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.

Indigenous health worker support for patients with poorly controlled type 2 diabetes: study protocol for a cluster randomised controlled trial of the Mana Tu programme.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) and its complications are more common among Maori and Pacific people compared with other ethnic groups in New Zealand. Comprehensive and sustained approaches that address social determinants of health are required to address this condition, including culturally specific interventions. Currently, New Zealand has no comprehensive T2DM management programme for Maori or Pacific people. METHODS AND ANALYSIS: The Mana Tu programme was developed by a Maori-led collaborative of primary healthcare workers and researchers, and codesigned with whanau (patients and their families) in order to address this gap. The programme is based in primary care and has three major components: a Network hub, Kai Manaaki (skilled case managers who work with whanau with poorly controlled diabetes) and a cross-sector network of services to whom whanau can be referred to address the wider determinants of health. The Network hub supports the delivery of the intervention through training of Kai Manaaki, referrals management, cross-sector network development and quality improvement of the programme. A two-arm cluster randomised controlled trial will be conducted to evaluate the effectiveness of the Mana Tu programme among Maori, Pacific people or those living in areas of high socioeconomic deprivation who also have poorly controlled diabetes (glycated haemoglobin, HbA1c, >65 mmol/mol (8%)), compared with being on a wait list for the programme. A total of 400 participants will be included from 10 general practices (5 practices per group, 40 participants per practice). The primary outcome is HbA1c at 12 months. Secondary outcomes include blood pressure, lipid levels, body mass index and smoking status at 12 months. This protocol outlines the proposed study design and analysis methods. ETHICS AND DISSEMINATION: Ethical approval for the trial has been obtained from the New Zealand Health and Disability Ethics Committee (17/NTB/249). Findings will be presented to practices and their patients at appropriate fora, and disseminated widely through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12617001276347; Pre-result.

Mana Tu: a whanau ora approach to type 2 diabetes.

In 2017, the National Hauora Coalition, a Maori-led Primary Health Organisation (PHO), was awarded a Long-Term Conditions Partnership Research grant to test the effectiveness of Mana Tu: a whanau ora approach to type 2 diabetes. With moves to replicate aspects of it in programmes around New Zealand, it is timely to describe the rationale for Mana Tu and the key components of its unique model of care. Mana Tu was developed in response to current ethnic and social inequities in type 2 diabetes rates, outcomes and wider determinants. It attempts to address various system, service and patient factors that impact on the whanau's ability to 'mana tu' or 'stand with authority' when living with a long-term condition. Results, including clinical, implementation and cost-effectiveness data, will be collected and analysed over the next two years.

Cardiovascular risk management at a Maori-led Primary Health Organisation--findings from a cross-sectional audit.

AIM: To examine the cardiovascular disease (CVD) risk profile and management for the first 12 months of an electronic risk assessment program at Tamaki Healthcare, Auckland. METHODS: An audit of risk assessment and medication data supplemented by a manual case record review. RESULTS: 1522 people were screened representing around 15.5% of the eligible population. Of the 1420 people with data available, 248 (17.5%) had a calculated 5-year CVD risk > or = 15% and another 177 (12.5%) had previous CVD. Maori were significantly more likely to be at high CVD risk than non-Maori (OR 2.07 (1.51-2.84); p<0.001). For Pacific peoples (mostly of Samoan, Tongan, Niuean, Fijian, or Cook Islands origin) there was no increased likelihood of high CVD risk. Medication data were available for 399 (95.5%) people at high CVD risk. Prescribing rates for this group were 78.1% for blood pressure lowering, 71.9% for lipid-lowering, 65.3% for anti-platelet ,and 50.3% for all three therapies. Whilst this group may represent the better end of the management spectrum, success in achieving treatment targets was modest. For 451 people with either diabetes or established CVD, 65.9% and 66.1% were not meeting blood pressure and lipid management recommendations respectively. There were very few disparities in prescribing rates and attainment of target levels by ethnic group. CONCLUSION: This study has shown that a primary care electronic risk assessment program can be rapidly implemented within 12 months. Although the sample may not be representative due to a small proportion screened so far, major disparities in risk factor prevalence rates were found- particularly for Maori. Furthermore, substantial guideline-practice gaps were encountered in the appropriate prescribing of cardiovascular medicines and attainment of recommended targets. Several Tamaki Healthcare initiatives to address these findings are discussed.