"Hurts less, lasts longer"; a qualitative study on experiences of young people receiving high-dose subcutaneous injections of benzathine penicillin G to prevent rheumatic heart disease in New Zealand.

BACKGROUND: Four-weekly intramuscular (IM) benzathine penicillin G (BPG) injections to prevent acute rheumatic fever (ARF) progression have remained unchanged since 1955. A Phase-I trial in healthy volunteers demonstrated the safety and tolerability of high-dose subcutaneous infusions of BPG which resulted in a much longer effective penicillin exposure, and fewer injections. Here we describe the experiences of young people living with ARF participating in a Phase-II trial of SubCutaneous Injections of BPG (SCIP). METHODOLOGY: Participants (n = 20) attended a clinic in Wellington, New Zealand (NZ). After a physical examination, participants received 2% lignocaine followed by 13.8mL to 20.7mL of BPG (Bicillin-LA®; determined by weight), into the abdominal subcutaneous tissue. A Kaupapa Maori consistent methodology was used to explore experiences of SCIP, through semi-structured interviews and observations taken during/after the injection, and on days 28 and 70. All interviews were recorded, transcribed verbatim, and thematically analysed. PRINCIPAL FINDINGS: Low levels of pain were reported on needle insertion, during and following the injection. Some participants experienced discomfort and bruising on days one and two post dose; however, the pain was reported to be less severe than their usual IM BPG. Participants were 'relieved' to only need injections quarterly and the majority (95%) reported a preference for SCIP over IM BPG. CONCLUSIONS: Participants preferred SCIP over their usual regimen, reporting less pain and a preference for the longer time gap between treatments. Recommending SCIP as standard of care for most patients needing long-term prophylaxis has the potential to transform secondary prophylaxis of ARF/RHD in NZ and globally.

Translating research into a relevant education activity to fulfil pharmacists' continuing professional development requirements.

Background: In New Zealand (NZ), provision of culturally safe care by pharmacists is mandated, including an expectation of understanding issues relevant to Maori, the Indigenous people of NZ, yet there are few pharmacy-specific resources to support attainment. Objectives: To: i) test whether a research-informed education activity (short video summarising research findings plus reflective exercises) meets NZ pharmacists' annual continuing professional development requirements including those relating to culturally safe care ii) identify suggested improvements to the education activity; and iii) identify individual pharmacists' proposed actions in response to reflection prompted by the education activity. Methods: Previous research was utilised to develop an education activity (short, animated research summary video and reflective questions). Participants (NZ-registered pharmacists or intern pharmacists) were asked to watch the video and respond to questions online related to perceived relevance and usefulness of the video to informing practice and meeting CPD requirements. Simple descriptive analysis (quantitative data) and general inductive thematic analysis (qualitative data) were applied to the research data. Results: Thirty-three people participated from Nov-Dec 2022. Most participants said the video was relevant/very relevant to practice (91%), that the reflective exercise was very or extremely useful (100%) and that it met their CPD requirements as relevant to cultural safety (100%). Conclusion: The education activity appeared to be an appropriate and relevant for CPD and was seen to be concise and exposed ideas in a logical and succinct manner with the potential to benefit the populations receiving care from these providers.

Subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for rheumatic heart disease secondary prophylaxis: a phase 1 open-label population pharmacokinetic study.

