Health and Wellness Coaching for 5-Year Projected Cardiovascular Health: A Randomized Controlled Trial.

Background and Objectives: Evidence of effective multifactorial lifestyle interventions for primary stroke prevention is lacking, despite the significant contribution of lifestyle to stroke burden. We aimed to determine the efficacy of health and wellness coaching (HWC) for primary stroke and cardiovascular disease (CVD) prevention in adults at a moderate-to-high CVD risk. Methods: This was a parallel, 2-arm, open-label, single-blinded, phase III randomized controlled trial to determine the efficacy of HWC for primary stroke prevention in individuals 30 years and older with a 5-year CVD risk ≥10% as measured by 5-year absolute CVD risk (as measured by the PREDICT tool) at 9 months post-randomization. Eligible participants were those with a 5-year CVD risk ≥10%, with no history of stroke, transient ischemic attack, or myocardial infarction. The relative risk reduction (RRR) and odds ratios (OR) were evaluated separately in those at moderate (10%-14%) 5-year CVD risk and those at high risk (≥15%) at baseline. The Life's Simple 7 (LS7) score for lifestyle-related CVD risk, as the indicator of cardiovascular health, was a key secondary outcome. Results: Of a total of 320 participants, 161 were randomized to the HWC group and 159 to the usual care (UC) group. HWC resulted in a statistically significant RRR of -10.9 (95% CI -21.0 to -0.9) in 5-year CVD risk in the higher CVD risk group but no change in the moderate risk group. An improvement in the total LS7 score was seen in the HWC group compared with the UC group (absolute difference = 0.485, 95% CI [0.073 to 0.897], p = 0.02). Improvement in blood pressure scores was statistically significantly greater in the HWC group than in the UC group for those at high risk of CVD (OR 2.28 [95% CI 1.12 to 4.63] and 1.55 [0.80 to 3.01], respectively). No statistically significant differences in mood scores, medication adherence, quality of life, and satisfaction with life scores over time or between groups were seen. Discussion: Health and wellness coaching resulted in a significant RRR in the 5-year CVD risk compared with UC at 9 months post-randomization in patients with a high baseline CVD risk. There was no improvement in CVD risk in the moderate risk group; hence, this study did not meet the primary hypothesis. However, this treatment effect is clinically significant (number needed to treat was 43). The findings suggest that HWC has potential if further refined to improve lifestyle risk factors of stroke.

Randomised pragmatic waitlist trial with process evaluation investigating the effectiveness of peer support after brain injury: protocol.

INTRODUCTION: Traumatic brain injury (TBI) is an important global health problem. Formal service provision fails to address the ongoing needs of people with TBI and their family in the context of a social and relational process of learning to live with and adapt to life after TBI. Our feasibility study reported peer support after TBI is acceptable to both mentors and mentees with reported benefits indicating a high potential for effectiveness and likelihood of improving outcomes for both mentees and their mentors. OBJECTIVES: To (a) test the effectiveness of a peer support intervention for improving participation, health and well-being outcomes after TBI and (b) determine key process variables relating to intervention, context and implementation to underpin an evidence-based framework for ongoing service provision. METHODS AND ANALYSIS: A randomised pragmatic waitlist trial with process evaluation. Mentee participants (n=46) will be included if they have moderate or severe TBI and are no more than 18 months post-injury. Mentor participants (n=18) will be people with TBI up to 6 years after injury, who were discharged from inpatient rehabilitation at least 1 year prior. The primary outcome will be mentee participation, measured using the Impact on Participation and Autonomy questionnaire after 22 weeks. Primary analysis of the continuous variables will be analysis of covariance with baseline measurement as a covariate and randomised treatment as the main explanatory predictor variable at 22 weeks. Process evaluation will include analysis of intervention-related data and qualitative data collected from mentors and service coordinators. Data synthesis will inform the development of a service framework for future implementation. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the New Zealand Health and Disability Ethics Committee (19/NTB/82) and Auckland University of Technology Ethics Committee (19/345). Dissemination of findings will be via traditional academic routes including publication in internationally recognised peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12619001002178.

