Health, wellbeing and nutritional impacts after 2 years of free school meals in New Zealand.

In 2020, a government-funded healthy school lunch program was introduced in a quarter of New Zealand schools, selected due to high levels of socio-economic barriers. This study assesses the impact of the introduction of the school lunch program from family (whanau), student and school principal perspectives. Across four schools, we conducted five focus groups (two with secondary students and three with family members) and four school principal interviews. Participating schools represented a range of contexts: primary and secondary, schools with cooks in on-site kitchens and schools receiving meals delivered by external caterers. Thematic analysis was used to develop themes describing the health, wellbeing and nutritional impact of the program. Family participants were 82% Indigenous Maori and self-identified as having 'borderline' (73.5%) or no financial security (8.8%). Seven positive impact themes were identified: improved food security, enhanced equity, increased appreciation of healthy foods for students, enhanced mana (wellbeing) for all, reduced financial hardship/stress for families, opportunities for nutritional learning and recognition that appreciation and uptake happen over time. Four negative impact themes were identified: low uptake that created food waste, perception that healthy food is not palatable for students, lack of knowledge of the program and loss of agency for students. This is the largest intervention in nutrition and food security for children implemented in New Zealand since the 1930's. The first 2 years have offered wellbeing and financial benefits for students and families, particularly when school environments promote uptake. More involvement of students and family members in the program planning is essential.

Values, Perspectives, and Experiences of Indigenous Maori Regarding Kidney Transplantation: A Qualitative Interview Study in Aotearoa/New Zealand.

RATIONALE & OBJECTIVE: In Aotearoa/New Zealand, Indigenous Maori experience inequitable delivery of kidney transplantation despite disproportionately higher rates of kidney failure. This study describes Maori patients' and families' values, perspectives, and experiences related to kidney transplantation. STUDY DESIGN: Qualitative interview study. SETTING & PARTICIPANTS: We conducted 40 in-depth interviews of 40 Maori: 8 who had received a transplant, 20 with chronic kidney disease (which included 10 on the deceased donor transplant list, 9 who were interested in transplantation and not currently waitlisted or who were ineligible for waitlisting, and 1 who was not interested in transplantation), 4 live-kidney donors, and 8 family members including 6 who had experiences with donor assessment. ANALYTICAL APPROACH: Data were analyzed inductively to generate themes and a conceptual framework. RESULTS: We identified 5 major themes: actively seeking a kidney transplant; evolving attitudes toward traditional values and practices; being confronted by interpersonal and systemic racism; poor information and communication; and challenged by social determinants of health. LIMITATIONS: Participants were recruited nationally through patient advocacy organizations and 1 regional kidney service. Potential participants unrelated to these groups or region could not be included. CONCLUSIONS: Maori participants were highly motivated to seek kidney transplantation and were inspired by positive experiences through donating and receiving a kidney. However, they faced barriers including social determinants, racism, and lack of information that impacted both direct experiences of transplantation and access to transplantation services.

Exploring rural and remote patients' experiences of health services for kidney disease in Aotearoa New Zealand: An in-depth interview study.

AIMS: People with chronic kidney disease (CKD) living in rural communities have increased risks of death, morbidity, hospitalization and poorer quality of life compared with people with CKD living in urban areas. This study explores the experiences and perceptions of rural and remote patients and families in relation to accessing health services for kidney disease in Aotearoa New Zealand. METHODS: We conducted an In-depth interview study. We purposively sampled adult patients with CKD and their caregivers who lived further than 100 km (62 miles) or more than 1 h drive from their nearest dialysis or transplant centre. Qualitative data were analyzed inductively to generate themes, subthemes and a conceptual framework. RESULTS: Of 35 participants, including 26 patients and nine caregivers, 51% were female, 71% travelled between 1 and 3 h to their nearest renal unit, and the remainder, between 3 and 6 h. We identified five themes and related subthemes: intense psychological impact of rurality; pressure of extended periods away from home; services not designed for rural and remote living; suffering from financial losses; and poor communication. CONCLUSION: Rural and remote patients with CKD and their caregivers face the added challenges of separation from family, social and community support and financial burden, which can have profound consequences on their psychological and physical well-being and that of their families.

Combining Cognitive Mapping and indigenous knowledge to improve food environments in regional New Zealand.