Since 1955, the recommended strategy for rheumatic heart disease (RHD) secondary prophylaxis has been benzathine penicillin G [BPG; 1.2 MU (900 mg)] injections administered intramuscularly every 4 weeks. Due to dosing frequency, pain, and programmatic challenges, adherence is suboptimal. It has previously been demonstrated that BPG delivered subcutaneously at a standard dose is safe and tolerable and has favorable pharmacokinetics, setting the scene for improved regimens with less frequent administration. The safety, tolerability, and pharmacokinetics of subcutaneous infusions of high-dose BPG were assessed in 24 healthy adult volunteers assigned to receive either 3.6, 7.2, or 10.8 MU (three, six, and nine times the standard dose, respectively) as a single subcutaneous infusion. The delivery of the BPG to the subcutaneous tissue was confirmed with ultrasonography. Safety assessments, pain scores, and penicillin concentrations were measured for 16 weeks post-dose. Subcutaneous infusion of penicillin (SCIP) was generally well tolerated with all participants experiencing transient, mild infusion-site reactions. Prolonged elevated penicillin concentrations were described using a combined zero-order (44 days) and first-order (t1/2 = 12 days) absorption pharmacokinetic model. In simulations, time above the conventionally accepted target concentration of 20 ng/mL (0.02 µg/mL) was 57 days for 10.8 MU delivered by subcutaneous infusion every 13 weeks compared with 9 days of every 4-weekly dosing interval for the standard 1.2 MU intramuscular dose (i.e., 63% and 32% of the dosing interval, respectively). High-dose SCIP (BPG) is safe, has acceptable tolerability, and may be suitable for up to 3 monthly dosing intervals for secondary prophylaxis of RHD.

Trends in penicillin dispensing during an acute rheumatic fever prevention programme.

AIM: Acute rheumatic fever (ARF), a serious inflammatory condition, often leads to rheumatic heart disease (RHD). Between 2011 and 2016, Aotearoa New Zealand implemented a rheumatic fever prevention programme (RFPP) to reduce high rates of ARF through improved community access to timely diagnosis and early treatment of group A streptococcal (GAS) pharyngitis, which has been shown to prevent subsequent ARF. This study aimed to quantify the change in penicillin antibiotic dispensing rates among children aged 18 years or younger during the RFPP. METHOD: This retrospective analysis utilised administrative data from the National Pharmaceutical Collection. Using a controlled, interrupted time series analysis, the effect of the RFPP on antibiotic dispensing rates was explored. Poisson regression models were used to assess the change in dispensing rates during the RFPP among control regions (those not in the RFPP) and regions participating in the RFPP. The primary measure was rate ratio (RR) for the difference between the observed versus counterfactual rates of penicillin dispensing. RESULT: A total of 12,154,872 dispensing records between 2005 and 2018 were included. Amoxicillin was the most frequently dispensed penicillin (57.7%), followed by amoxicillin-clavulanate (23.4%). Amoxicillin dispensing increased by 4.3% in regions operating the RFPP compared to the increase in control regions (p<0.001). The overall rate of penicillin dispensing decreased, driven by a rapid decline in amoxicillin-clavulanate dispensing. CONCLUSION: During the RFPP an increase in amoxicillin dispensing was seen in regions participating in the programme and regions outside of the programme, indicating the programmatic approach led to improved adherence to recommended first-line antibiotics.

Qualitative assessment of healthy volunteer experience receiving subcutaneous infusions of high-dose benzathine penicillin G (SCIP) provides insights into design of late phase clinical studies.

INTRODUCTION: Secondary prophylaxis to prevent rheumatic heart disease (RHD) progression, in the form of four-weekly intramuscular benzathine benzylpenicillin G (BPG) injections, has remained unchanged since 1955. Qualitative investigations into patient preference have highlighted the need for long-acting penicillins to be delivered less frequently, ideally with reduced pain. We describe the experience of healthy volunteers participating in a phase-I safety, tolerability and pharmacokinetic trial of subcutaneous infusions of high-dose benzathine penicillin G (BPG)-the SCIP study (Australian New Zealand Clinical Trials Registry ACTRN12622000916741). METHODS: Participants (n = 24) received between 6.9 mL to 20.7 mL (3-9 times the standard dose) of BPG as a single infusion into the abdominal subcutaneous tissues via a spring-driven syringe pump over approximately 20 minutes. Semi-structured interviews at four time points were recorded, transcribed verbatim and thematically analysed. Tolerability and specific descriptors of the experience were explored, alongside thoughts on how the intervention could be improved for future trials in children and young adults receiving monthly BPG intramuscular injections for RHD. RESULTS: Participants tolerated the infusion well and were able describe their experiences throughout. Most reported minimal pain, substantiated via quantitative pain scores. Abdominal bruising at the infusion site did not concern participants nor impair normal activities. Insight into how SCIP could be improved for children included the use of topical analgesia, distractions via television or personal devices, a drawn-out infusion time with reduced delivery speed, and alternative infusion sites. Trust in the trial team was high. CONCLUSION: Qualitative research is an important adjunct for early-phase clinical trials, particularly when adherence to the planned intervention is a key driver of success. These results will inform later-phase SCIP trials in people living with RHD and other indications.

