Hauora Maori - Maori health: a right to equal outcomes in primary care.

BACKGROUND: For more than a century, Maori have experienced poorer health than non-Maori. In 2019 an independent Tribunal found the Government had breached Te Tiriti o Waitangi by "failing to design and administer the current primary health care system to actively address persistent Maori health inequities". Many Maori (44%) have unmet needs for primary care. Seven models of primary care were identified by the funders and the research team, including Maori-owned practices. We hypothesised patient health outcomes for Maori would differ between models of care. METHODS: Cross-sectional primary care data were analysed at 30 September 2018. National datasets were linked to general practices at patient level, to measure associations between practice characteristics and patient health outcomes. PRIMARY OUTCOMES: polypharmacy (≥ 55 years), HbA1c testing, child immunisations, ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Regressions include only Maori patients, across all models of care. RESULTS: A total of 660,752 Maori patients were enrolled in 924 practices with 124,854 in 65 Maori-owned practices. Maori practices had: no significant association with HbA1c testing, ambulatory sensitive hospitalisations or ED attendances, and a significant association with lower polypharmacy (3.7% points) and lower childhood immunisations (13.4% points). Maori practices had higher rates of cervical smear and cardiovascular risk assessment, lower rates of HbA1c tests, and more nurse (46%) and doctor (8%) time (FTE) with patients. The average Maori practice had 52% Maori patients compared to 12% across all practices. Maori practices enrolled a higher percentage of children and young people, five times more patients in high deprivation areas, and patients with more multimorbidity. More Maori patients lived rurally (21.5% vs 15%), with a greater distance to the nearest ED. Maori patients were more likely to be dispensed antibiotics or tramadol. CONCLUSIONS: Maori practices are an expression of autonomy in the face of enduring health system failure. Apart from lower immunisation rates, health outcomes were not different from other models of care, despite patients having higher health risk profiles. Across all models, primary care need was unmet for many Maori, despite increased clinical input. Funding must support under-resourced Maori practices and ensure accountability for the health outcomes of Maori patients in all models of general practice.

An innovative Indigenous-led model for integrated COVID-19 case management in Auckland, New Zealand: lessons from implementation.

In Aotearoa/New Zealand (NZ), the Indigenous Maori population have been more severely impacted than non-Maori throughout the COVID-19 pandemic, and less well served by NZ's COVID-19 response. This case-study describes an innovative Indigenous-led service delivery model, which was designed and implemented to improve the case and contact management of Maori with COVID-19 in Auckland. We outline the context in which the conventional public health case and contact management was failing Maori and the factors which enabled Indigenous innovation and leadership. We describe the details of the model and how the approach fundamentally differed to the conventional approach to care. Qualitative and quantitative data on impact of the model are shared, along with the key barriers and enablers in the implementation of the model. The Maori Regional Coordination Hub (MRCH) model offers a valuable alternative to the conventional public health case and contact management approach, and this case study highlights lessons which may be applicable to improving the design and delivery of public health services to other Indigenous and marginalized groups.

Invitation methods for Indigenous New Zealand Maori in lung cancer screening: Protocol for a pragmatic cluster randomized controlled trial.

Lung cancer screening can significantly reduce mortality from lung cancer. Further evidence about how to optimize lung cancer screening for specific populations, including Aotearoa New Zealand (NZ)'s Indigenous Maori (who experience disproportionately higher rates of lung cancer), is needed to ensure it is equitable. This community-based, pragmatic cluster randomized trial aims to determine whether a lung cancer screening invitation from a patient's primary care physician, compared to from a centralized screening service, will optimize screening uptake for Maori. Participating primary care practices (clinics) in Auckland, Aotearoa NZ will be randomized to either the primary care-led or centralized service for delivery of the screening invitation. Clinic patients who meet the following criteria will be eligible: Maori; aged 55-74 years; enrolled in participating clinics in the region; ever-smokers; and have at least a 2% risk of developing lung cancer within six years (determined using the PLCOM2012 risk prediction model). Eligible patients who respond positively to the invitation will undertake shared decision-making with a nurse about undergoing a low dose CT scan (LDCT) and an assessment for Chronic Obstructive Pulmonary Disease (COPD). The primary outcomes are: 1) the proportion of eligible population who complete a risk assessment and 2) the proportion of people eligible for a CT scan who complete the CT scan. Secondary outcomes include evaluating the contextual factors needed to inform the screening process, such as including assessment for Chronic Obstructive Pulmonary Disease (COPD). We will also use the RE-AIM framework to evaluate specific implementation factors. This study is a world-first, Indigenous-led lung cancer screening trial for Maori participants. The study will provide policy-relevant information on a key policy parameter, invitation method. In addition, the trial includes a nested analysis of COPD in the screened Indigenous population, and it provides baseline (T0 screen round) data using RE-AIM implementation outcomes.

Addressing rheumatic fever inequities in Aotearoa New Zealand: a scoping review of prevention interventions.

