Ma te Whakarongo-a qualitative study exploring the impact of middle ear disease on New Zealand Maori.

AIM: The study aimed to explore the impact of middle ear disease on the lives of New Zealand Maori. Ear disease is common, yet there is a paucity of research into the effect it has on people's lives, particularly indigenous populations. METHOD: The study used Kaupapa Maori-based qualitative methodology and involved a series of seven semi-structured interviews with Maori adults living with middle ear disease. RESULTS: All participants felt there were delays in recognition and treatment of their ear condition and that there were barriers to accessing healthcare. The ear condition prevented participation in cultural and recreational activities, particularly those involving water. The associated hearing loss affected education and employment opportunities, and together with ear discharge, resulted in social isolation and disconnection from Te Ao Maori (the Maori world). Overall, the condition impacted negatively on mental and spiritual wellbeing. Participants felt that funding for hearing aids, earlier recognition and treatment of the condition and healthcare staff with a better understanding of Te Ao Maori could reduce the morbidity associated with middle ear disease. CONCLUSION: The study demonstrates that living with middle ear disease presents many challenges and disadvantages for Maori and the importance of early detection and referral to specialist care.

Impact of diabetes on surgery and radiotherapy for breast cancer.

PURPOSES: This study aims to examine whether diabetes has an impact on the use of surgery and adjuvant radiotherapy in treating women with localised breast cancer. METHODS: Women diagnosed with stage I-III breast cancer between 2005 and 2020 were identified from Te Rehita Mate Utaetae-Breast Cancer Foundation New Zealand National Register, with diabetes status determined using New Zealand's Virtual Diabetes Register. The cancer treatments examined included breast conserving surgery (BCS), mastectomy, breast reconstruction after mastectomy, and adjuvant radiotherapy after BCS. Logistic regression modelling was used to estimate the adjusted odds ratio (OR) and 95% confidence interval (95% CI) of having cancer treatment and treatment delay (> 31 days) for patients with diabetes at the time of cancer diagnosis compared to patients without diabetes. RESULTS: We identified 25,557 women diagnosed with stage I-III breast cancer in 2005-2020, including 2906 (11.4%) with diabetes. After adjustment for other factors, there was no significant difference overall in risk of women with diabetes having no surgery (OR 1.12, 95% CI 0.94-1.33), although for patients with stage I disease not having surgery was more likely (OR 1.45, 95% CI 1.05-2.00) in the diabetes group. Patients with diabetes were more likely to have their surgery delayed (adjusted OR of 1.16, 95% CI 1.05-1.27) and less likely to have reconstruction after mastectomy compared to the non-diabetes group-adjusted OR 0.54 (95% CI 0.35-0.84) for stage I cancer, 0.50 (95% CI 0.34-0.75) for stage II and 0.48 (95% CI 0.24-1.00) for stage III cancer. CONCLUSIONS: Diabetes is associated with a lower likelihood of receiving surgery and a greater delay to surgery. Women with diabetes are also less likely to have breast reconstruction after mastectomy. These differences need to be taken in to account when considering factors that may impact on the outcomes of women with diabetes especially for Maori, Pacific and Asian women.

A kia ora, a wave and a smile: an urban marae-led response to COVID-19, a case study in manaakitanga.

BACKGROUND: When COVID-19 emerged, there were well-founded fears that Maori (indigenous peoples of Aotearoa (New Zealand)) would be disproportionately affected, both in terms of morbidity and mortality from COVID-19 itself and through the impact of lock-down measures. A key way in which Kokiri (a Maori health provider) responded was through the establishment of a pataka kai (foodbank) that also provided a gateway to assess need and deliver other support services to whanau (in this case, client). Maori values were integral to this approach, with manaakitanga (kindness or providing care for others) at the heart of Kokiri's actions. We sought to identify how Kokiri operated under the mantle of manaakitanga, during Aotearoa's 2020 nationwide COVID-19 lockdown and to assess the impact of their contributions on Maori whanau. METHODS: We used qualitative methods underpinned by Maori research methodology. Twenty-six whanau interviews and two focus groups were held, one with eight kaimahi (workers) and the other with seven rangatahi (youth) kaimahi. Data was gathered between June and October 2020 (soon after the 2020 lockdown restrictions were lifted), thematically analysed and interpreted using a Maori worldview. RESULTS: Three key themes were identified that aligned to the values framework that forms the practice model that Kokiri kaimahi work within. Kaitiakitanga, whanau and manaakitanga are also long-standing Maori world values. We identified that kaitiakitanga (protecting) and manaakitanga (with kindness) - with whanau at the centre of all decisions and service delivery - worked as a protective mechanism to provide much needed support within the community Kokiri serves. CONCLUSIONS: Maori health providers are well placed to respond effectively in a public-health crisis when resourced appropriately and trusted to deliver. We propose a number of recommendations based on the insights generated from the researchers, kaimahi, and whanau. These are that: Maori be included in pandemic planning and decision-making, Maori-led initiatives and organisations be valued and adequately resourced, and strong communities with strong networks be built during non-crisis times.

