Pae Ora (Disestablishment of Maori Health Authority) Amendment Act 2024: further Crown breaches of Te Tiriti o Waitangi.

The Waitangi Tribunal in their Wai 2575 Report recommended the establishment of Te Aka Whai Ora (the Maori Health Authority) to remedy some of the contemporary breaches of Te Tiriti o Waitangi (Te Tiriti). Te Aka Whai Ora was the culmination of decades of Maori advocacy for the establishment of independent Maori health leadership, policymaking and commissioning. Under urgency, the new National-led coalition Government passed the Pae Ora (Disestablishment of Maori Health Authority) Amendment Act 2024 in February. In this paper we use Critical Tiriti Analysis (CTA), a five-stage process, to review the extent to which the Act is compliant with the five elements of Te Tiriti (the authoritative Maori text), the preamble, the three written articles and the oral article. We found that the Act had very limited Tiriti compliance and the potential to do great harm. We offered practical suggestions how this could have been avoided.

Implications for COVID-19 vaccine uptake: A systematic review.

BACKGROUND: Globally, increasing coronavirus disease (COVID-19) vaccination coverage remains a major public health concern in the face of high rates of COVID-19 hesitancy among the general population. We must understand the impact of the determinants of COVID-19 vaccine uptake when designing national vaccination programmes. We aimed to synthesise nationwide evidence regarding COVID-19 infodemics and the demographic, psychological, and social predictors of COVID-19 vaccination uptake. METHODS: We systematically searched seven databases between July 2021 and March 2022 to retrieve relevant articles published since COVID-19 was first reported on 31 December 2019 in Wuhan, China. Of the 12,502 peer-reviewed articles retrieved from the databases, 57 met the selection criteria and were included in this systematic review. We explored COVID-19 vaccine uptake determinants before and after the first COVID-19 vaccine roll-out by the Food and Drug Authority (FDA). RESULTS: Increased COVID-19 vaccine uptake rates were associated with decreased hesitancy. Concerns about COVID-19 vaccine safety, negative side effects, rapid development of the COVID-19 vaccine, and uncertainty about vaccine effectiveness were associated with reluctance to be vaccinated. After the US FDA approval of COVID-19 vaccines, phobia of medical procedures such as vaccine injection and inadequate information about vaccines were the main determinants of COVID-19 vaccine hesitancy. CONCLUSION: Addressing effectiveness and safety concerns regarding COVID-19 vaccines, as well as providing adequate information about vaccines and the impacts of pandemics, should be considered before implementation of any vaccination programme. Reassuring people about the safety of medical vaccination and using alternative procedures such as needle-free vaccination may help further increase vaccination uptake.

Providing maternity care for disadvantaged women in Aotearoa New Zealand: The impact on midwives.

BACKGROUND: Health inequities and socio-economic disadvantage are causes for concern in Aotearoa New Zealand. Becoming pregnant can increase a woman's vulnerability to poverty, with the potential for an increase in multiple stressful life events. Providing midwifery care to women living in socio-economic deprivation has been found to add additional strains for midwives. Exploring the perspectives of the midwives providing care to women living with socio-economic deprivation can illuminate the complexities of maternity care. AIM: To explore the impact on midwives when providing care for socio-economically disadvantaged women in Aotearoa New Zealand. METHOD: Inductive thematic analysis was used to analyse an open-ended question from a survey that asked midwives to share a story around maternal disadvantage and midwifery care. FINDINGS: A total of 214 stories were received from midwives who responded to the survey. Providing care to disadvantaged women had an impact on midwives by incurring increased personal costs (time, financial and emotional), requiring them to navigate threats and uncertainty and to feel the need to remedy structural inequities for women and their wider families. These three themes were moderated by the relationships midwives held with women and affected the way midwives worked across the different maternity settings. CONCLUSION: Midwives carry a greater load when providing care to socio-economically deprived women. Enabling midwives to continue to provide the necessary support for women living in socio-economic deprivation is imperative and requires additional resources and funding.

Rates of new HIV diagnoses among Indigenous peoples in Canada, Australia, New Zealand, and the United States: 2009-2017.