ISSUE ADDRESSED: Hawke's Bay has one of the highest rates of childhood obesity in New Zealand. While several initiatives exist aiming to decrease obesity through physical activity, there are few nutritional interventions. This study adopted a systems science and matauranga Maori approach to identify and target underlying drivers of rising childhood obesity and engage the community to improve the food environment. METHODS: Cognitive mapping interviews (CM) with local stakeholders (school principals, Iwi and district health board representatives, education managers and local councillors) were conducted. The aim was to map participants' mental models of the causes of rising childhood obesity and to identify key principles for engaging with the local community in a meaningful, impactful and culturally appropriate way for future action. RESULTS: Eleven interviews were conducted face-to-face and cognitive maps were constructed. Follow-up interviews were carried out online, due to COVID restrictions, to present the maps and for interviewees to make any adjustments. Four composite themes emerged through centrality and cluster analysis of the resulting cognitive maps: the importance of building in matauranga Maori (Maori knowledge and ways of being), the "hauora" of children, working with the community and integrating existing initiatives. Two contextual factors are also considered: the growing need for food security in our communities and the opportunity to start interventions in the school setting. CONCLUSION: Cognitive mapping can produce useful insights in the early stages of community engagement. The six "pou" (pillars) underscore the importance of incorporating indigenous knowledge when embarking on public health interventions, particularly around obesity and in regional communities. SO WHAT?: When designing a public health initiative with a community with a high indigenous population, indigenous knowledge should be promoted to focus on holistic health, working with the community and creating opportunities for cohesion. These founding principles will be used to structure future community actions to improve children's food environments in regional New Zealand.

Proximal and distal influences on dietary change among a diverse group with prediabetes participating in a pragmatic, primary care nurse-led intervention: a qualitative study.

OBJECTIVE: To understand motivators, facilitators and challenges to dietary change amongst a diverse sample of New Zealanders with prediabetes participating in a primary care nurse-led individualised dietary intervention. DESIGN: A qualitative study involving semi-structured, face-to-face interviews with a stratified sample of adults with prediabetes and BMI ≥ 25 kg/m2, purposefully selected from a larger 2-year primary care-based prediabetes dietary intervention study. Thematic analysis was undertaken. A socio-ecological model guided interpretation. SETTING: Hawke's Bay, Aotearoa/New Zealand, April 2018-March 2020. PARTICIPANTS: Fifty-eight people aged 28-69 years, with similar numbers of men and women, indigenous Maori and non-Maori, and those who had and had not regressed to normoglycaemia at 6 months. RESULTS: Motivators for wanting to make dietary changes were determination not to progress to diabetes; wanting to be healthy and contribute to others and encouragement by others. Facilitators for adopting and maintaining changes were a strong desire to be healthy; personal determination and feeling supported. Challenges were compromised control over life and environmental factors; feeling unsupported by others; social occasions; financial constraints and living with other health conditions. Developing their own strategies to overcome challenges was empowering, enabling a sense of control. These factors were similar across demographic and glycaemic outcome groups. CONCLUSIONS: Influences on dietary change involved personal, interpersonal, organisational, environmental and policy factors. Although findings appeared similar across groups, dietary interventions need to address the specific ways motivators, facilitators and challenges manifest for individuals and social groups and be tailored accordingly within the context of the wider obesogenic and socio-economic environment.

Understanding the experiences, perspectives and values of indigenous women around smoking cessation in pregnancy: systematic review and thematic synthesis of qualitative studies.

BACKGROUND: The prevalence of smoking during pregnancy among indigenous women approaches 50% and is associated with sudden infant death, pregnancy loss, preterm delivery, low birth weight, and anatomical deformity. This study aims to synthesise qualitative studies by reporting experiences, perceptions, and values of smoking cessation among pregnant indigenous women to inform potential interventions. METHOD: A highly-sensitive search of MEDLINE, Embase, PsychINFO, and CINAHL, in conjunction with analysis of Google Scholar and reference lists of related studies was conducted in March 2018. We utilised two methods (thematic synthesis and an indigenous Maori analytical framework) in parallel to analyse data. Completeness of reporting in studies was evaluated using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) framework. RESULTS: We included seven studies from Australia and New Zealand involving 250 indigenous women. Three themes were identified. Realising well-being and creating agency included giving the best start to baby, pride in being a healthy mum, female role models, and family support. Understanding the drivers for smoking included the impact of stress and chaos that hindered prioritisation of self-care, the social acceptability of smoking, guilt and feeling judged, and inadequate information about the risks of smoking. Indigenous women strongly preferred culturally responsive approaches to smoking cessation, placing value on programs designed specifically for and by indigenous people, that were accessible, and provided an alternative to smoking. CONCLUSION: Future interventions and smoking cessation programmes might be more effective and acceptable to indigenous women and families when they harness self-agency and the desire for a healthy baby, recognise the high value of indigenous peer involvement, and embed a social focus in place of smoking as a way to maintain community support and relationships. Development and evaluation of smoking cessation programs for pregnant indigenous women and families is warranted.