Disparities in post-operative mortality between Maori and non-Indigenous ethnic groups in New Zealand.

AIM: To describe disparities in post-operative mortality experienced by Indigenous Maori compared to non-Indigenous New Zealanders. METHODS: We completed a national study of all those undergoing a surgical procedure between 2005 and 2017 in New Zealand. We examined 30-day and 90-day post-operative mortality for all surgical specialties and by common procedures. We compared age-standardised rates between ethnic groups (Maori, Pacific, Asian, European, MELAA/Other) and calculated hazard ratios (HRs) using Cox proportional hazards regression modelling adjusted for age, sex, deprivation, rurality, comorbidity, ASA score, anaesthetic type, procedure risk and procedure specialty. RESULTS: From nearly 3.9 million surgical procedures (876,976 acute, 2,990,726 elective/waiting list), we observed ethnic disparities in post-operative mortality across procedures, with the largest disparities occurring between Maori and Europeans. Maori had higher rates of 30- and 90-day post-operative mortality across most broad procedure categories, with the disparity between Maori and Europeans strongest for elective/waiting list procedures (eg, elective/waiting list musculoskeletal procedures, 30-day mortality: adj. HR 1.93, 95% CI 1.56-2.39). CONCLUSIONS: The disparities we observed are likely driven by a combination of healthcare system, process and clinical team factors, and we have presented the key mechanisms within these factors.

A Mobile- and Web-Based Health Intervention Program for Diabetes and Prediabetes Self-Management (BetaMe/Melon): Process Evaluation Following a Randomized Controlled Trial.

BACKGROUND: Technology-assisted self-management programs are increasingly recommended to patients with long-term conditions such as diabetes. However, there are a number of personal and external factors that affect patients' abilities to engage with and effectively utilize such programs. A randomized controlled trial of a multi-modal online program for diabetes self-management (BetaMe/Melon) was conducted in a primary care setting, and a process evaluation was completed at the end of the study period. OBJECTIVE: This process evaluation aimed to examine the utilization patterns of BetaMe/Melon, identify which components participants found most (and least) useful, and identify areas of future improvement. METHODS: Process evaluation data were collected for intervention arm participants from 3 sources: (1) the mobile/web platform (to identify key usage patterns over the 16-week core program), (2) an online questionnaire completed during the final study assessment, and (3) interviews conducted with a subset of participants following the study period. Participants were classified as "actively engaged" if any usage data was recorded for the participant (in any week), and patterns were reported by age, gender, ethnicity, and diabetes/prediabetes status. The online questionnaire asked participants about the usefulness of the program and whether they would recommend BetaMe/Melon to others according to a 5-point Likert Scale. Of 23 invited participants, 18 participated in a digitally recorded, semistructured telephone interview. Interview data were thematically analyzed. RESULTS: Out of the 215 participants, 198 (92%) received an initial health coaching session, and 160 (74%) were actively engaged with the program at some point during the 16-week core program. Engagement varied by demographic, with women, younger participants, and ethnic majority populations having higher rates of engagement. Usage steadily declined from 50% at Week 0 to 23% at Week 15. Participants ranked component usefulness as education resources (63.7%), health coaches (59.2%), goal tracking (48.8%), and online peer support (42.1%). Although 53% agreed that the program was easy to use, 64% would recommend the program to others. Interview participants found BetaMe/Melon useful overall, with most identifying beneficial outcomes such as increased knowledge, behavioral changes, and weight loss. Barriers to engagement were program functionality, internet connectivity, incomplete delivery of all program components, and participant motivation. Participants suggested a range of improvements to the BetaMe/Melon program. CONCLUSIONS: The program was generally well received by participants; active engagement was initially high, although it declined steadily. Maintaining participant engagement over time, individualizing programs, and addressing technical barriers are important to maximize potential health benefits from online diabetes self-management programs. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12617000549325; https://tinyurl.com/y622b27q.

Impact of a comprehensive digital health programme on HbA1c and weight after 12 months for people with diabetes and prediabetes: a randomised controlled trial.