OBJECTIVE: To compare rates and trends of HIV diagnoses among Indigenous peoples in Canada (First Nations, Métis, Inuit, and other non-specified), Australia (Aboriginal and Torres Strait Islanders), the USA (American Indian, Alaska Native, Native Hawaiian, and Other Pacific Islanders), and New Zealand (Maori). DESIGN: We employed publicly available surveillance data from 2009 to 2017 to estimate the rate per 100 000 of HIV diagnoses. Estimated annual percentage change (EAPC) in diagnosis rates was calculated using Poisson regression. SETTING: The four countries have passive population-based HIV surveillance programs. PARTICIPANTS: Population estimates from respective census programs were used as rate denominators. MAIN OUTCOME MEASURES: Estimated annual HIV diagnosis rate per 100 000 and EAPC were calculated for total Indigenous peoples, women, and men. RESULTS: As of 2017, rates of HIV were highest in Canada (16.22, 95% confidence interval (CI): 14.30--18.33) and lowest in New Zealand (1.36, 95% CI: 0.65--2.50). Australia had a rate of 3.81 (95% CI: 2.59--5.40) and the USA 3.22 (95% CI: 2.85--3.63). HIV diagnosis rates among the total Indigenous population decreased in Canada (-7.92 EAPC, 95% CI: -9.34 to -6.49) and in the USA (-4.25 EAPC, 95% CI: -5.75 to -2.73) but increased in Australia (5.10 EAPC, 95% CI: 0.39--10.08). No significant trends over time were observed in New Zealand (2.23 EAPC, 95% CI: -4.48 to 9.47). CONCLUSION: Despite limitations to conducting cross-national comparisons, there are substantial differences in HIV diagnosis rates in these four countries that may be reflective of divergent national policies and systems that affect the health status of Indigenous peoples.

HIV Among Indigenous peoples: A Review of the Literature on HIV-Related Behaviour Since the Beginning of the Epidemic.

From the early days of the HIV epidemic, Indigenous peoples were identified as a population group that experiences social and economic determinants-including colonialism and racism-that increase exposure to HIV. There are now substantial disparities in HIV rates between Indigenous and non-Indigenous peoples in some countries. We conducted a comprehensive literature review to assess the evidence on HIV-related behaviors and determinants in four countries-Australia, Canada, New Zealand and the United States-in which Indigenous peoples share important features of colonization and marginalization. We identified 107 articles over more than 20 years. The review highlights the determinants of HIV-related behaviors including domestic violence, stigma and discrimination, and injecting drug use. Many of the factors associated with HIV risk also contribute to mistrust of health services, which in turn contributes to poor HIV and health outcomes among Indigenous peoples.

A patient-centred approach to health service delivery: improving health outcomes for people with chronic illness.

BACKGROUND: The Wagner Model provides a framework that can help to facilitate health system transition towards a chronic care oriented model. Drawing on elements of this framework as well as health policy related to patient centred care, we describe the health needs of patients with chronic illness and compare these with services which should ideally be provided by a patient-centred health system. This paper aims to increase understanding of the challenges faced by chronically ill patients and family carers in relation to their experiences with the health care system and health service providers. METHOD: We interviewed patients, carers and health care professionals (HCPs) about the challenges faced by people living with complicated diabetes, chronic heart failure or chronic obstructive pulmonary disease. RESULTS: Patients indicated that they had a range of concerns related to the quality of health care encounters with health care professionals (HCPs), with these concerns being expressed as needs or wants. These included: 1) the need for improved communication and information delivery on the part of HCPs; 2) well organised health services and reduced waiting times to see HCPs; 3) help with self care; 4) greater recognition among professionals of the need for holistic and continuing care; and 5) inclusion of patients and carers in the decision making processes. CONCLUSIONS: In order to address the challenges faced by people with chronic illness, health policy must be more closely aligned with the identified needs and wants of people affected by chronic illness than is currently the case.

Implementation and effectiveness of 'care navigation', coordinated management for people with complex chronic illness: rationale and methods of a randomised controlled trial.