Designing for health equity: A mixed method study exploring community experiences and perceptions of pharmacists' role in minor ailment care.

BACKGROUND: Minor ailments are self-limiting, easily diagnosable and treatable conditions. Funded pharmacist minor ailments services (PMAS) have been posited to improve medicines access equity and, despite ethnic minorities across the globe experiencing reduced access to medicines and health care, PMAS internationally have not explicitly centered ethnic equity in service design or outcome measurement. OBJECTIVE: To explore Maori experiences of minor ailments care and perceptions of the pharmacists' role. METHODS: This mixed methods study collected data through facilitated wananga (collaborative knowledge-sharing group discussions). Eligible participants (Maori, 18 years plus, obtained medicine from pharmacy in last 3 years) were recruited through local pharmacist networks using convenience sampling. Wananga included qualitative data collection through discussion using a topic guide and a quantitative questionnaire. Indigenous theory was applied within a general inductive approach to thematic development to analyze qualitative data. Quantitative data was reported using simple descriptive statistics. RESULTS: Thirteen wananga (3 in-person, 10 online) were conducted from September 2021-February 2022 with 62 participants from seven New Zealand regions. The minor ailments that participants were most likely to seek treatment from pharmacy first, instead of a doctor, were eczema (87.2%), coughs and colds (85.7%), headlice (85.7%), insect bites (83.9%), and hayfever (83.9%). Four themes were generated from the qualitative data: designing the right environment for minor ailment care; clinically and culturally safe care; moving from stigmatizing to strengths-based services; the benefits of PMAS. Participant-informed ideas for PMAS service development centered on Maori aspirations included: developing clinically and culturally safe pharmacy environments, enabling medicine supply outside of the physical pharmacy setting, avoiding stigmatizing language when promoting PMAS availability, and collaborative practice with other health providers. CONCLUSION: This study provides important recommendations when developing PMAS to increase the likelihood of delivering equitable care, and has international application across multiple pharmacy and health service settings.

Cohort profile: methodology and cohort characteristics of the Aotearoa New Zealand Rheumatic Heart Disease Registry.

PURPOSE: To create a cohort with high specificity for moderate and severe rheumatic heart disease (RHD) in New Zealand, not reliant on International Classification of Diseases discharge coding. To describe the demography and cardiac profile of this historical and contemporary cohort. DESIGN AND PARTICIPANTS: Retrospective identification of moderate or severe RHD with disease onset by 2019. Case identification from the following data sources: cardiac surgical databases, RHD case series, percutaneous balloon valvuloplasty databases, echocardiography databases, regional rheumatic fever registers and RHD clinic lists. The setting for this study was a high-income country with continued incidence of acute rheumatic fever (ARF). FINDINGS TO DATE: A Registry cohort of 4959 patients was established. The initial presentation was RHD without recognised prior ARF in 41%, and ARF in 59%. Ethnicity breakdown: Maori 38%, Pacific 33.5%, European 21.9%, other 6.7%. Ethnic disparities have changed significantly over time. Prior to 1960, RHD cases were 64.3% European, 25.3% Maori and 6.7% Pacific. However, in contrast, from 2010 to 2019, RHD cases were 10.7% European, 37.4% Maori and 47.2% Pacific.Follow-up showed 32% had changed region of residence within New Zealand from their initial presentation. At least one cardiac intervention (cardiac surgery, transcatheter balloon valvuloplasty) was undertaken in 64% of the cohort at a mean age of 40 years. 19.8% of the cohort had multiple cardiac interventions. At latest follow-up, 26.9% of the cohort died. Of those alive, the mean follow-up is 20.5+19.4 years. Maori and Pacific led governance groups have been established to provide data governance and oversight for the registry. FUTURE PLANS: Detailed mortality and morbidity of the registry cases will be defined by linkage to New Zealand national health data collections. The contemporary cohort of the registry will be available for future studies to improve clinical management and outcomes for the 3450 individuals living with chronic RHD.