He Tuhononga Whaiaro: A Kaupapa Maori Approach to Mate Wareware (Dementia) and Cognitive Assessment of Older Maori.

AIM: The aim of this study is to investigate Maori (Indigenous peoples of Aotearoa New Zealand) understandings of dementia (mate wareware) and develop a framework to inform assessment of cognitive impairment. METHOD: Qualitative, kaupapa Maori (Maori approach) research with 241 older Maori (kaumatua) involving 17 focus groups across Aotearoa New Zealand (NZ) and eight families (whanau) from one region. We thematically analyzed transcribed data from audio-recorded interviews. RESULTS: Two overarching themes, namely, connection (Tuhononga) and self (Whaiaro), and eight subthemes in particular mind (hinengaro), spirit (wairua), body (tinana), family (whanau), social connection (whanaungatanga), identity and role (tuakiri), place (wahi), and ancestors (tupuna) emerged. Maori language (Te Reo Maori) was important for cognitive health. CONCLUSION: The findings embedded in cultural values improve understanding of dementia (mate wareware) in Maori. These themes can inform the assessment of older Maori with cognitive impairment. For those without cognitive impairment, the Tuhononga Whaiaro framework suggests factors potentially crucial for healthy aging in Maori.

Attitudes of rural communities towards the use of technology for health purposes in New Zealand: a focus group study.

OBJECTIVES: Examine attitudes to using online health and wellness services, and determine what barriers may exist to this in two rural communities in New Zealand. DESIGN: A thematic analysis informed by a social constructivist paradigm explored the attitudes of youth and adults to give voice to these communities. Eighteen focus groups-nine in each region-were held for an hour each, with between three and nine participants in each group. SETTING: Two rural areas at the Northern and Southern ends of New Zealand were chosen. In each area, we partnered with a local health centre providing primary care services. Three localities were identified within each region where we conducted the data collection. PARTICIPANTS: Participants were youth aged 12-15 years, aged 16-20 years and adults over 21 years. Overall, 74 females and 40 males were recruited. Recruitment occurred through schools, community organisations or personal contacts of the facilitators, who were youth workers in their respective communities. Ethnicity of the participants was representative of each area, with a higher percentage of Maori participants in Northland. RESULTS: Eight themes were identified which described participants' attitudes to technology use in healthcare. Themes covered accessibility, cost, independence, anonymity and awareness issues: technology makes health information easily accessible; access to technology can be limited in rural communities; technology can reduce the cost of healthcare but it is too expensive for some; technology increases independence and autonomy of people's own health; independent healthcare decisions come with risks; anonymity encourages people to seek help online; technology can help raise awareness and provide peer-support for people with health issues; technology impacts on social relationships. CONCLUSIONS: Participants-particularly youth-were generally positive about the role of technology in healthcare delivery, and interested in ways technology could improve autonomy and access to health and wellness services.

Measuring stroke and transient ischemic attack burden in New Zealand: Protocol for the fifth Auckland Regional Community Stroke Study (ARCOS V).

Aim: The goal of this paper is to provide a protocol for conducting a fifth population-based Auckland Regional Community Stroke study (ARCOS V) in New Zealand. Methods and Discussion: In this study, for the first time globally, (1) stroke and TIA burden will be determined using the currently used clinical and tissue-based definition of stroke, in addition to the WHO clinical classifications of stroke used in all previous ARCOS studies, as well as more advanced criteria recently suggested for an "ideal" population-based stroke incidence and outcomes study; and (2) age, sex, and ethnic-specific trends in stroke incidence and outcomes will be determined over the last four decades, including changes in the incidence of acute cerebrovascular events over the last decade. Furthermore, information at four time points over a 40-year period will allow the assessment of effects of recent changes such as implementation of the FAST campaign, ambulance pre-notification, and endovascular treatment. This will enable more accurate projections for health service planning and delivery. Conclusion: The methods of this study will provide a foundation for future similar population-based studies in other countries and populations.

Mate wareware: Understanding 'dementia' from a Maori perspective.