BACKGROUND: Chronic illness is a significant driver of the global burden of disease and associated health care costs. People living with severe chronic illness are heavy users of acute hospital services; better coordination of their care could potentially improve health outcomes while reducing hospital use. The Care Navigation trial will evaluate an in-hospital coordinated care intervention on health service use and quality of life in chronically ill patients. METHODS/DESIGN: A randomised controlled trial in 500 chronically ill patients presenting to the emergency department of a hospital in Western Sydney, Australia. Participants have three or more hospital admissions within a previous 12 month period and either aged ≥70 years; or aged ≥45 years and of Aboriginal or Torres Strait Islander descent; or aged ≥ 16 with a diagnosis of a respiratory or cardiology related illness. Patients are randomised to either the coordinated care program (Care Navigation), or to usual care. The Care Navigation program consists of dedicated nurses who conduct patient risk assessments, oversee patient nursing while in hospital, and guide development of a care plan for the management of chronic illness after being discharged from hospital. These nurses also book community appointments and liaise with general practitioners. The main outcome variables are the number of emergency department re-presentations and hospital readmissions, and quality of life during a 24 month follow-up. Secondary outcomes are length of hospital stay, mortality, time to first hospital re-admission, time to first emergency department re-presentation, patient satisfaction, adherence to prescribed medications, amount and type of in-hospital referrals made for consultations and diagnostic testing, and the number and type of community health referrals. A process evaluation and economic analysis will be conducted alongside the randomised trial. DISCUSSION: A trial of in-hospital care coordination may support recent evidence that engaging primary health services in care plans linked to multidisciplinary team support improves patient outcomes and reduces costs to the health system. This will inform local, national and international health policy. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12609000554268.

Strategic approaches to enhanced health service delivery for Aboriginal and Torres Strait Islander people with chronic illness: a qualitative study.

BACKGROUND: Aboriginal and Torres Strait Islander people with chronic illness confront multiple challenges that contribute to their poor health outcomes, and to the health disparities that exist in Australian society. This study aimed to identify barriers and facilitators to care and support for Aboriginal and Torres Strait Islander people with chronic illness. METHODS: Face-to-face in-depth interviews were conducted with Aboriginal and Torres Strait Islander people with diabetes, chronic heart failure or chronic obstructive pulmonary disease (n-16) and family carers (n = 3). Interviews were transcribed verbatim and the transcripts were analysed using content analysis. Recurrent themes were identified and these were used to inform the key findings of the study. RESULTS: Participants reported both negative and positive influences that affected their health and well-being. Among the negative influences, they identified poor access to culturally appropriate health services, dislocation from cultural support systems, exposure to racism, poor communication with health care professionals and economic hardship. As a counter to these, participants pointed to cultural and traditional knowledge as well as insights from their own experiences. Participants said that while they often felt overwhelmed and confused by the burden of chronic illness, they drew strength from being part of an Aboriginal community, having regular and ongoing access to primary health care, and being well-connected to a supportive family network. Within this context, elders played an important role in increasing people's awareness of the impact of chronic illness on people and communities. CONCLUSIONS: Our study indicated that non-Indigenous health services struggled to meet the needs of Aboriginal and Torres Strait Islander people with chronic illness. To address their complex needs, health services could gain considerably by recognising that Aboriginal and Torres Strait Islander patients have a wealth of cultural knowledge at their disposal. Strategies to ensure that this knowledge is integrated into care and support programs for Aboriginal and Torres Strait Islander people with chronic illness should achieve major improvements.

With good intentions: complexity in unsolicited informal support for Aboriginal and Torres Strait Islander peoples. A qualitative study.

BACKGROUND: Understanding people's social lived experiences of chronic illness is fundamental to improving health service delivery and health outcomes, particularly in relation to self-management activity. In explorations of social lived experiences this paper uncovers the ways in which Aboriginal and Torres Strait Islander people with chronic illness experience informal unsolicited support from peers and family members. METHODS: Nineteen Aboriginal and Torres Islander participants were interviewed in the Serious and Continuing Illness Policy and Practice Study (SCIPPS). Participants were people with Type 2 diabetes (N = 17), chronic obstructive pulmonary disease (N = 3) and/or chronic heart failure (N = 11) and family carers (N = 3). Participants were asked to describe their experience of having or caring for someone with chronic illness. Content and thematic analysis of in-depth semi-structured interviews was undertaken, assisted by QSR Nvivo8 software. RESULTS: Participants reported receiving several forms of unsolicited support, including encouragement, practical suggestions for managing, nagging, growling, and surveillance. Additionally, participants had engaged in 'yarning', creating a 'yarn' space, the function of which was distinguished as another important form of unsolicited support. The implications of recognising these various support forms are discussed in relation to responses to unsolicited support as well as the needs of family carers in providing effective informal support. CONCLUSIONS: Certain locations of responsibility are anxiety producing. Family carers must be supported in appropriate education so that they can provide both solicited and unsolicited support in effective ways. Such educational support would have the added benefit of helping to reduce carer anxieties about caring roles and responsibilities. Mainstream health services would benefit from fostering environments that encourage informal interactions that facilitate learning and support in a relaxed atmosphere.