Maori, pharmacists, and medicines adherence - A mixed methods study exploring indigenous experiences of taking medicines 'as prescribed' and mechanisms of support.

Background: Medicines are the most common medical intervention and medicines adherence is associated with improved clinical outcomes. Understanding drivers and experiences of medicines adherence is important for optimising medicines use. Maori (Indigenous people of Aotearoa New Zealand) experience inequities in access to medicines yet little evidence exists regarding Maori and medicines adherence, or the role of pharmacists in supporting medicines adherence for Maori. Objectives: To explore Maori experiences of medicines adherence and non-adherence, and pharmacists' role in supporting adherence. Methods: This was a convergent parallel mixed methods study. Facilitated wananga (collaborative knowledge-sharing group discussions) were undertaken either online or in-person with eligible participants, using convenience and snowball sampling to recruit. Participants were eligible if they were Maori, 18 years or older, and had recently obtained medicine from a pharmacy. Wananga involved semi-structured interviewing and questionnaire completion. General inductive coding and thematic analysis and descriptive statistical analysis were used respectively, and findings were situated in social, cultural and political Maori contexts. Results: Thirteen wananga were conducted with 62 participants (71% female, median age range 35-44) from September 2021 to February 2022. Four themes were identified: The aspirations of hauora Maori (Maori wellbeing) - medicines as a component of holistic wellbeing; whanaungatanga (relationships); knowledge; and whanau (family and support network) advocacy and problem solving. Forgetting to take medicines was the most frequently identified reason for non-adherence, followed by not having medicines on hand, adverse effects, and lack of symptoms of health conditions. Participants identified that proactive pharmacist support, including developing caring therapeutic relationships, sharing knowledge, acknowledging medicines as just one component of holistic wellbeing, and giving adherence tips to support routine medicine taking were positive ways that pharmacists could support medicines adherence. Conclusions: Factors contributing to medicines adherence were diverse and participants identified numerous practical solutions that pharmacists, health service providers and policymakers could employ to support Maori medicines adherence.

Reducing healthcare inequities for Maori using Telehealth during COVID-19.

AIM: Maori experience barriers to accessing timely, quality healthcare. The March 2020 COVID-19 lockdown in New Zealand required provision of Telehealth consultation options in primary care. Telehealth consultations have the potential to improve access to healthcare for Maori, and thereby reduce health inequities. Conversely, Telehealth may present additional barriers that contribute to inequities overall. This scoping project investigated Maori experiences of Telehealth consultations during the March 2020 COVID-19 lockdown. METHOD: Semi-structured key informant interviews were completed with five Maori health professionals, six Maori Telehealth patients, and six Maori in-clinic patients, about their healthcare consultation experiences during COVID-19 lockdown. Participants were asked about what worked, what did not work, and for suggestions to improve future Telehealth provision to Maori whanau. Kaupapa Maori methodology underpinned thematic analysis of the interviews. RESULTS: Key findings are presented in three overarching themes: benefits (safety, cost, time, options); challenges (health literacy, access to Information Technology (IT), supply and demand, limited physical assessment); and suggested improvements (systems fit for purpose, supporting IT and health literacy, Telehealth as a routine option, rapport building, and cross system efficiency and information sharing). CONCLUSION: Telehealth is a viable long-term option that can support Maori whanau access to healthcare.

Understanding the workforce that supports Maori and Pacific peoples with type 2 diabetes to achieve better health outcomes.