Experiences, perspectives and values of Indigenous peoples regarding kidney transplantation: systematic review and thematic synthesis of qualitative studies.

BACKGROUND: Kidney transplantation is considered best practice treatment for end stage kidney disease (ESKD), however Indigenous patients are substantially less likely to receive either a deceased or live donor kidney transplant than non-Indigenous patients. We describe Indigenous peoples' experiences and perspectives including traditional values around kidney transplantation to inform international transplant programs. METHODS: We conducted a systematic review of qualitative studies involving Indigenous adults who have experience with or perceptions of kidney transplantation. We searched MEDLINE, Embase, PsychINFO, and CINAHL, in conjunction with analysis of Google Scholar and reference lists of related studies till July 2019. We utilised thematic synthesis to analyse data. Completeness of reporting in studies was evaluated using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) framework. RESULTS: Eight studies involving 225 Indigenous participants were included. Five themes were identified: strong desire for transplantation (seeking normality and freedom from dialysis, wanting to reduce burden of disease within community); lack of partnership in shared decision-making (receiving inadequate information, ineffective communication); barriers to live kidney donation (difficulty asking, apprehension about impact on donor, avoiding additional financial burden and fear of complications); cultural considerations (influence of traditional values and beliefs, reconciling traditional values with pragmatic need); and experiencing lack of cultural competence in clinical care (struggling with prejudice and ignorance, mistrust of clinicians and health system). CONCLUSION: Indigenous participants had a strong desire for a kidney transplant and recognised the need for more readily available kidney transplants for others in their communities with ESKD. However, they faced prejudice and a lack of cultural competence by health workers as well as wider barriers to transplantation in systems that did not support effective and culturally appropriate delivery of information and care. Traditional cultural values also influenced decisions regarding kidney transplantation but such values were moderated when considering transplantation. Transplantation programs need to identify and mitigate barriers, such as the financial burden, promote cultural safety and incorporate traditional values into the promotion of transplantation in order to address inequitable transplantation rates. REGISTRATION: Not applicable.

Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition.

BACKGROUND: Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. METHODS: A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Maori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa - Maori Medical Practitioners Association (Te ORA) and consultation with Maori medical practitioners via Te ORA. RESULTS: Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the 'taken for granted' power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming 'competent' in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. CONCLUSIONS: A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

Predictors of breastfeeding duration in a predominantly Maori population in New Zealand.

BACKGROUND: Although breastfeeding duration in New Zealand's indigenous Maori is shorter than in non-Maori, we know little about barriers or motivators of breastfeeding in this community. The aim of this analysis was to identify predictors for extended duration of breastfeeding amongst participants drawn from predominantly Maori communities in regional Hawke's Bay. METHODS: Mother/baby dyads were recruited from two midwifery practices serving predominantly Maori women in mostly deprived areas, for a randomised controlled trial comparing the risks and benefits of an indigenous sleeping device (wahakura) and a bassinet. Questionnaires were administered at baseline (pregnancy) and at one, three and six months postnatal. Several questions relating to breastfeeding and factors associated with breastfeeding were included. The data from both groups were pooled to examine predictors of breastfeeding duration. RESULTS: Maori comprised 70.5% of the 197 participants recruited. The median time infants were fully breastfed was eight weeks and Maori women were more likely to breastfeed for a shorter duration than New Zealand European women with an odds-ratio (OR) of 0.45 (95% CI 0.24, 0.85). The key predictors for extended duration of breastfeeding were the strong support of the mother's partner (OR = 3.64, 95% CI 1.76, 7.55) or her mother for breastfeeding (OR = 2.47, 95% CI 1.27, 4.82), longer intended duration of maternal breastfeeding (OR = 1.02, 95% CI 1.00, 1.03) and being an older mother (OR = 1.07, 95% CI 1.02, 1.12). The key predictors for shorter duration of breastfeeding were pacifier use (OR = 0.28, 95% CI 0.17, 0.46), daily cigarette smoking (OR = 0.51, 95% CI 0.37, 0.69), alcohol use (OR = 0.54, 95% CI 0.31, 0.93) and living in a more deprived area (OR 0.40, 95% CI 0.22, 0.72). CONCLUSIONS: Breastfeeding duration in this group of mainly Maori women was shorter than the national average. Increasing the duration of breastfeeding by these mothers could be further facilitated by ante and postnatal education involving their own mothers and their partners in the support of breastfeeding and by addressing pacifier use, smoking and alcohol use.