Effective communication is crucial to self-management: the experiences of immigrants to Australia living with diabetes.

OBJECTIVES: Ageing immigrant populations now pose problems for the management of chronic illness in Australia. This article asks questions about the experiences of immigrants in Australia with type II diabetes mellitus (DM). What impact, if any, have health policies had on the lives of immigrants? How do their experiences of living with DM compare with those of people with DM who were born in Australia? METHODS: Semi-structured interviews were conducted with 32 participants who had DM (n = 25) or cared for someone with DM (n = 7). Fifteen participants had migrated to Australia and English was not their first language. Participants were asked to describe their experience of managing diabetes. RESULTS: Immigrants to Australia confront linguistic and cultural barriers that create an extra layer of problems not experienced by Australian-born people. Older people who were born overseas face obstacles to effective engagement with the health system that weaken their ability to take an active part in the management of their conditions. CONCLUSIONS: Chronic disease policy is failing immigrants to Australia. Health professionals and services must recognize the central role that cultural diversity plays in self-management and the impact that this can have on health outcomes for immigrants with chronic illness.

HIV diagnoses in indigenous peoples: comparison of Australia, Canada and New Zealand.

In industrial countries, a number of factors put indigenous peoples at increased risk of HIV infection. National surveillance data between 1999 and 2008 provided diagnoses for Aboriginal and Torres Strait Islanders (Australia), First Nations, Inuit and Métis (Canada excluding Ontario and Quebec) and Maori (New Zealand). Each country provided similar data for a non-indigenous comparison population. Direct standardisation used the 2001 Canadian Aboriginal male population for comparison of five-year diagnosis rates in 1999-2003 and 2004-2008. Using the general population as denominators, we report diagnosis ratios for presumed heterosexual transmission, men who have sex with men (MSM) and intravenous drug users (IDU). Age standardised HIV diagnosis rates in indigenous peoples in Canada in 2004-2008 (178.1 and 178.4/100 000 for men and women respectively) were higher than in Australia (48.5 and 12.9/100 000) and New Zealand (41.9 and 4.3/100 000). Higher HIV diagnosis rates related to heterosexual contact among Aboriginal peoples, especially women, in Canada confirm a widening epidemic beyond the conventional risk groups. This potential of a generalised epidemic requires urgent attention in Aboriginal communities; available evidence can inform policy and action by all stakeholders. Although less striking in Australia and New Zealand, these findings may be relevant to indigenous peoples in other countries.

Achieving a balanced life in the face of chronic illness.

The increasing prevalence of chronic disease is a driver of health system reform in most economically advanced nations. A consistent theme within these reforms is building greater patient-centredness into the health care delivery. This study aims to develop an in-depth understanding of the experience of patients and family carers affected by chronic illness that will be the basis on which to propose policy and health system interventions that are patient-centred. Participants struggled with the ongoing tasks of balancing their lives with the increasing demands and intrusion of chronic illness. Their attempts to achieve a balance were seriously hampered by fragmented services, complexity in navigating health services, relationships with health professionals and others, and co-morbidity. Future policy directions include designing models of care and infrastructure that enable patients and their family carers to balance life and illness, and aligning patient-centred care not only within health services but also with community and social support services.

Informal care and the self-management partnership: implications for Australian health policy and practice.