AIM: To investigate Maori (Indigenous people of Aotearoa New Zealand) understandings of dementia, its causes, and ways to manage a whanau (extended family) member with dementia. METHOD: We undertook kaupapa Maori research (Maori informed research) with 223 kaumatua (Maori elders) who participated in 17 focus groups across seven study regions throughout Aotearoa New Zealand and eight whanau from the Waikato region. We audio recorded all interviews, transcribed them and then coded and categorised the data into themes. RESULTS: Mate wareware (becoming forgetful and unwell) ('dementia') affects the wairua (spiritual dimension) of Maori. The findings elucidate Maori understandings of the causes of mate wareware, and the role of aroha (love, compassion) and manaakitanga (hospitality, kindness, generosity, support, caring) involved in caregiving for whanau living with mate wareware. Participants perceived cultural activities acted as protective factors that optimised a person's functioning within their whanau and community. CONCLUSION: Whanau are crucial for the care of a kaumatua with mate wareware, along with promoting healthy wairua for all. Whanau urgently need information to assist with their knowledge building and empowerment to meet the needs of a member affected by mate wareware. This requires collaborative healthcare practice and practitioners accessing the necessary matauranga Maori (Maori knowledge) to provide culturally appropriate and comprehensive care for whanau.

Do data from child protective services and the police enhance modelling of perinatal risk for paediatric abusive head trauma? A retrospective case-control study.

OBJECTIVES: First, to investigate whether there is a relationship between a family being known to child protective services or police at the time of birth and the risk of abusive head trauma (AHT, formerly known as shaken baby syndrome). Second, to investigate whether data from child protective services or police improve a predictive risk model derived from health records. DESIGN: Retrospective case control study of child protective service and police records. SETTING: Nine maternity hospitals. PARTICIPANTS: 142 consecutive cases of AHT admitted to a tertiary children's hospital from 1991 to 2010 and born in one of the nine participating maternity hospitals. 550 controls matched by the date and hospital of birth. OUTCOME MEASURE: Abusive head trauma. RESULTS: There is a relationship between families known to child protective services or police and the risk of AHT. Notification to child protective services: univariable OR 7.24 (95% CI 4.70 to 11.14). Involvement with youth justice: univariable OR 8.94 (95% CI 4.71 to 16.95). Police call-out for partner violence: univariable OR 3.85 (95% CI 2.51 to 5.91). Other violence offence: univariable OR 2.73 (95% CI 1.69 to 4.40). Drug offence: univariable OR 2.82 (95% CI 1.63 to 4.89). However, in multi-variable analysis with data from perinatal health records, notification to child protective services was the only one of these variables to remain in the final model (OR 4.84; 95% CI 2.61 to 8.97) and had little effect on overall predictive power. The area under the receiver operating characteristic curve was 89.5% (95% CI 86.6 to 92.5) using variables from health data alone and 90.9% (95% CI 88.0 to 93.7) when notification was added. CONCLUSIONS: Family involvement with child protective services or police is associated with increased risk of AHT. However, accessing such data at the time of birth would add little predictive power to a risk model derived from routine health information.

Making sense of recovery after traumatic brain injury through a peer mentoring intervention: a qualitative exploration.

OBJECTIVE: To explore the acceptability of peer mentoring for people with a traumatic brain injury (TBI) in New Zealand. DESIGN: This is a qualitative descriptive study exploring the experiences reported by mentees and mentors taking part in a feasibility study of peer mentoring. Interviews with five mentees and six mentors were carried out. Data were analysed using conventional content analysis. SETTING: The first mentoring session took place predischarge from the rehabilitation unit. The remaining five sessions took place in mentees' homes or community as preferred. PARTICIPANTS: Twelve people with TBI took part: six mentees (with moderate to severe TBI; aged 18-46) paired with six mentors (moderate to severe TBI >12 months previously; aged 21-59). Pairing occurred before mentee discharge from postacute inpatient brain injury rehabilitation. Mentors had been discharged from rehabilitation following a TBI between 1 and 5 years previously. INTERVENTION: The peer mentoring programme consisted of up to six face-to-face sessions between a mentee and a mentor over a 6-month period. The sessions focused on building rapport, exploring hopes for and supporting participation after discharge through further meetings and supported community activities. RESULTS: Data were synthesised into one overarching theme: making sense of recovery. This occurred through the sharing of experiences and stories; was pivotal to the mentoring relationship; and appeared to benefit both mentees and mentors. Mentors were perceived as valued experts because of their personal experience of injury and recovery, and could provide support in ways that were different from that provided by clinicians or family members. Mentors required support to manage the uncertainties inherent in the role. CONCLUSIONS: The insight mentors developed through their own lived experience established them as a trusted and credible source of hope and support for people re-engaging in the community post-TBI. These findings indicate the potential for mentoring to result in positive outcomes.

