Working Together to Support Self-Determination for Tangata Kapo (Blind and Low Vision) Maori: An Exemplar.

This paper addresses the marginalisation of tangata kapo Maori (blind and low-vision Indigenous New Zealanders) in health- and vision-related research, despite New Zealand's commitments to international conventions. Utilising a purakau-based approach, it challenges existing colonial narratives and emphasises the importance of Maori perspectives. We advocate for Maori self-determination over research processes. This paper shares insights from a systematic review and the development of a declaration for engaging with tangata kapo Maori, reflecting the 3-year collaborative process. The Materials and Methods section details a Kaupapa Maori-grounded data collection, prioritising relationships and cultural practices. Feedback loops with participants and forums ensure accurate representation. In conclusion, the study underscores NZ government obligations and presents the "3Rs" framework-relationships, respect, and reciprocity-as essential for meaningful research engagements with tangata kapo Maori. The findings contribute valuable insights to guide future research practices, advocating for the inclusion and recognition of tangata kapo Maori rights in practice and research.

Harti Hauora Tamariki: randomised controlled trial protocol for an opportunistic, holistic and family centred approach to improving outcomes for hospitalised children and their families in Aotearoa, New Zealand.

Background: Health and wellbeing inequities between the Indigenous Maori and non-Maori populations in Aotearoa, New Zealand continue to be unresolved. Within this context, and of particular concern, hospitalisations for diseases of poverty are increasing for tamariki Maori (Maori children). To provide hospitalised tamariki Maori, and their whanau (families) comprehensive support, a wellbeing needs assessment; the Harti Hauora Tamariki Tool (The Harti tool) was developed. The purpose of this study is to determine how effective the Harti tool is at identifying wellbeing needs, ensuring the documentation of needs, enabling access to services and improving wellbeing outcomes for tamariki and their whanau. Methods: The study uses a Kaupapa Maori methodology with qualitative and quantitative methods. Qualitative methods include in-depth interviews with whanau. This paper presents an overview of a randomised, two parallel, controlled, single blinded, superiority trial for quantitative evaluation of the Harti programme, and hospital satisfaction with care survey. Participants will be Maori and non-Maori tamariki/children aged 0-4 years admitted acutely to the paediatric medical wards at Waikato Hospital, Hamilton, Aotearoa New Zealand. They will be randomised electronically into the intervention or usual care group. The intervention group will receive usual care in addition to the Harti programme, which includes a 24-section health needs assessment delivered by trained Maori navigators to whanau during the time they are in hospital. The primary endpoint is the relative risk of an acute hospital readmission in the 30 days following discharge for the intervention group patients compared with control group patients. Secondary outcomes include access and utilisation of preventative health services including: oral health care, general practice enrolment, immunisation, healthy home initiatives, smoking cessation and the Well Child Tamariki Ora universal health checks available free of charge for children in Aotearoa New Zealand. Discussion: Randomised controlled trials are a gold standard for measuring efficacy of complex multifaceted interventions and the results will provide high quality evidence for implementing the intervention nationwide. We expect that this study will provide valuable evidence for health services and policy makers who are considering how to improve the configuration of paediatric hospital services. Trial registration: The study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), registration number: ACTRN12618001079235.

Reciprocal relations between cardiovascular disease, employment, financial insecurity, and post cardiac event recovery among Maori men: a case series.

