Local-Indigenous Autonomy and Community Streetscape Enhancement: Learnings from Maori and Te Ara Mua-Future Streets Project.

In settler countries, attention is now extending to the wellbeing benefits of recognising and promoting the Indigenous cultural identity of neighbourhoods as a contributing factor to more equitable and healthier communities. Re-indigenisation efforts to (re)implement cultural factors into urban design can be challenging and ineffective without the leadership and collaboration of local-Indigenous peoples. Undertaken in Aotearoa New Zealand, Te Ara Mua - Future Street project, demonstrated that co-design has critical potential in the reclamation of Indigenous autonomy, increased local-Indigenous presence and revitalisation of cultural identity. Employing a Kaupapa Maori (Maori-centred) research approach, we focused on the workings and perspectives of mana whenua (local-Indigenous peoples) and community stakeholder engagement in Te Ara Mua. An Indigenous theoretical framework, Te Pae Mahutonga, was utilised in the data analysis to explore perspectives of Indigenous collective agency, empowerment, and wellbeing. Our research demonstrates that developing capacity amongst Indigenous communities is integral for effective engagement and that the realisation of autonomy in urban design projects has broader implications for Indigenous sovereignty, spatial justice and health equity. Significantly, we argue that future community enhancement strategies must include not only re-designing and re-imagining initiatives, but also re-indigenising.

Suburb-level changes for active transport to meet the SDGs: Causal theory and a New Zealand case study.

The 2030 Agenda for Sustainable Development and its Sustainable Development Goals (SDGs) represent a historic global linking of health, equity and environmental sustainability. Accumulated evidence suggests that improving urban neighbourhoods to make them safer and more attractive for walking and cycling can accelerate progress towards the SDGs. The pathways to change are complex, non-linear and involve multiple pathways and multiple SDG outcomes, yet the SDG goals are often considered in isolation. Further, there have been few studies of environmental interventions for healthier transport that foreground equity. The aim of this paper is to describe and demonstrate practically how integrated interventions for placemaking and active transport can contribute to a wide range of SDG targets. First, we take an evidence-based approach to describing how such interventions are connected to targets within the SDGs. Second, we propose a complex causal theory of the pathways to change and the inter-relationships between SDGs. Third, we show, with concrete examples, how a case study project in Auckland, New Zealand illustrates these pathways, contributing to achieving the SDG targets, including barriers and challenges. We find that by addressing Goal 11 in particular ways that focus on equity (Goal 10), eight of the other goals can also be advanced. Our causal theory describes one balancing and 12 reinforcing patterns of behaviour that link interventions improvements to neighbourhoods with ten of the SDGs in a complex system. Our case study demonstrates that it is possible to successfully put this causal theory into practice through interventions, but these require strong partnerships between researchers, public health practitioners, policy-makers and communities, long-term evaluation and addressing both physical and social environments.

Systematic literature review of built environment effects on physical activity and active transport - an update and new findings on health equity.

BACKGROUND: Evidence is mounting to suggest a causal relationship between the built environment and people's physical activity behaviours, particularly active transport. The evidence base has been hindered to date by restricted consideration of cost and economic factors associated with built environment interventions, investigation of socioeconomic or ethnic differences in intervention effects, and an inability to isolate the effect of the built environment from other intervention types. The aims of this systematic review were to identify which environmental interventions increase physical activity in residents at the local level, and to build on the evidence base by considering intervention cost, and the differential effects of interventions by ethnicity and socioeconomic status. METHODS: A systematic database search was conducted in June 2015. Articles were eligible if they reported a quantitative empirical study (natural experiment or a prospective, retrospective, experimental, or longitudinal research) investigating the relationship between objectively measured built environment feature(s) and physical activity and/or travel behaviours in children or adults. Quality assessment was conducted and data on intervention cost and whether the effect of the built environment differed by ethnicity or socioeconomic status were extracted. RESULTS: Twenty-eight studies were included in the review. Findings showed a positive effect of walkability components, provision of quality parks and playgrounds, and installation of or improvements in active transport infrastructure on active transport, physical activity, and visits or use of settings. There was some indication that infrastructure improvements may predominantly benefit socioeconomically advantaged groups. Studies were commonly limited by selection bias and insufficient controlling for confounders. Heterogeneity in study design and reporting limited comparability across studies or any clear conclusions to be made regarding intervention cost. CONCLUSIONS: Improving neighbourhood walkability, quality of parks and playgrounds, and providing adequate active transport infrastructure is likely to generate positive impacts on activity in children and adults. The possibility that the benefits of infrastructure improvements may be inequitably distributed requires further investigation. Opportunities to improve the quality of evidence exist, including strategies to improve response rates and representativeness, use of valid and reliable measurement tools, cost-benefit analyses, and adequate controlling for confounders.