The Pepi-Pod study: Overnight video, oximetry and thermal environment while using an in-bed sleep device for sudden unexpected death in infancy prevention.

AIM: The aim of this study was to identify the potential risks and benefits of sleeping infants in a Pepi-Pod distributed to families with high risk of sudden unexpected death in infancy compared to a bassinet. METHODS: Forty-five mostly indigenous Maori mothers who were referred by local health providers to receive a Pepi-Pod were surveyed at recruitment, 1 and 3 months. A sleep study at 1 month included infrared video, oximetry and temperature measures. RESULTS: When compared with 89 historical bassinet controls, an intention-to-treat analysis of questionnaires showed no increase in direct bed sharing but demonstrated significantly less sharing of the maternal bedroom at both interviews, with the majority of those not sleeping in the maternal bedroom, actually sleeping in the living room. The 1 month 'as-used' analysis showed poorer maternal sleep quality. The 'as-used' analysis of video data (24 Pepi-Pod and 113 bassinet infants) also showed no increase in direct bed sharing, head covering or prone/side sleep position. Differences in oxygen saturation were not significant, but heart rate was higher in the Pepi-Pod infants by 8.37 bpm (95% confidence interval 4.40, 12.14). Time in the thermal comfort zone was not different between groups despite Pepi-Pod infants being situated in significantly warmer rooms. CONCLUSIONS: Overall, we found that most differences in infant risk behaviours in a Pepi-Pod compared to a bassinet were small, with confidence intervals excluding meaningful differences. We noted poorer maternal sleep quality at 1 month. Higher infant heart rates in the Pepi-Pod group may be related to higher room temperatures. The Pepi-Pod appears physiologically safe but is associated with lower reported maternal sleep quality.

The recent fall in postperinatal mortality in New Zealand and the Safe Sleep programme.

AIM: Postneonatal mortality rates changed very little from 2000 until recently. There has been a decrease in mortality in New Zealand from 2009 to 2015. This study describes an infant Safe Sleep programme and postulates it is the cause for the recent decrease in deaths. METHODS: The Safe Sleep programme involved as follows: a focus on preventing accidental suffocation, a 'blitz' approach to SUDI education, the targeted provision of portable infant Safe Sleep devices (ISSD) and the development of Safe Sleep policy across all district health boards (DHBs). RESULTS: Participation in the education 'blitz' by health professionals exceeded one in 23 live births, distribution of Safe Sleep leaflets exceeded two for every live birth, and over 16 500 ISSDs have been distributed to vulnerable infants. Postperinatal mortality fell 29% from 2009 to 2015 (2.8 to 2.0/1000 live births). The fall has been greatest for Maori and in regions with the most intensive programmes. CONCLUSION: The recent fall in postperinatal mortality has not happened by chance. It is likely that the components of end-stage prevention strategy, a focus on preventing accidental suffocation, the education 'blitz', the targeted supply of ISSDs and strengthened health policy, have all contributed to varying degrees.

Methodology and recruitment for a randomised controlled trial to evaluate the safety of wahakura for infant bedsharing.