BACKGROUND: Disparities in cardiovascular outcomes between Maori and non-Maori persist despite technological advances in the treatment of cardiovascular disease and improved service provision. Little is known about how social determinants of health, such as income [in]security affect Maori men's access, treatment, and recovery from cardiovascular disease. This paper explores the contexts within which cardiovascular disease is experienced and healthcare becomes embedded. METHODS: This study utilized a case-comparative narrative approach to document and make sense of the patient experiences of four male Maori patients who, in the previous 6 months, had come through cardiac investigation and treatment at Waikato Hospital, a large tertiary cardiac center in New Zealand. Participant accounts were elicited using a culturally patterned narrative approach to case development, informed by Kaupapa Maori Research practices. It involved three repeat 1-3-hour interviews recorded with participants (12 interviews); the first interviews took place 5-16 weeks after surgery/discharge. RESULTS: Each of the four case studies firstly details a serious cardiac event(s) before describing the varying levels of financial worry they experienced. Major financial disruptions to their lives were at the forefront of the concerns of those facing financial insecurity-as opposed to their medical problems. Financial hardship within the context of an unresponsive welfare system impacted the access to care and access to funding contributed to psychological distress for several participants. Economic security and reciprocal relationships between employers and employees facilitated positive treatment experiences and recovery. CONCLUSION: Findings suggest that although multiple factors influence participant experiences and treatment outcomes, financial [in]security, and personal income is a key determinant. The heterogeneity in participant narratives suggests that although general inequities in health may exist for Maori as a population group, these inequities do not appear to be uniform. We postulate diverse mechanisms, by which financial insecurity may adversely affect outcomes from treatment and demonstrate financial security as a significant determinant in allowing patients to respond to and recover from cardiovascular disease more effectively.

Understanding the context of hospital transfers and away-from-home hospitalisations for Maori.

In Aotearoa New Zealand, people regularly travel away from their home to receive hospital care. While the role of whanau support for patients in hospital is critical for Maori, there is little information about away-from-home hospitalisations. This paper describes the frequency and patterning of away-from-home hospitalisations and inter-hospital transfers for Maori. Data from the National Minimum Dataset (NMDS), for the 6-year period of 1 January 2009-31 December 2014, were analysed. Basic frequencies, means and descriptive statistics were produced using SAS software. We found that more than 10% of all routine hospitalisations constituted an away-from-home hospitalisation for Maori; that is, a hospitalisation that was in a district health board (DHB) other than the DHB of usual residence for the patient. One quarter (25.19%) of transfer hospitalisations were to a DHB other than the patient's DHB of domicile. Away-from-home hospital admissions increase for Maori as deprivation increases for both routine and transfer admissions, with over half of Maori hospital admissions among people who live in areas of high deprivation. This analysis aids in understanding away-from-home hospitalisations for Maori whanau, the characteristics associated with these types of hospitalisations and supports the development and implementation of policies which better meet whanau Maori needs. The cumulative impact of the need to travel to hospital for care, levels of poverty and a primarily reimbursement-based travel assistance system all perpetuate an unequal cost burden placed upon Maori whanau.

Holistic antenatal education class interventions: a systematic review of the prioritisation and involvement of Indigenous Peoples' of Aotearoa New Zealand, Australia, Canada and the United States over a 10-year period 2008 to 2018.

BACKGROUND: Research into the effectiveness of antenatal education classes is crucial for Indigenous Peoples from Aotearoa New Zealand, Australia, Canada and the United States who experience poorer maternal and infant health outcomes compared to non-Indigenous populations. Our systematic review questions were intended to determine the extent of Indigenous Peoples prioritisation and involvement in antenatal education classes, and to understand the experience of Indigenous Peoples from these countries in antenatal education classes. METHODS: Using a standardised protocol, we systematically searched five electronic databases for primary research papers on antenatal education classes within the four countries noted and identified 17 papers that met the criteria. We undertook a qualitative meta-synthesis using a socio-critical lens. RESULTS: Systematic review of the academic literature demonstrates that Indigenous Peoples of Aotearoa New Zealand, Australia, Canada and the United States are not prioritised in antenatal education classes with only two of 17 studies identifying Indigenous participants. Within these two studies, Indigenous Peoples were underrepresented. As a result of poor engagement and low participation numbers of Indigenous Peoples in these antenatal education classes, it was not possible to understand the experiences of Indigenous Peoples. CONCLUSION: Given that Indigenous Peoples were absent from the majority of studies examined in this review, it is clear little consideration is afforded to the antenatal health needs and aspirations of Indigenous Peoples of Aotearoa New Zealand, Australia, Canada and the United States. To address the stark antenatal health inequities of Indigenous Peoples, targeted Indigenous interventions that consider culture, language, and wider aspects of holistic health must be privileged. TRIAL REGISTRATION: PROSPERO Registration ID: CRD4202017658.