Can formal collaborative methodologies improve quality in primary health care in New Zealand? Insights from the EQUIPPED Auckland Collaborative.

INTRODUCTION: Auckland District Health Board was one of four District Health Boards to trial the Breakthrough Series (BTS) methodology to improve the management of long-term conditions in New Zealand, with support from the Ministry of Health. AIM: To improve clinical outcomes, facilitate planned care and promote quality improvement within participating practices in Auckland. METHODS: Implementation of the Collaborative followed the improvement model / Institute for Healthcare Improvement methodology. Three topic areas were selected: system redesign, cardio-vascular disease/diabetes, and self-management support. An expert advisory group and the Improvement Foundation Australia helped guide project development and implementation. Primary Health Organisation facilitators were trained in the methodology and 15 practice teams participated in the three learning workshops and action periods over 12 months. An independent evaluation study using both quantitative and qualitative methods was conducted. RESULTS: Improvements were recorded in cardiovascular disease risk assessment, practice-level systems of care, self-management systems and follow-up and coordination for patients. Qualitative research found improvements in coordination and teamwork, knowledge of practice populations and understanding of managing long-term conditions. CONCLUSION: The Collaborative process delivered some real improvements in the systems of care for people with long-term conditions and a change in culture among participating practices. The findings suggest that by strengthening facilitation processes, improving access to comprehensive population audit tools and lengthening the time frame, the process has the potential to make significant improvements in practice. Other organisations should consider this approach when investigating quality improvement programmes.

Hospital admissions for people with diagnosed diabetes: challenges for diabetes prevention and management programmes.

AIM: To identify the extent to which people with diabetes are admitted as inpatients to Counties Manukau District Health Board (CMDHB) hospitals compared to all New Zealand, and the costs of these admissions. METHOD: Search of National Minimum Dataset for inpatient public hospital discharges with any mention of Type 1 or Type 2 diabetes from 1996-2007. RESULTS: Overall 13% of all CMDHB inpatient discharges mentioned diabetes in 2007 compared with 12% nationally. There were differences by ethnicity among those discharges aged 45 to 64 years, with Pacific (38%), Indian (31%) and Maori (31%) being more than three times as likely as European/Other people (10%) to experience a diabetes-recorded admission. There was a substantial increase in the rate of admission per 1000 where diabetes was recorded over 1996-2007, with Maori (31%) and Pacific (52%) people aged 45-64 years showing the largest increases. Findings from Counties Manukau tended to be comparable with total New Zealand data in terms of the percentage of people with diabetes who were inpatients in 2007, but relatively more inpatients in Counties Manukau had diabetes recorded (consistent with its high population of people with diabetes). Costs of admissions, laboratory investigations, and pharmaceuticals for people with diabetes were estimated to be $66 million per annum higher than for people without diabetes, in Counties Manukau alone. CONCLUSION: The findings give support to balanced system-wide strategies (such as the Let's Beat Diabetes programme in Counties Manukau) that focus on both upstream (prevention) and downstream (management and coordinated care) responses to diabetes. The study points to a long-term and significant capacity challenge for secondary care services to respond to the forecast growth in the incidence of Type 2 diabetes, particularly in Counties Manukau. The findings also pose challenges for transfer of care to primary care providers after a hospital episode and the flow of information between care settings.