BACKGROUND: Prevalence of Type 2 diabetes mellitus (T2DM) is high among Maori and other Pacific Island peoples in New Zealand. Current health services to address T2DM largely take place in primary healthcare settings and have, overall, failed to address the significant health inequities among Maori and Pacific people with T2DM. Culturally comprehensive T2DM management programmes, aimed at addressing inequities in Maori or Pacific diabetes management and workforce development, are not extensively available in New Zealand. Deliberate strategies to improve cultural safety, such as educating health professionals and fostering culturally safe practices must be priority when funding health services that deliver T2DM prevention programmes. There is a significant workforce of community-based, non-clinical workers in South Auckland delivering diabetes self-management education to Maori and Pacific peoples. There is little information on the perspectives, challenges, effectiveness, and success of dietitians, community health workers and kai manaaki (KM) in delivering these services. This study aimed to understand perspectives and characteristics of KM and other community-based, non-clinical health workers, with a focus on how they supported Maori and Pacific Peoples living with T2DM to achieve better outcomes. METHODS: This qualitative study undertaken was underpinned by the Tangata Hourua research framework. Focus groups with dietitians, community health workers (CHWs) and KM took place in South Auckland, New Zealand. Thematic analysis of the transcripts was used to identify important key themes. RESULTS: Analysis of focus group meetings identified three main themes common across the groups: whakawhanaungatanga (actively building relationships), cultural safety (mana enhancing) and cultural alignment to role, with a further two themes identified only by the KM and CHWs, who both strongly associated a multidisciplinary approach to experiences of feeling un/valued in their roles, when compared with dietitians. Generally, all three groups agreed that their roles required good relationships with the people they were working with and an understanding of the contexts in which Maori and Pacific Peoples with T2DM lived. CONCLUSIONS: Supporting community based, non-clinical workers to build meaningful and culturally safe relationships with Maori and Pacific people has potential to improve diabetes outcomes.

The whitewashing of contracts: Unpacking the discourse within Maori health provider contracts in Aotearoa/New Zealand.

Maori health providers emerged in Aotearoa/New Zealand in the 1980s as a mechanism to achieve self-determination for Maori communities. However, the contracts funding Maori health providers limit expressions of self-determination and fail to reflect Te Tiriti O Waitangi, the founding treaty of Aotearoa/New Zealand. Significant health reforms are proposed in Aotearoa/New Zealand, including the creation of a Maori Health Authority that will commission services from Maori health providers. This paper aims to critique the government contracts provided to Maori health providers in the light of the health reforms. A discourse analysis was undertaken on contracts held by a Maori health provider. The study was informed by a Kaupapa Maori congruent methodology that centralised Maori knowledge. The contractural language utilised a variety of discursive techniques that ultimately limit the power of Maori health providers. These discursive techniques included the redefinition of Maori concepts of self-determination, the use of rhetoric that was not matched by action, reshaping Maori health priorities to reflect the funders' priorities and the application of a deficit lens to Maori health issues. The discursive techniques present in these contracts is consistent with previous work demonstrating a failure of funders to centralise Maori knowledge and ways of being. Success of the proposed health reforms and the Maori Health Authority should require dismantling of non-Maori ways of commissioning and contracting, otherwise there is the continued risk of discriminatory contracting practices limiting the expression of self-determination for Maori health providers.

Structured review of primary interventions to reduce group A streptococcal infections, acute rheumatic fever and rheumatic heart disease.

Rheumatic heart disease (RHD) is a large, preventable, global public health burden. In New Zealand (NZ), acute rheumatic fever (ARF) and RHD rates are highest for Maori and Pacific children. This structured review explores the evidence for primary prevention interventions to diagnose and effectively treat group A Streptococcus (GAS) pharyngitis and skin infections to reduce rates of ARF and RHD. Medline, EMBASE and Scopus databases were searched as well as other electronic publications. Included were 50 publications from 1980 onwards. This review has identified that there is little available evidence for effective primary prevention strategies to reduce ARF rates in NZ. However, two primary intervention strategies that should be considered by communities at high-risk of ARF are: the use of school-based clinics to identify and treat GAS pharyngitis and GAS skin infections; and intramuscular benzathine penicillin G with lignocaine analgesia in children who present with a GAS positive throat.

Iwi (tribal) data collection at a primary health care organisation in Aotearoa.