Positively Pregnant: Development and piloting of a mobile app for social and emotional well-being in pregnancy.

This paper describes development of a mobile e-health application, Positively Pregnant, which provides tools to meet the psychological challenges of pregnancy and transition to parenthood. Positively Pregnant was developed with input from maternity carers and consumers, incorporating local cultures and contexts as well as international research on effective interventions for stress management and mental well-being. The prototype app was piloted with 88 New Zealand women. Participants in the pilot used an average of 11.96 (SD = 7.44) components, and most were satisfied (45.1%) or neutral (40.3%) regarding the app. For 23 of the 26 interactive components, the majority of those who tried the component reported that they found it helpful. Participants reported a significant reduction in subjective stress (η2 = .088, p = .023). Feedback from pilot participants was incorporated in a version of the app that was publically launched as a free tool to support developing families. Mobile e-health applications are a promising medium for providing preventative interventions and psychoeducation about the social and emotional challenges of pregnancy and early parenting; Positively Pregnant is an example of a tool, grounded in strength-based, empirically supported strategies, to provide parents with support and information at this critical time.

He Pikinga Waiora Kimi Ora lifestyle programme: case study of a successful community-based Indigenous diabetes intervention.

AIM: To co-design and implement a whanau-centred, community-based lifestyle programme (Kimi Ora) intended to ensure no worsening of HbA1c and to improve wellbeing for Maori whanau and communities with diabetes or pre-diabetes. METHODS: Maori healthcare providers, community members, research advisors and wider stakeholders used a co-design process underpinned by He Pikinga Waiora to collaboratively develop and implement Kimi Ora Control group comparisons and participants were recruited from Te Kohao Health. Multi-method monitoring and collection captured individual, whanau and community data. RESULTS: Kimi Ora was run in two communities in Aotearoa New Zealand. In total, there were 35 participants who took part in an eight-week programme offered five times alongside a comparison group comprising 21 participants. Kimi Ora resulted in significant improvements on all biomedical measures compared to baseline, and participants had gains relative to the comparison group for variables including weight, BMI, blood pressure and waist measurement. Of particular note was the 100% retention rate and sustained community support for Kimi Ora. CONCLUSIONS: Outcomes from Kimi Ora demonstrate this programme, which was actively tailored for and worked with Maori communities in a responsive and flexible manner, resulted in successful biomedical outcomes, high engagement and high retention.

Observations by and Conversations with Health Workers and Hospital Personnel Involved in Transferring Maori Patients and Whanau to Waikato Hospital in Aotearoa New Zealand.

The predominant focus of Aotearoa New Zealand's public health system on biomedical models of health has left little room for meaningful engagement with holistic indigenous approaches. Culturally appropriate provision and support are recognized for their relevance and importance during hospital transferals. Hospital staff involved in transfers to one of New Zealand's trauma centers share their observations of whanau Maori engagement during an admission away from their home base. Sixteen key informants share their experiences, which are presented as strategies and challenges to whanau engagement. Three main themes highlight challenges within the health system that make it difficult for hospital staff to engage whanau in the desired ways and as often as both parties would like. Key informants described services and practices that are not designed with patients and their whanau in mind; instead they are designed by clinicians around the needs of administrative systems. As employees within the public health system, key informants felt powerless to challenge dominant settings. Nevertheless, employees managed to circumnavigate processes. Our findings highlight the need for continued decolonization and anti-racism work within public health settings.

Experiences of Maori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research.