AIMS/HYPOTHESIS: The aim of this RCT was to evaluate the effectiveness of a digital health programme (BetaMe/Melon) vs usual care in improving the control of type 2 diabetes and prediabetes in a primary care population. METHODS: We conducted a randomised parallel-group two-arm single-blinded superiority trial in the primary care setting in two regions of New Zealand. Eligible participants were identified through Primary Health Organisations and participating practices. Eligibility criteria were as follows: age 18-75 years, HbA1c 41-70 mmol/mol (5.9-8.6%), not taking insulin, and daily access to the internet. BetaMe/Melon is a 12 month mobile-device and web-based programme with four components: health coaching; evidence-based resources; peer support; and goal tracking. Participants were randomised into the intervention or control arm (1:1 allocation) based upon baseline HbA1c (prediabetes or diabetes range), stratified by practice and ethnicity. Research nurses and the study biostatistician were blind to study arm. Primary outcomes of the study were changes in HbA1c and weight at 12 months, using an intention-to-treat analysis. RESULTS: Four hundred and twenty-nine individuals were recruited between 20 June 2017 and 11 May 2018 (n = 215 intervention arm, n = 214 control arm), most of whom were included in analyses of co-primary outcomes (n = 210/215, 97.7% and n = 213/214, 99.5%). HbA1c levels at 12 months did not differ between study arms: mean difference was -0.9 mmol/mol (95% CI -2.9, 1.1) (-0.1% [95% CI -0.3, 0.1]) for the diabetes group and was 0.0 mmol/mol (95% CI -0.9, 0.9) (0.0% [95% CI -0.1, 0.1]) for the prediabetes group. Weight reduced slightly at 12 months for participants in both study arms, with no difference between arms (mean difference -0.4 kg [95% CI -1.3, 0.5]). CONCLUSIONS/INTERPRETATION: This study did not demonstrate clinical effectiveness for this particular programme. Given their high costs, technology-assisted self-management programmes need to be individually assessed for their effectiveness in improving clinical outcomes for people with diabetes. TRIAL REGISTRATION: www.anzctr.org.au ACTRN12617000549325 (universal trial number U1111-1189-9094) FUNDING: This study was funded by the Health Research Council of New Zealand, the Ministry of Health New Zealand and the Healthier Lives National Science Challenge. Graphical abstract.

Pill for this and a pill for that: A cross-sectional survey of use and understanding of medication among adults with multimorbidity.

OBJECTIVE: To understand the challenges managing medication use and knowledge of people living with multimorbidity. METHODS: A cross-sectional survey of 234 adults with multimorbidity, identified using retrospective hospital discharge data. Participants were recruited from two primary health organisations in New Zealand. RESULTS: Three quarters of participants (75%) were prescribed four or more medications, and one in four (27%) were prescribed eight or more medications. Participants reported knowing what their medications were for (88%, 95% CI 81.4-93.8) and when to take them (99%, 95% CI 97.5-99.9). However, over a fifth (22%, 95% CI 13.7-30.4) reported some problems managing multiple medications, and 40% (95% CI 30.2-50.2) reported a problem with side effects. CONCLUSION: The results highlight the need to consider how prescribing can be adapted for people with multimorbidity and move beyond the application of multiple disease-specific guidelines.

Effect of multimorbidity on health service utilisation and health care experiences.

INTRODUCTION Multimorbidity, the co-existence of two or more long-term conditions, is associated with poor quality of life, high health care costs and contributes to ethnic health inequality in New Zealand (NZ). Health care delivery remains largely focused on management of single diseases, creating major challenges for patients and clinicians. AIM To understand the experiences of people with multimorbidity in the NZ health care system. METHODS A questionnaire was sent to 758 people with multimorbidity from two primary health care organisations (PHOs). Outcomes were compared to general population estimates from the NZ Health Survey. RESULTS Participants (n = 234, 31% response rate) reported that their general practitioners (GPs) respected their opinions, involved them in decision-making and knew their medical history well. The main barriers to effective care were short GP appointments, availability and affordability of primary and secondary health care, and poor communication between clinicians. Access issues were higher than for the general population. DISCUSSION Participants generally had very positive opinions of primary care and their GP, but encountered structural issues with the health system that created barriers to effective care. These results support the value of ongoing changes to primary care models, with a focus on patient-centred care to address access and care coordination.

BetaMe: impact of a comprehensive digital health programme on HbA1c and weight at 12 months for people with diabetes and pre-diabetes: study protocol for a randomised controlled trial.