OBJECTIVE: The Serious and Continuing Illness Policy and Practice Study (SCIPPS) aims to improve the care and support for patients with chronic illness and their family carers. Here we describe the carers' contribution to the self-management partnership and discuss the policy and practice implications that are relevant to improving the support available for informal care in Australia. DESIGN: A secondary analysis of SCIPPS data. Fourteen carers of patients between 45 and 85 years with chronic heart failure, chronic obstructive pulmonary disease and diabetes were conveniently sampled from western Sydney and the Australian Capital Territory. Semi-structured interviews were conducted. Data were analysed using qualitative content analysis. RESULTS: Key roles that carers perform in the self-management partnership included: home helper; lifestyle coach; advocate; technical care manager; and health information interpreter. Two negative consequences of juggling these roles included: self-neglect and conflict. CONCLUSIONS: Rigid eligibility criteria limit carers' access to essential support programs which underestimates and undervalues their contributions to the self-management partnership. Support services should focus on the development of practical skills to perform the caregiving roles. In addition, health professionals require support to work more effectively with carers to minimise the conflict that can overshadow the care and self-management partnership.

Health policy responses to rising rates of multi-morbid chronic illness in Australia and New Zealand.

OBJECTIVE: To examine current health policy in Australia and New Zealand and assess the extent to which the policies equip these countries to meet the challenges associated with increasing rates of multi-morbid chronic illnesses. METHOD: We examined reports from agencies holding data relating to chronic illness in both countries, looking at prevalence trends and the frequency of multiple morbidities being recorded. We undertook content analysis of health policy documents from Australian and New Zealand government agencies. RESULTS: The majority of people with chronic illness have multiple morbidities. Multi-morbid chronic illnesses significantly effect the health of people in both Australia and New Zealand and place substantial demands on the health systems of those countries. These consequences are both predicted to increase dramatically in the near future. Despite this, neither country explicitly acknowledges multi-morbidity as a major factor in their policies addressing chronic illness. CONCLUSION AND IMPLICATION: In addition to considering policy responses to chronic illness, policy makers should explicitly consider policies shaped to address the needs of people with multi-morbid chronic illness.

An investigation of the phenomenon of non-consensual sex among Maori men who have sex with men.

Instances of non-consensual sex (NCS) among men are highly under-reported. The research that has been conducted into this issue shows, however, that men who have sex with men experience higher rates of NCS than do other men and that these men are likely not to report that they have been subjected to NCS largely because there are no support systems in place for them. For a long time, there has been an expectation that while men might perpetrate acts of sexual violence against women, they cannot be the victims of such acts. These factors are compounded for Maori men who experience NCS. These men report that they suffer a range of long-term health effects and that they are unable to access culturally appropriate services to help overcome the effects of these negative health outcomes. At the same time, Maori men report that they have managed to find support within their cultural networks. Support services for Maori men who experience NCS need to be established and they need to incorporate appropriate cultural components into their processes and services.

Reclaiming the past to inform the future: contemporary views of Maori sexuality.

For hundreds of years, indigenous peoples have struggled to resist the imposition of Western, colonialist views of sexuality. Today, this tension continues as religious bodies attempt to impose a form of sexuality and sexual expression that derives from narrow fundamental interpretations of religious scripture. For the Maori, the indigenous people of New Zealand, the struggle to resist this imposition has a long history, which continues today. This paper draws on historical accounts including oral histories, depictions of Maori sexuality that reside in art forms such as carvings and archival material in order to describe Maori sexuality as it was lived and experienced in pre-European times. More recent information from the Maori Sexuality Project is used to inform these historical records. Together, these historical and contemporary sources provide a view of Maori sexuality that contrasts strongly with the view espoused by some Christian churches. Our understanding of Maori sexuality indicates that Maori were traditionally accepting of sexual diversity and difference and sought to embrace these elements of sexuality rather than to exclude them. The implications of these findings for the sexual rights and health of indigenous peoples, as well as for the ongoing development of Maori communities, is discussed.

Strengthening Maori participation in the New Zealand health and disability workforce.

Substantial progress has been made in Maori health and disability workforce development in the past 15 years. Key factors in successful programs to increase Maori health workforce recruitment and retention include Maori leadership, mentorship and peer support; and comprehensive support within study programs and in the transitions between school, university and work. The interventions to date provide a strong basis for ongoing action to address inequities in Maori health workforce participation, and are likely to be relevant to health workforce development approaches for other indigenous peoples.