OBJECTIVE: This paper aims to synthesise the broader perspectives of Maori patients and their whanau (extended family, family group) of their treatment within the public health system. Our research question was 'What are the experiences of Maori in the public health and/or hospital system in Aotearoa New Zealand?' METHODS: A systematic search using PRISMA protocols and reflexive typology organised around the categories of Maori, public healthcare and qualitative research identified 14 papers that covered all three categories. We undertook a qualitative metasynthesis on these papers using a critical community psychology approach. RESULTS: Maori patients and whanau from the included papers mention both barriers and facilitators to health. We categorised barriers as organisational structures, staff interactions and practical considerations. Facilitators were categorised as the provision of whanau support in the form of practical assistance, emotional care and health system navigation. CONCLUSIONS: For many Maori, the existing public health system is experienced as hostile and alienating. Whanau members provide support to mitigate this, but it comes as a cost to whanau. Implications for public health: Public health providers must find ways to ensure that Maori consistently experience positive, high-quality healthcare interactions that support Maori ways of being.

Whanau Maori explain how the Harti Hauora Tool assists with better access to health services.

In this paper, whanau Maori highlight how a Kaupapa Maori-centred intervention (the Harti Hauora Tamariki tool, hereafter Harti tool) has improved interactions with health services. The Harti tool is undergoing a randomised control trial (RCT) at Waikato Hospital in New Zealand. As part of the RCT, the authors engaged in a series of qualitative interviews with whanau members of tamariki Maori (children aged 0-5 years) admitted to Waikato Hospital's paediatric ward. Whanau who met at least one criteria for New Zealand's domains of deprivation were included. Using a Kaupapa Maori approach to the study, participants shared their views on barriers and facilitators to accessing health resources and primary care services. The interviews conducted highlight how the Harti tool, when administered in a culturally appropriate and respectful manner that prioritised relationship-building, enabled better connection to healthcare services. Prevalent in our analysis were connections to wider determinants of health and ways to reduce existing health inequities. To conclude the paper, how the Harti tool has enhanced feelings of being in control of health, with the potential to reduce the likelihood of a hospital readmission, is highlighted.

Critical reflection for researcher-community partnership effectiveness: the He Pikinga Waiora process evaluation tool guiding the implementation of chronic condition interventions in Indigenous communities.

Critically reflecting on researcher-community partnerships is a key component in implementing chronic condition interventions in Indigenous communities. This paper draws on the results and learnings from a process evaluation that measures how well two research-community partnerships have followed the He Pikinga Waiora (HPW) Implementation Framework while co-designing chronic condition interventions in primary care. The HPW framework is centred on Indigenous self-determination and knowledge surrounded by community engagement, cultural centredness, systems thinking and integrated knowledge translation. The evaluation included in-depth interviews and online surveys with 10 team members. The findings demonstrate that the HPW framework was followed well, with strengths particularly in community engagement and relationship building. Areas for improvement included systems thinking and integrated knowledge translation to support sustainability of the interventions. The need for partnerships to use process evaluation results to support critical reflection is asserted, which helps build strong trust and synergy, power sharing and effective and sustainable implementation practices. It is concluded that the HPW framework is well suited to evaluating implementation of health interventions in primary care as it assists in the facilitation of better collaboration between researchers and Indigenous communities, and encourages the implementation team to reflect on power and privilege.

What protects against pre-diabetes progressing to diabetes? Observational study of integrated health and social data.

AIMS: To examine the incidence of type 2 diabetes in people with newly diagnosed prediabetes and the factors that protect against this progression. METHODS: The study population was 14,043 adults with pre-diabetes enrolled in a primary health organization in the upper North Island of New Zealand. Glycated hemoglobin (HbA1c) and body mass index (BMI) were linked to government health, census and social datasets in the Statistics New Zealand Integrated Data Infrastructure. Adults with a first diagnosis of pre-diabetes between 2009 and 2017 (HbA1c in range 5.9-6.6% [41-49 mmol/mol]) were followed-up for type 2 diabetes incidence. Cox regression was used to examine protective factors and adjust for potential confounding. RESULTS: Cumulative diabetes incidence was 5.0% after three years. Progression was greater in younger adults, men, people with higher HbA1c, greater BMI and a more recent diagnosis. Progression was lower in people treated with metformin, and Indigenous language speakers. Higher progression rates for Maori (Indigenous population) and Pacific peoples (migrants to New Zealand) were related to higher baseline HbA1c. CONCLUSIONS: This is the first study to identify Indigenous language as a protective factor against diabetes, and results confirm obesity as a key target for population prevention. People with identified risk factors should be prioritized for pre-diabetes interventions.