Patient experience of a psychiatric Mother Baby Unit.

BACKGROUND: Mothers with severe mental illness are vulnerable and engage with services cautiously due to fears of stigma and custody loss. To develop best practice standards and patient-centred services, the subjective experience of those who use it must inform service improvement and policy. METHOD: This study utilised exploratory concurrent mixed methods design with primarily qualitative data. Women admitted between April 2015 and December 2016 to a newly developed psychiatric Mother Baby Unit (MBU) in New Zealand were invited to participate in this study. Qualitative data were collected in three ways: (i) semi-structured interviews incorporating Maori concepts of health and wellness by research assistants near discharge; (ii) invitation to provide anonymous feedback in writing using an open format; (iii) unsolicited verbal feedback provided during a home visit three months after discharge. Thematic analysis was undertaken. Demographic and clinical information was collected prospectively for mother-infant pairs during the course of admission and three months post-discharge. RESULTS: Forty-five people participated in the study. High rates of satisfaction were described. Strengths of the service-as perceived by mothers-included co-admission of mother and infant, staff warmth and availability, transparent practice, inclusion of families, and having a comfortable environment. Mothers described intense distress and confusion, as well as negative self-perceptions when acutely unwell. Infant co-admission and the inclusion of partners and other family members alleviated mothers' distress. Personal attributes of staff, practical support with caregiving, a range of therapeutic approaches and holistic care were all valued. Feedback collected three months after discharge was the most reflective. Significant inter-ethnic differences were not apparent. CONCLUSIONS: The experience of inpatient care can have lasting influence on recovery and wellbeing. Employing a Maori model of health broadened the holistic nature of enquiry. The approach and timing taken in seeking the views of participants' yielded different information, all of which is of value to service evaluation and refinement. The findings suggest that keeping mothers and infants together during health service utilisation such as MBUs should be a priority for policy makers and service designers. This approach is consistent with Maori values, combining the importance of whanau relationships (kinship), wairua (spiritual connectivity), hinengaro (the mind) and tinana (physical health). These findings suggest that 'holistic care'-in this case following a Maori holistic health model-is important in mental health settings.

Strengths and Difficulties Questionnaire: internal validity and reliability for New Zealand preschoolers.

OBJECTIVES: This observational study examines the internal construct validity, internal consistency and cross-informant reliability of the Strengths and Difficulties Questionnaire (SDQ) in a New Zealand preschool population across four ethnicity strata (New Zealand European, Maori, Pasifika, Asian). DESIGN: Rasch analysis was employed to examine internal validity on a subsample of 1000 children. Internal consistency (n=29 075) and cross-informant reliability (n=17 006) were examined using correlations, intraclass correlation coefficients and Cronbach's alpha on the sample available for such analyses. SETTING AND PARTICIPANTS: Data were used from a national SDQ database provided by the funder, pertaining to New Zealand domiciled children aged 4 and 5 and scored by their parents and teachers. RESULTS: The five subscales do not fit the Rasch model (as indicated by the overall fit statistics), contain items that are biased (differential item functioning (DIF)) by key variables, suffer from a floor and ceiling effect and have unacceptable internal consistency. After dealing with DIF, the Total Difficulty scale does fit the Rasch model and has good internal consistency. Parent/teacher inter-rater reliability was unacceptably low for all subscales. CONCLUSION: The five SDQ subscales are not valid and not suitable for use in their own right in New Zealand. We have provided a conversion table for the Total Difficulty scale, which takes account of bias by ethnic group. Clinicians should use this conversion table in order to reconcile DIF by culture in final scores. It is advisable to use both parents and teachers' feedback when considering children's needs for referral of further assessment. Future work should examine whether validity is impacted by different language versions used in the same country.

