combined to build learner confidence and self-reported indigenous health competencies. These findings suggest empirical evidence to support a curriculum approach to indigenous health teaching that enhances clinical learning.

Curricular initiatives that enhance student knowledge and perceptions of sexual and gender minority groups: a critical interpretive synthesis

BACKGROUND

There is no accepted best practice for optimizing tertiary student knowledge, perceptions, and skills to care for sexual and gender diverse groups. The objective of this research was to synthesize the relevant literature regarding effective curricular initiatives designed to enhance tertiary level student knowledge, perceptions, and skills to care for sexual and gender diverse populations.

METHODS

A modified Critical Interpretive Synthesis using a systematic search strategy was conducted in 2015. This method was chosen to synthesize the relevant qualitative and quantitative literature as it allows for the depth and breadth of information to be captured and new constructs to be illuminated. Databases searched include AMED, CINAHL EBM Reviews, ERIC, Ovid MEDLINE, Ovid Nursing Database, PsychInfo, and Google Scholar.

RESULTS

Thirty-one articles were included in this review. Curricular initiatives ranging from discrete to multimodal approaches have been implemented. Successful initiatives included discrete sessions with time for processing, and multi-modal strategies. Multi-modal approaches that encouraged awareness of one's lens and privilege in conjunction with facilitated communication seemed the most effective.

CONCLUSIONS

The literature is limited to the evaluation of explicit curricula. The wider cultural competence literature offers further insight by highlighting the importance of broad and embedded forces including social influences, the institutional climate, and the implicit, or hidden, curriculum. A combined interpretation of the complementary cultural competence and sexual and gender diversity literature provides a novel understanding of the optimal content and context for the delivery of a successful curricular initiative.

What can we learn from patients to improve their non-invasive ventilation experience? 'It was unpleasant; if I was offered it again, I would do what I was told'

Objectives

Non-invasive ventilation (NIV) is widely used as a lifesaving treatment in acute exacerbations of chronic obstructive pulmonary disease; however, little is known about the patients' experience of this treatment. This study was designed to investigate the experiences and perceptions of participants using NIV. The study interprets the participants' views and explores implications for clinical practice.

Methods

Participants with respiratory failure requiring NIV were interviewed 2 weeks after discharge. A grounded theory methodology was used to order and sort the data. Theoretical sufficiency was achieved after 15 participants.

Results

Four themes emerged from the data: levels of discomfort with NIV, cognitive experiences with NIV, NIV as a life saver and concern for others. NIV was uncomfortable for participants and affected their cognition; they still reported considering NIV as a viable option for future treatment. Participants described a high level of trust in healthcare professionals and delegated decision-making to them regarding ongoing care.

Conclusions

This study provides insights into ways clinicians could improve the physical experience for patients with NIV. It also identifies a lack of recall and delegation of decision-making, highlighting the need for clinical leadership to advocate for patients.

Higher prevalence of left ventricular hypertrophy in two Māori cohorts: findings from the Hauora Manawa/Community Heart Study

OBJECTIVES

Cardiovascular disease (CVD) is the leading cause of mortality in New Zealand with a disproportionate burden of disease in the Māori population. The Hauora Manawa Project investigated the prevalence of cardiovascular risk factors and CVD in randomly selected Māori and non-Māori participants. This paper reports the prevalence of structural changes in the heart.

METHODS

A total of 252 rural Māori, 243 urban Māori; and 256 urban non-Māori underwent echocardiography to assess cardiac structure and function. Multivariable logistic regression was used to determine variables associated with heart size.

RESULTS

Left ventricular (LV) mass measurements were largest in the rural Māori cohort (183.5,sd 61.4), intermediate in the urban Māori cohort (169.7,sd 57.1) and smallest in the non-Māori cohort (152.6,sd 46.7; p<0.001). Similar patterns were observed for other measurements and indexation had no impact. One-third (32.3%) met the gender-based ASE criteria for LV hypertrophy (LVH) with higher prevalence in both Maori cohorts (highest in the rural cohort). There were three significant predictors of LVH: rural Māori (p=0.0001); age (p<0.0001); and gender (p=0.0048).

CONCLUSION

Structural and functional heart abnormalities are more prevalent in Māori compared to non-Māori, and especially rural Māori. Early identification should lead to better management, ultimately improving life expectancy and quality of life.

Improving Maori health through clinical assessment: Waikare o te Waka o Meihana

Health professionals play an important role in addressing indigenous health inequalities. This paper describes the further development and a new conceptualisation of the Meihana model (2007) and the Hui process (2011), which together have formed the indigenous health framework in the University of Otago, Christchurch undergraduate medical education programme for 4th-6th year medical students over the past 5 years. The components of the framework are defined followed by description of their application to clinical assessment. The indigenous health framework has been evaluated by medical students, health practitioners, Maori patients and whanau over this time and has been rated favourably as a clinically relevant framework that supports health practitioners to work effectively with Maori patients and whanau.