Corrigendum to: Whanau Maori explain how the Harti Hauora Tool assists with better access to health services.

In this paper, whanau Maori highlight how a Kaupapa Maori-centred intervention (the Harti Hauora Tamariki tool, hereafter Harti tool) has improved interactions with health services. The Harti tool is undergoing a randomised control trial (RCT) at Waikato Hospital in New Zealand. As part of the RCT, the authors engaged in a series of qualitative interviews with whanau members of tamariki Maori (children aged 0-5 years) admitted to Waikato Hospital's paediatric ward. Whanau who met at least one criteria for New Zealand's domains of deprivation were included. Using a Kaupapa Maori approach to the study, participants shared their views on barriers and facilitators to accessing health resources and primary care services. The interviews conducted highlight how the Harti tool, when administered in a culturally appropriate and respectful manner that prioritised relationship-building, enabled better connection to healthcare services. Prevalent in our analysis were connections to wider determinants of health and ways to reduce existing health inequities. To conclude the paper, how the Harti tool has enhanced feelings of being in control of health, with the potential to reduce the likelihood of a hospital readmission, is highlighted.

He aha te mea nui o te ao? He tangata! (What is the most important thing in the world? It is people!).

This paper highlights the importance of people as a central factor in improving health for Maori (Indigenous people of New Zealand). How whanau (family) relationships, connections, values and inspiration are integral to achieving Indigenous health goals is explained. Descriptions of how community researchers, healthcare staff, consumers and academics worked together to design interventions for two health services (in the Waikato and Bay of Plenty regions) is included. Through highlighting the experiences of health consumers, the potential for future interventions to reduce the advancement of pre-diabetes among whanau is described. Evidence from the study interviews reinforces the importance of whanau and whakapapa (heritage) as enabling factors for Indigenous people to improve health. Specifically, the positive effect of whanau enhancing activities that support peoples' aspirations of tino rangatiratanga (self-determination) in their lives when engaging with health care has been observed. This study highlights the many positives that have emerged, and offers an opportunity for taking primary health to the next level by placing whanau alongside Indigenous primary care providers at the centre of change strategies.

Implementation framework for chronic disease intervention effectiveness in Maori and other indigenous communities.

BACKGROUND: About 40% of all health burden in New Zealand is due to cancer, cardiovascular disease, and type 2 diabetes/obesity. Outcomes for Maori (indigenous people) are significantly worse than non-Maori; these inequities mirror those found in indigenous communities elsewhere. Evidence-based interventions with established efficacy may not be effective in indigenous communities without addressing specific implementation challenges. We present an implementation framework for interventions to prevent and treat chronic conditions for Maori and other indigenous communities. THEORETICAL FRAMEWORK: The He Pikinga Waiora Implementation Framework has indigenous self-determination at its core and consists of four elements: cultural-centeredness, community engagement, systems thinking, and integrated knowledge translation. All elements have conceptual fit with Kaupapa Maori aspirations (i.e., indigenous knowledge creation, theorizing, and methodology) and all have demonstrated evidence of positive implementation outcomes. APPLYING THE FRAMEWORK: A coding scheme derived from the Framework was applied to 13 studies of diabetes prevention in indigenous communities in Australia, Canada, New Zealand, and the United States from a systematic review. Cross-tabulations demonstrated that culture-centeredness (p = .008) and community engagement (p = .009) explained differences in diabetes outcomes and community engagement (p = .098) explained difference in blood pressure outcomes. IMPLICATIONS AND CONCLUSIONS: The He Pikinga Waiora Implementation Framework appears to be well suited to advance implementation science for indigenous communities in general and Maori in particular. The framework has promise as a policy and planning tool to evaluate and design effective interventions for chronic disease prevention in indigenous communities.