Primary prevention of stroke and cardiovascular disease in the community (PREVENTS): Methodology of a health wellness coaching intervention to reduce stroke and cardiovascular disease risk, a randomized clinical trial.

Rationale Stroke is a major cause of death and disability worldwide, yet 80% of strokes can be prevented through modifications of risk factors and lifestyle and by medication. While management strategies for primary stroke prevention in high cardiovascular disease risk individuals are well established, they are underutilized and existing practice of primary stroke prevention are inadequate. Behavioral interventions are emerging as highly promising strategies to improve cardiovascular disease risk factor management. Health Wellness Coaching is an innovative, patient-focused and cost-effective, multidimensional psychological intervention designed to motivate participants to adhere to recommended medication and lifestyle changes and has been shown to improve health and enhance well-being. Aims and/or hypothesis To determine the effectiveness of Health Wellness Coaching for primary stroke prevention in an ethnically diverse sample including Maori, Pacific Island, New Zealand European and Asian participants. Design A parallel, prospective, randomized, open-treatment, single-blinded end-point trial. Participants include 320 adults with absolute five-year cardiovascular disease risk ≥ 10%, calculated using the PREDICT web-based clinical tool. Randomization will be to Health Wellness Coaching or usual care groups. Participants randomized to Health Wellness Coaching will receive 15 coaching sessions over nine months. Study outcomes A substantial relative risk reduction of five-year cardiovascular disease risk at nine months post-randomization, which is defined as 10% relative risk reduction among those at moderate five-year cardiovascular disease risk (10-15%) and 25% among those at high risk (>15%). Discussion This clinical trial will determine whether Health Wellness Coaching is an effective intervention for reducing modifiable risk factors, and hence decrease the risk of stroke and cardiovascular disease.

Perinatal Risk and Protective Factors for Pediatric Abusive Head Trauma: A Multicenter Case-Control Study.

OBJECTIVE: To estimate associations between factors recorded in pregnancy and the first week of life and subsequent abusive head trauma. STUDY DESIGN: Multicenter, retrospective case-control study of perinatal records from 142 cases of abusive head trauma and 550 controls, matched by date and hospital of birth from 1991 to 2010. Multiple logistic regression assessed the relationship between perinatal exposures and abusive head trauma. RESULTS: The risk of abusive head trauma decreased with increasing maternal age (OR, 0.91 per year; 95% CI 0.85-0.97) and increasing gestational age at birth (OR 0.79 per week; 95% CI 0.69-0.91). Mothers of cases were more likely to be Maori (OR 4.61; 95% CI 1.98-10.78), to be single (OR 5.10; 95% CI 1.83-14.23), have recorded social concerns (OR 4.29; 95% CI 1.32-13.91), and have missing data for antenatal care, partner status, social concerns, and substance abuse (OR 13.53; 95% CI 2.39-76.47). Case mothers were more likely not to take supplements in pregnancy (OR 3.53; 95% CI 1.30-9.54), to have membrane rupture longer than 48 hours before delivery (OR 13.01; 95% CI 2.84-59.68), and to formula feed (OR for mixed breast and formula feeding 6.06; 95% CI 2.39-15.36) before postnatal discharge (median 3 days). CONCLUSIONS: Factors associated with subsequent abusive head trauma can be identified from routine perinatal records. Targeted interventions initiated perinatally could possibly prevent some cases of abusive head trauma. However, any plans for targeted prevention strategies should consider not only those with identified risk factors but also those for which data are missing.

Cross-cultural acceptability and utility of the strengths and difficulties questionnaire: views of families.