BACKGROUND: Sudden Unexpected Death in Infancy (SUDI) has persistent high rates in deprived indigenous communities and much of this mortality is attributable to unsafe sleep environments. Whilst health promotion worldwide has concentrated on avoidance of bedsharing, the indigenous Maori community in New Zealand has reproduced a traditional flax bassinet (wahakura) designed to be used in ways that include bedsharing. To date there has been no assessment of the safety of this traditional sleeping device. METHODS/DESIGN: This two arm randomised controlled trial is being conducted with 200 mother-baby dyads recruited from Maori communities in areas of high deprivation in the Hawkes Bay, New Zealand. They are randomised to wahakura or bassinet use and investigation includes questionnaires at baseline (pregnancy), when baby is 1, 3, and 6 months, and an overnight video sleep study at 1 month with monitoring of baby temperature and oxygen saturation, and measurement of baby urinary cotinine and maternal salivary oxytocin. Outcome measures are amount of time head covered, amount of time in thermal comfort zone, number of hypoxic events, amount of time in the assigned sleep device, amount of time breastfeeding, number of parental (non-feed related) touching infant events, amount of time in the prone sleep position, the number of behavioural arousals and the amount of time infant is awake overnight. Survey data will compare breastfeeding patterns at 1, 3, and 6 months as well as data on maternal mind-mindedness, maternal wellbeing, attachment to baby, and maternal sleep patterns. DISCUSSION: Indigenous communities require creative SUDI interventions that fit within their prevailing world view. This trial, and its assessment of the safety of a wahakura relative to a standard bassinet, is an important contribution to the range of SUDI prevention research being undertaken worldwide. TRIALS REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12610000993099 Registered 16th November 2010.

Health care delivery of kidney transplantation to indigenous Maori in Aotearoa New Zealand: A qualitative interview study with clinician stakeholders.

OBJECTIVES: Indigenous people experience higher rates of kidney failure than do non-Indigenous Peoples. However, compared to Indigenous patients, health care systems deliver kidney transplantation to non-Indigenous patients at a substantially higher rate and more frequently as the first treatment of kidney failure. Indigenous Maori patients in Aotearoa New Zealand report numerous barriers to kidney transplantation. We explore the perspectives of clinicians as stakeholders in the delivery of kidney transplantation. METHODS: In 2021/2022 we conducted in-depth qualitative interviews with key stakeholder clinicians within kidney transplantation services in Aotearoa New Zealand, asking them about the issues for Maori patients. We used thematic analysis informed by critical theory to identify key findings and used structural coding to categorize the themes at the level of society, health system, and health services. RESULTS: We interviewed 18 clinicians (nine nephrologists, including two transplant nephrologists, and nine nurses, including six transplant coordinators). We identified nine themes from stakeholders related to delivery of kidney transplantation services to Maori patients and whanau (family), categorized according to three main levels: Firstly, at the level of society (the impact of colonization and distrust). Secondly, the health care system (failure to prevent and manage kidney disease, health care model delivers inequitable outcomes, and inadequate Maori health professional workforce). Thirdly, health care services (transplantation reliant on patient and family resources, complex assessment causes untimely delays, clinical criteria for transplantation, and lack of clinician ability to effect change). CONCLUSIONS: Delivery of kidney transplantation to Indigenous Peoples is impacted at the level of society, health care system, and health care service. To address inequities, a broad approach that addresses each of these levels is required.

Ngati and healthy: translating diabetes prevention evidence into community action.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is a major health issue in New Zealand Maori. Clinical trials have demonstrated potential for the prevention of T2DM, but whether community public health programmes aiming to prevent diabetes are effective is untested. OBJECTIVE: To describe the planning and design of an intervention aiming to translate T2DM prevention clinical trial evidence into a community-wide population health intervention in a high risk predominantly Maori community. APPROACH: Community concerns about the diabetes burden were heard by the local diabetes nurse, herself a tribal member, and discussed with a locally raised academic. Project planning ensued. The intervention and its evaluation were designed using a participatory community development model. The planned intervention had three components: community-wide health promotion initiatives conveying healthy lifestyle messages, community education and monitoring for identified high-risk individuals and their extended families, and a structural strategy aimed at adapting local environments to support lifestyle changes. The evaluation plan involved interrupted time series surveys coupled with formative and process evaluations rather than a randomised control trial design. DISCUSSION: Consulting communities, validating community concerns and prioritising cultural and ethical issues were key steps. Time spent developing good relationships amongst the health provider and academic research team members at the outset proved invaluable, as the team were united in addressing the project planning and implementation challenges, such as funding obstacles that arose because of our ethically and culturally appropriate non-randomised control trial evaluation design. The pre-intervention survey demonstrated high rates of diabetes (13%), insulin resistance (33%) and risk factors, and provided evidence for positive, as opposed to negative, lifestyle intervention messages. CONCLUSION: Community-wide lifestyle interventions have the potential to reduce rates of type 2 diabetes and other chronic diseases in high-risk communities, but require a high level of commitment from the health sector and buy-in from the community. Adequate commitment, leadership, planning and resources are essential.