INTRODUCTION Indigenous peoples' rights include the right to self-determine one's identity. For Maori, this includes self-assignment of ethnicity, and traditional identities such as Iwi (tribe). New Zealand's Ministry of Health requires health services to collect ethnicity data using standard protocols. Iwi data are also collected by some health services; however, with no health-specific protocols, little is known about Iwi data collection and quality. The National Hauora Coalition (NHC) Primary Healthcare Organisation (PHO) sought to understand Iwi data collection across its network of primary care providers. AIM To understand Iwi data collection at the NHC PHO; specifically, is it being routinely collected, how is it being collected and what are the results? METHODS In 2017, NHC's general practice clinics were invited to submit their enrolment forms, which capture ethnicity and potentially Iwi information, by e-mail to the audit team. Forms were reviewed to determine whether Iwi information was being collected and if so, what question was being used. Iwi numbers were collated from the annual data extract. RESULTS Thirty-three of a total of 35 clinics (94%) submitted their enrolment forms to the audit team. Nine of the 33 clinics (27%) sought Iwi name/s with a specific question on their enrolment form. Six different 'Iwi' questions were used by the nine clinics. The data extract revealed that the NHC had Iwi data for 13% (2672/20,814) of its Maori enrolments. Ngapuhi were the largest Iwi group at the NHC. DISCUSSION This is the first study to describe the quantity and quality of Iwi data collection in NZ primary care. Standard procedures for collecting, recording and using Iwi data are being developed by the NHC PHO. These could inform national protocols to optimise the quality of Iwi data.

Rheumatic heart disease in Indigenous young peoples.

Indigenous children and young peoples live with an inequitable burden of acute rheumatic fever and rheumatic heart disease. In this Review, we focus on the epidemiological burden and lived experience of these conditions for Indigenous young peoples in Australia, New Zealand, and Canada. We outline the direct and indirect drivers of rheumatic heart disease risk and their mitigation. Specifically, we identify the opportunities and limitations of predominantly biomedical approaches to the primary, secondary, and tertiary prevention of disease among Indigenous peoples. We explain why these biomedical approaches must be coupled with decolonising approaches to address the underlying cause of disease. Initiatives underway to reduce acute rheumatic fever and rheumatic heart disease in Australia, New Zealand, and Canada are reviewed to identify how an Indigenous rights-based approach could contribute to elimination of rheumatic heart disease and global disease control goals.

Pacific Fono: a community-based initiative to improve rheumatic fever service delivery for Pacific Peoples in South Auckland.

BACKGROUND AND CONTEXT Rheumatic fever inequitably affects Maori and Pacific children in New Zealand. School-based throat swabbing services, such as the South Auckland Mana Kidz programme, are a key element of rheumatic fever prevention interventions. ASSESSMENT OF THE PROBLEM Counties Manukau has the highest national rates of rheumatic fever (4.7 per 100,000 for first recorded rates). Given these disparities, Mana Kidz undertook an exploratory, community-based initiative to improve its service delivery for Pacific Peoples. RESULTS Mana Kidz held a Pacific Leaders' Fono (meeting) to discuss initiatives to improve rheumatic fever outcomes in South Auckland focused around challenges and solutions for addressing rheumatic fever, effective engagement strategies and leadership qualities needed to drive initiatives. Oral and written responses from 66 attendees were collected and thematically analysed. Four key themes were identified around challenges and solutions for rheumatic fever: social determinants of health; cultural responsiveness; health system challenges; and education, promotion and literacy. Three effective engagement strategies were identified: by Pacific for Pacific; developing a rheumatic fever campaign; improving health services. Three key leadership attributes were identified: culturally responsive leaders; having specific expertise and skills; youth-driven leadership. STRATEGIES FOR IMPROVEMENT Mana Kidz has now created Pacific leadership roles in rheumatic fever governance groups, promotes Pacific workforce development and endorses Pacific-led initiatives and partnerships. LESSONS Recognising the value of critical reflection and the importance of good governance and collaborative, right-based partnerships in health services.

Beyond awareness: Towards a critically conscious health promotion for rheumatic fever in Aotearoa, New Zealand.