BACKGROUND: Screening children for behavioural difficulties requires the use of a tool that is culturally valid. We explored the cross-cultural acceptability and utility of the Strengths and Difficulties Questionnaire for pre-school children (aged 3-5) as perceived by families in New Zealand. METHODS: A qualitative interpretive descriptive study (focus groups and interviews) in which 65 participants from five key ethnic groups (New Zealand European, Maori, Pacific, Asian and other immigrant parents) took part. Thematic analysis using an inductive approach, in which the themes identified are strongly linked to the data, was employed. RESULTS: Many parents reported they were unclear about the purpose of the tool, affecting its perceived value. Participants reported not understanding the context in which they should consider the questions and had difficulty understanding some questions and response options. Maori parents generally did not support the questionnaire based approach, preferring face to face interaction. Parents from Maori, Pacific Island, Asian, and new immigrant groups reported the tool lacked explicit consideration of children in their cultural context. Parents discussed the importance of timing and multiple perspectives when interpreting scores from the tool. CONCLUSIONS: In summary, this study posed a number of challenges to the use of the Strengths and Difficulties Questionnaire in New Zealand. Further work is required to develop a tool that is culturally appropriate with good content validity.

Whakawhiti Korero, a Method for the Development of a Cultural Assessment Tool, Te Waka Kuaka, in Maori Traumatic Brain Injury.

The importance of tools for the measurement of outcomes and needs in traumatic brain injury is well recognised. The development of tools for these injuries in indigenous communities has been limited despite the well-documented disparity of brain injury. The wairua theory of traumatic brain injury (TBI) in Maori proposes that a culturally defined injury occurs in tandem with the physical injury. A cultural response is therefore indicated. This research investigates a Maori method used in the development of cultural needs assessment tool designed to further examine needs associated with the culturally determined injury and in preparation for formal validation. Whakawhiti korero is a method used to develop better statements in the development of the assessment tool. Four wananga (traditional fora) were held including one with whanau (extended family) with experience of traumatic brain injury. The approach was well received. A final version, Te Waka Kuaka, is now ready for validation. Whakawhiti korero is an indigenous method used in the development of cultural needs assessment tool in Maori traumatic brain injury. This method is likely to have wider applicability, such as Mental Health and Addictions Services, to ensure robust process of outcome measure and needs assessment development.

An examination of Maori tamariki (child) and taiohi (adolescent) traumatic brain injury within a global cultural context.

OBJECTIVE: This paper provides a pragmatic review of the literature to describe the size and shape of Maori tamariki (child) and taiohi (adolescent) traumatic brain injury (TBI) and highlight issues pertinent to psychiatrists. A review of the literature describing cultural aspects of international TBI research further contextualises these findings. METHODOLOGY: Literature searches using the words indigenous, ethnic, culture, native, native American, native Alaskan, native Hawaiian, Maori, aboriginal, traumatic brain injury, rehabilitation, paediatric, disparities and epidemiology were undertaken. Reference lists were also examined. RESULTS: The literature is adult-centric and selected papers are summarised. Significant gaps in the literature were found. Recent local epidemiological studies describe Maori tamariki and taiohi as being significantly over-represented in TBI populations, with poorer outcomes including higher mortality rates. International research shows evidence of 'minority' culture being a risk factor for certain causes of injury and a differential rehabilitation service response. CONCLUSIONS: These findings are important for psychiatrists working with Maori. They underscore the importance of asking effectively about possible TBI history. Implications for future research to address literature gaps are evident. Kaupapa Maori rangahau (research) could be used to explore application of tikanga Maori (cultural lore) in prevention, rehabilitation and psychiatric management.

Te Ira Tangata: a Zelen randomised controlled trial of a treatment package including problem solving therapy compared to treatment as usual in Maori who present to hospital after self harm.