"We Need a System that's Not Designed to Fail Maori": Experiences of Racism Related to Kidney Transplantation in Aotearoa New Zealand.

BACKGROUND: Reported experiences of racism in Aotearoa New Zealand are consistently associated with negative measures of health, self-rated health, life satisfaction, and reduced access to high-quality healthcare with subsequent poor health outcomes. In this paper, we report on perceptions and experiences of prejudice and racism by Indigenous Maori with kidney disease and their family members and donors who took part in a wider study about experiences of kidney transplantation. METHODS: We conducted semi-structured interviews with 40 Maori between September and December 2020. Participants included those with kidney disease who had considered, were being worked up for, or who had already received a kidney transplant as well as family members and potential or previous donors. We examined the data for experiences of racism using a theoretical framework for racism on three levels: institutionalised racism, personally mediated racism, and internalised racism. RESULTS: We identified subthemes at each level of racism: institutional (excluded and devalued by health system; disease stigmatization; discriminatory body weight criteria, lack of power), personally mediated (experiencing racial profiling; explicit racism), and internalized racism (shame and unworthiness to receive a transplant). CONCLUSIONS: The wide-reaching experiences and perceptions of racism described by participants with kidney disease and their families in this research point to an unfair health system and suggest that racism may be contributing to kidney transplantation inequity in Aotearoa New Zealand. Addressing racism at all levels is imperative if we are to address inequitable outcomes for Maori requiring kidney transplantation.

A diagnosis of prediabetes when combined with lifestyle advice and support is considered helpful rather than a negative label by a demographically diverse group: A qualitative study.

AIMS: The aim of this study was to explore the experience and perceptions of a diagnosis of prediabetes among a demographically diverse sample of New Zealanders who had, and had not, regressed to normoglycaemia following participation in a primary care nurse-delivered intervention for 6 months. The sample included Indigenous Maori who have high rates of diabetes and associated co-morbidities. METHODS: A purposefully selected sample of 58 people with prediabetes and BMI >25 kg/m2, stratified by male/female, Maori/non-Maori, and those who had/had not regressed to normoglycaemia, after completing 6-months of a prediabetes intervention were interviewed. Interviews were audio-recorded and transcribed. Data were analysed by thematic analysis. RESULTS: Most participants recalled being shocked when told they had prediabetes, but they did not perceive the diagnosis to be a label in a negative sense, and some, described the diagnosis as helpful. Participants appreciated knowing that prediabetes could be reversed, and the opportunity to be able to take supported action and make lifestyle changes through the nurse-delivered prediabetes lifestyle intervention. Participants' clear preference was to take control and make dietary changes, not to take Metformin. CONCLUSIONS: Prediabetes was not considered a negative label, but an opportunity, when coupled with a primary care nurse-delivered dietary intervention.

Systems Mapping of the New Zealand Free and Healthy School Lunch Programme: Perspectives from Lunch Providers.

As part of the COVID-19 economic recovery package, the Aotearoa New Zealand Government rolled out a universal free and healthy lunch programme to the 25% least advantaged schools nationwide. This study explored experiences of school lunch providers in the Hawke's Bay region. The aim was to create a systems map identifying points of intervention through which the lunch programme could be improved to meet the goal of reducing child food insecurity. Twelve lunch providers were interviewed to generate casual loop diagrams which were examined and integrated to form a single systems map. Seven themes arose during analysis: teacher support, principal support, nutrition guidelines and government support, supply chain, ingredient suppliers, student feedback and food waste. Teacher support was important for getting students to try new foods and eat the nutritious lunches. Principal support was a strong theme impacting opportunities for broader student engagement. This study employed systems science to highlight the importance of support from different stakeholders within the lunch programme to achieve the goal of reduced child food insecurity. Further work is needed to ensure the programme meets the wider goals of the government and community, and to determine the potential broader benefits of the programme.