Since 2014, the Rheumatic Fever Prevention Programme has targeted communities in Aotearoa, New Zealand affected by high rates of rheumatic fever (RF): namely, Maori and Pacific families. Initiated with the aim of reducing ethnic health disparities, the Health Promotion Agency attempted to use culturally appropriate approaches by engaging in consultative processes with Maori and Pacific communities and health leaders in developing the intervention. However, these consultations largely focused on evaluating strategies for reaching "priority" audiences with the message to get sore throats checked and on changing health-seeking behaviours. There was little regard for what the structural roots of RF in Aotearoa might suggest about equitable interventions, nor for the potentially harmful effects of the messages and their presentation. The concept of structural violence can be a useful analytical tool to critically evaluate such interventions which attempt to address health disparities but do not meaningfully attend to equity. Drawing on three ethnographic studies with: 1) Northland Maori families (Anderson et al., 2015); 2) North Island Maori and Pacific families (Anderson et al., 2017); and 3) Maori and Pacific children at a South Auckland school (Spray, 2020), we show how recategorising RF disparities as expressions of violence reveals how, despite including cultural consultation, interventions may still inequitably distribute responsibility. In particular, by responsibilising communities affected with the highest rates of RF, the intervention creates collateral damage of stigma, internalised blame, emotional suffering and hypervigilance that reproduces structural violence. We suggest that attending to how families experience public health messaging in the context of their daily lives may guide a more critical and culturally safe health promotion that looks beyond awareness and behaviour and towards equity.

Oral and dental health and health care for Maori with type 2 diabetes: A qualitative study.

OBJECTIVES: Type 2 diabetes mellitus (T2DM) and periodontal disease are two highly prevalent, directly and independently associated long-term conditions that disproportionately impact Indigenous Maori in New Zealand (NZ). Although poorly understood, a number of social and biological mechanisms connect these conditions. This qualitative study explored experiences of T2DM and oral and dental (hereafter oral/dental) health; access to oral/dental health care; whether participants' experiences supported or challenged existing evidence; and sought suggestions for improving oral/dental health in a high-deprivation rural area of Northland, NZ. METHODS: Participants (n = 33) meeting the study criteria: self-identified Maori ethnicity, aged ≥ 18-years with glycated haemoglobin (HBA1c) >65 mmol/L were recruited via the local primary care clinic in September-December 2015; two left the study prior to data collection. During face-to-face semi-structured interviews, participants (n = 31) were asked How does diabetes affect your teeth? and When did you last access dental care? Kaupapa Maori (KM) theory and methodology provided an important decolonizing lens to critically analyse the fundamental causes of Indigenous health inequities. RESULTS: Independent analysis of qualitative data by three KM researchers identified four themes: access barriers to quality care; pathways to edentulism; the 'cost' of edentulism; and, unmet need. Results contributed towards informing Mana Tu-an evidence-based KM programme for diabetes in primary care-to be introduced in this and other communities from 2018. CONCLUSIONS: Oral health is integral to diabetes management, and vice versa. Subsidized specialist referrals for oral-dental health care for Maori with T2DM could improve glycaemic control and diabetes outcomes and reduce diabetes-related complications among this population.

Social exclusion and community in an urban retirement village.

Large purpose-built retirement complexes including continuing care options are increasingly popular ways to 'age in place' for older people in New Zealand and internationally. Promoted by their corporate owners as a lifestyle choice offering a wealth of activities and social interaction in manicured settings along with security and increasing care on site as needed, these entities offer new ways for wealthier older people to age. Applying an ethnographic approach to a case study residential complex in Auckland, New Zealand, we explore how residents experience inclusion and exclusion, and sense of community within such environments with a diversity of fit and frail residents. Data was collected from interviews, walk-about conversations, social site mapping and a selection of media material to gain an understanding of the social issues important to the residents. The twelve participants, aged between 70 and 87, were all independent residents living in the independent part of the complex, which is situated in a socio-economically wealthy suburb of Auckland. We identified that social connections were often fragile, and existing social group membership was key to shared community experiences and a sense of belonging. Residents who found themselves on the social fringes, particularly as newcomers or through health decline, were at risk of marginalisation, stigma, and social exclusion. Further, we identified how the design and layout, and tensions in the structure of the resident-management relationship potentially hinder inclusiveness and sense of community. These findings shed light on alternative experiences at odds with the commercial and populist framing of these places as age-friendly and inclusive communities promoting active lifestyles.