BACKGROUND: Maori, the indigenous people of New Zealand, who present to hospital after intentionally harming themselves, do so at a higher rate than non-Maori. There have been no previous treatment trials in Maori who self harm and previous reviews of interventions in other populations have been inconclusive as existing trials have been under powered and done on unrepresentative populations. These reviews have however indicated that problem solving therapy and sending regular postcards after the self harm attempt may be an effective treatment. There is also a small literature on sense of belonging in self harm and the importance of culture. This protocol describes a pragmatic trial of a package of measures which include problem solving therapy, postcards, patient support, cultural assessment, improved access to primary care and a risk management strategy in Maori who present to hospital after self harm using a novel design. METHODS: We propose to use a double consent Zelen design where participants are randomised prior to giving consent to enrol a representative cohort of patients. The main outcome will be the number of Maori scoring below nine on the Beck Hopelessness Scale. Secondary outcomes will be hospital repetition at one year; self reported self harm; anxiety; depression; quality of life; social function; and hospital use at three months and one year. DISCUSSION: A strength of the study is that it is a pragmatic trial which aims to recruit Maori using a Maori clinical team and protocol. It does not exclude people if English is not their first language. A potential limitation is the analysis of the results which is complex and may underestimate any effect if a large number of people refuse their consent in the group randomised to problem solving therapy as they will effectively cross over to the treatment as usual group. This study is the first randomised control trial to explicitly use cultural assessment and management. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000952246.

General practitioners' views about diagnosing and treating depression in Maori and non-Maori patients.

INTRODUCTION: The study investigated general practitioners' (GPs') views about recognising and treating depression among patients to establish possible reasons for reported lower levels of diagnosis and treatment of depression among Maori compared to non-Maori patients. METHODS: Semi-structured interviews with 23 GPs in the Auckland region, including both Maori and non-Maori GPs, elicited GPs' views about risk factors for depression, recognising depression and circumstances in which GPs would prescribe medication or recommend other treatments for depression. FINDINGS: A framework was developed which incorporated the strategies GPs reported using to diagnose and treat depression. This consisted of three categories: (a) how depression is identified, (b) factors influencing treatment decisions, and (c) treatment outcomes. Reasons reported by GPs as most likely to lead to ethnic differences in diagnosing depression were greater stigma relating to admitting depression among Maori patients, Maori patients being less likely to talk about being depressed, and the need for patients to have effective communication with their GP. Effective communication, where Maori patients felt free to talk about personal feelings, was more likely when there was an established relationship between the GP and patient. CONCLUSION: The findings are consistent with previous reports that depression is less likely to be diagnosed by GPs among Maori patients, compared to non-Maori patients. GPs who are able to establish effective communication with patients, gain their trust and take account of the reluctance of some Maori patients to talk about personal feelings, are more likely to diagnose and treat depression effectively.

Whakaora nga moemoea o nga tupuna--living the dreams of the ancestors. Future planning in a Kaupapa Maori CAMHS team.

OBJECTIVE: The aim of this study was to identify and operationalize aspects of a future planning process for sustainable delivery of Kaupapa Maori (Specialist Maori) mental health from a team called He Kakano, within Child and Adolescent Mental Health Services in South Auckland, New Zealand. METHODS: A 2-day hui (meeting) was held with members of the team and a facilitator, Whaea Moe Milne. Review of background national epidemiological data, local data, information from community, carer and tangata whaiora (consumer) stakeholders and the existing He Kakano Model of Care was undertaken. Use of tikanga (Maori protocol and practices) was evident throughout the hui. RESULTS: A number of aspects of tikanga were identified as essential to the positive outcomes of the future plan. This paper reports one in particular, that of whakatauaki (proverbs where the originator is known). "Whakaora nga moemoea o nga tupuna--living the dreams of the ancestors" is a whakatauaki articulated by Whaea Moe Milne, which was identified as helpful in influencing the strategic planning thinking and decision-making process for He Kakano. This whakatauaki enabled the identification of shared goals, values, beliefs, behaviours and an action plan. The existing and ongoing relationship with Whaea Moe Milne was identified as an important element in the way in which the whakatauaki was received and reflected on. CONCLUSIONS: Use of tikanga Maori, in this case, whakatauaki, was helpful in developing future planning for He Kakano. This suggests that use of tikanga may be beneficial in other settings where planning for sustainable Maori responsive services is undertaken. Further work in this area is likely to benefit service development, strategic planning, workforce development and have an impact on improving health outcomes for Maori.