BACKGROUND: Long-term conditions (LTCs) are the biggest contributor to health loss in New Zealand. The economic cost and burden on the health system is substantial and growing. Self-management strategies offer a potential way to reduce the pressure on health services. This study evaluates a comprehensive self-management programme (the BetaMe programme) delivered by mobile and web-based technologies for people with Type 2 diabetes (T2DM) and pre-diabetes. The primary aim of this study is to evaluate the effectiveness of the BetaMe programme versus usual care among primary care populations in improving the control of T2DM and pre-diabetes, as measured by change in HbA1c and weight over 12 months. METHODS: Participants will be recruited through two primary healthcare organisations and a Maori healthcare provider in New Zealand (n = 430). Eligible participants will be 18 to 75 years old, with T2DM or pre-diabetes, with an HbA1c of 41-70 mmol/mol up to 2 years prior to study commencement. Eligible participants who consent to participate will be individually randomised to the control arm (usual care) or intervention arm (usual care and BetaMe). The programme consists of a 16-week core followed by a maintenance period of 36 weeks. It incorporates (1) individualised health coaching, (2) goal setting and tracking, (3) peer support in an online forum and (4) educational resources and behaviour-change tools. The primary outcome measures are change in HbA1c and weight at 12 months. Secondary outcomes are changes in waist circumference, blood pressure, patient activation and diabetes-specific behaviours. All outcomes will be assessed at 4 and 12 months for the total study population and for Maori and Pacific participants specifically. All primary analyses will be based on intention-to-treat. Primary analysis will use linear mixed models comparing mean outcome levels adjusted for initial baseline characteristics at 12 months. DISCUSSION: This is a randomised controlled trial of a comprehensive self-management intervention for people with diabetes and pre-diabetes. If effective, this programme would allow healthcare providers to deliver an intervention that is person-centred and supports the self-care of people with T2DM, pre-diabetes and potentially other LTCs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ID: ACTRN12617000549325 . Registered on 19 April 2017.

A walking stick in one hand and a chainsaw in the other: patients' perspectives of living with multimorbidity.

AIMS: Multimorbidity is common, yet there are major gaps in research, particularly among younger and indigenous populations. This research aimed to understand patients' perspectives of living with multimorbidity. METHODS: A qualitative study of 61 people living with multimorbidity, 27 of whom were Maori and a third aged under 65, from urban and rural regions in New Zealand. Six focus groups and 14 interviews were conducted, recorded, transcribed and analysed. RESULTS: For many participants, living with multimorbidity disrupted their 'normal' lives, posing challenges in everyday activities such as eating and toileting, working and managing medications. Dealing with the health system posed challenges such as accessing appointments and having enough time in consultations. Cultural competency, good communication and continuity of care from healthcare providers were all valued. Participants had many recommendations to improve management, including a professional single point of contact to coordinate all specialist care. CONCLUSIONS: Living with multimorbidity is often challenging requiring people to manage their conditions while continuing to live their lives. This research suggests changes are needed in the health system in New Zealand and elsewhere to better manage multimorbidity thus improving patient's lives and reducing costs to the health sector and wider society.

Dissonant roles: The experience of Maori in cancer care.

Indigenous peoples have poorer health outcomes than their non-indigenous counterparts and this applies to cancer outcomes for Maori in Aotearoa/New Zealand. Differential access to and quality of healthcare contributes to poorer survival rates for Maori. This research provides insight into some of the mechanisms that hinder and facilitate care access. Thirty four people who had undergone cancer treatment (19 Maori and 15 non-Maori) were interviewed by two Maori researchers. The analysis of the interview transcripts was informed by membership categorization analysis. This form of analysis attends to the categories that are used and the activities and characteristics associated with those categories. From this analysis it is argued that the classical patient role, or sick role, inadequately captures the kind of role that some Maori take in relation to their healthcare. Maori can also have culturally specific family (whanau) influences and a greater draw towards alternative approaches to healthcare. Dissonant roles contribute to a different experience for Maori. A better understanding of the categories and roles that are relevant to those who have cancer provides opportunities to attenuate the monocultural impacts of healthcare.

Cancer care decision making in multidisciplinary meetings.

Little research has been undertaken on the actual decision-making processes in cancer care multidisciplinary meetings (MDMs). This article was based on a qualitative observational study of two regional cancer treatment centers in New Zealand. We audiorecorded 10 meetings in which 106 patient cases were discussed. Members of the meetings categorized cases in varying ways, drew on a range of sources of authority, expressed different value positions, and utilized a variety of strategies to justify their actions. An important dimension of authority was encountered authority-the authority a clinician has because of meeting the patient. The MDM chairperson can play an important role in making explicit the sources of authority being drawn on and the value positions of members to provide more clarity to the decision-making process. Attending to issues of process, authority, and values in MDMs has the potential to improve cancer care decision making and ultimately, health outcomes.