Culture of Healthy Eating and Food Environments, Policies, and Practices in Regional New Zealand Schools.

The school food environment plays an important role in shaping students' dietary choices, which often influence future dietary behaviours. We surveyed primary and secondary schools in Hawke's Bay, New Zealand, to measure the comprehensiveness and strength of food policies, describe the culture of food provision, and identify barriers to improving school food environments. Fifty-one schools were included in the final analysis, with 58.8% having a food policy, most of which used a generic template. Schools with food policies and those participating in the free and healthy lunch programme were more likely to have a strong culture around healthy eating. Common barriers to healthy eating were food outlets near school and resistance from students. Secondary schools reported facing more barriers to implementing healthy eating cultures, were more likely to use food as classroom rewards and to sell food to students, most of which was unhealthy. Hawke's Bay schools participating in food provision programmes are successfully improving their food environments through improved culture and delivery of healthy food; however, more action is needed to strengthen the wording and guidance in food policies and reduce the provision of unhealthy food in schools before effective change can be achieved.

Healthy Food Environments in Early Learning Services: An Analysis of Manager Survey Responses, Menus and Policies in Regional New Zealand Early Childhood Education and Care Centres.

Healthy food environments in early childhood play an important role in establishing health-promoting nutritional behaviours for later life. We surveyed Early Learning Services (ELS) in the Hawke's Bay region of New Zealand and describe common barriers and facilitators to providing a healthy food environment, through descriptive survey analysis and thematic analysis of open-ended questions. We used a policy analysis tool to assess the strength and comprehensiveness of the individual centre's nutrition policies and we report on the healthiness of menus provided daily in the centres. Sixty-two centres participated and 96.7% had policies on nutrition compared to 86.7% with policies on drinks. Of the 14 full policies provided for analysis, identified strengths were providing timelines for review and encouraging role modelling by teachers. The main weaknesses were communication with parents and staff, lack of nutrition training for staff and absence of policies for special occasion and fundraising food. With regard to practices in the ELS, food for celebrations was more likely to be healthy when provided by the centre rather than brought from home. Food used in fundraising was more likely to be unhealthy than healthy, though <20% of centres reported using food in fundraising. Only 40% of menus analysed met the national guidelines by not including any 'red' (unhealthy) items. Centre Managers considered the biggest barriers to improving food environments to be a lack of parental support and concerns about food-related choking. These results highlight the need for future focus in three areas: policies for water and milk-only, celebration and fundraising food; increased nutrition-focused professional learning and development for teachers; and communication between the centre and parents, as a crucial pathway to improved nutrition for children attending NZ early childhood education and care centres.

Community Co-Design of Regional Actions for Children's Nutritional Health Combining Indigenous Knowledge and Systems Thinking.

Children's nutrition is highly influenced by community-level deprivation and socioeconomic inequalities and the health outcomes associated, such as childhood obesity, continue to widen. Systems Thinking using community-based system dynamics (CBSD) approaches can build community capacity, develop new knowledge and increase commitments to health improvement at the community level. We applied the formal structure and resources of a Group Model Building (GMB) approach, embedded within an Indigenous worldview to engage a high deprivation, high Indigenous population regional community in New Zealand to improve children's nutrition. Three GMB workshops were held and the youth and adult participants created two systems map of the drivers and feedback loops of poor nutrition in the community. Maori Indigenous knowledge (matauranga) and approaches (tikanga) were prioritized to ensure cultural safety of participants and to encourage identification of interventions that take into account social and cultural environmental factors. While the adult-constructed map focused more on the influence of societal factors such as cost of housing, financial literacy in communities, and social security, the youth-constructed map placed more emphasis on individual-environment factors such as the influence of marketing by the fast-food industry and mental wellbeing. Ten prioritized community-proposed interventions such as increasing cultural connections in schools, are presented with the feasibility and likely impact for change of each intervention rated by community leaders. The combination of community-based system dynamics methods of group model building and a matauranga Maori worldview is a novel Indigenous systems approach that engages participants and highlights cultural and family issues in the systems maps, acknowledging the ongoing impact of historical colonization in our communities.