Introduction Rheumatic fever is a preventable illness caused by untreated Group A Streptococcus (GAS) infection. Despite reductions in most high-income countries, rheumatic fever rates remain a concern in Aotearoa New Zealand. Pacific and Maori people are inequitably affected, with risk of initial hospitalisation due to rheumatic fever 12- and 24-fold more likely, respectively, compared to non-Maori and non-Pacific people. Aim This scoping review aims to explore the range of interventions and initiatives in New Zealand seeking to prevent GAS and rheumatic fever, with a particular focus on Pacific and Maori. Methods Databases Scopus, Medline, EMBASE and CINAHL, along with grey literature sources, were searched to broadly identify interventions in New Zealand. Data were screened for eligibility and the final articles were charted into a stocktake table. Results Fifty-eight studies were included, reporting 57 interventions. These targeted school-based throat swabbing, awareness and education, housing, secondary prophylaxis, improving primary care guidelines and diagnosis of sore throats and skin infections. Some interventions reported short-term outcomes of improvements in awareness, a reduction in rheumatic fever risk and fewer hospitalisations. Evaluation outcomes were, however, lacking for many initiatives. Pacific and Maori people primarily served only in an advisory or delivery capacity, rather than as partners in co-design or leadership from the beginning. Discussion Although positive outcomes were reported for some interventions identified in this review, rheumatic fever rates have not shown any long-term reduction over time. Co-designing interventions with affected communities could ensure that strategies are better targeted and do not contribute to further stigma.

Interventions designed to improve uptake of allopurinol for gout treatment in Aotearoa New Zealand: a scoping review.

Introduction Gout in Aotearoa New Zealand (NZ) remains an equity issue. The prevalence in Pacific and Maori people is one of the highest internationally. Although Pacific and Maori experience earlier onset and higher burden of gout, which can severely impact their quality of life, their management of it is often sub-optimal. Aim To conduct a scoping review of the NZ literature for interventions to improve the uptake/management of allopurinol for gout and their evaluation. Methods Databases Medline, Scopus, Embase, and CINAHL Plus and the grey literature were searched systematically to identify all NZ intervention studies aiming to improve allopurinol uptake for gout treatment. Interventions included: if they were delivered in NZ, aimed to improve allopurinol uptake, and were provided in English. A narrative approach was used to extract and synthesise data. Results Eighteen peer-reviewed and grey literature publications met the search criteria. Interventions clustered into three domains: multifaceted or multi-practitioner; gout app; and online booklets or fact sheets. Serum urate levels improved in multi-faceted or multi-practitioner interventions only, whereas the gout app only improved patients' awareness and understanding of gout and medications. Online fact sheets and booklets need more active utilisation from health professionals to improve gout health literacy. Discussion Most gout interventions in NZ use multifaceted or multi-practitioner approaches. Although most interventions successfully controlled serum urate levels and improved equitable access for gout patients to urate-lowering therapy, these interventions did not sustain retention, completion, and engagement for certain population groups, particularly Pacific and Maori, who experience a higher burden of gout.

Co-designing an intervention to prevent rheumatic fever in Pacific People in South Auckland: a study protocol.

BACKGROUND: Rheumatic fever is an autoimmune condition that occurs in response to an untreated Group A Streptococcus throat or skin infection. Recurrent episodes of rheumatic fever can cause permanent damage to heart valves, heart failure and even death. Maori and Pacific people in Aotearoa New Zealand experience some of the highest rates globally, with Pacific children 80 times more likely to be hospitalised for rheumatic fever and Maori children 36 times more likely than non-Maori, non-Pacific children. Community members from the Pacific People's Health Advisory Group, research officers from the Pacific Practice-Based Research Network and University of Auckland researchers identified key health priorities within the South Auckland community that needed to be addressed, one of which was rheumatic fever. The study outlined in this protocol aims to co-design, implement, and evaluate a novel intervention to reduce rheumatic fever rates for Pacific communities in South Auckland. METHODS: This participatory mixed-methods study utilises the Fa'afaletui method and follows a three-phase approach. Phase 1 comprises a quantitative analysis of the rheumatic fever burden within Auckland and across New Zealand over the last five years, including sub-analyses by ethnicity. Phase 2 will include co-design workshops with Pacific community members, families affected by rheumatic fever, health professionals, and other stakeholders in order to develop a novel intervention to reduce rheumatic fever in South Auckland. Phase 3 comprises the implementation and evaluation of the intervention. DISCUSSION: This study aims to reduce the inequitable rheumatic fever burden faced by Pacific communities in South Auckland via a community-based participatory research approach. The final intervention may guide approaches in other settings or regions that also experience high rates of rheumatic fever. Additionally, Maori have the second-highest incidence rates of rheumatic fever of all ethnic groups, thus community-led approaches 'by Maori for Maori' are also necessary. TRIAL REGISTRATION: The Australian New Zealand Clinical Trial Registry has approved the proposed study: ACTRN12622000565741 and ACTRN12622000572763 .

Reducing healthcare inequities for Maori using Telehealth during COVID-19.

AIM: Maori experience barriers to accessing timely, quality healthcare. The March 2020 COVID-19 lockdown in New Zealand required provision of Telehealth consultation options in primary care. Telehealth consultations have the potential to improve access to healthcare for Maori, and thereby reduce health inequities. Conversely, Telehealth may present additional barriers that contribute to inequities overall. This scoping project investigated Maori experiences of Telehealth consultations during the March 2020 COVID-19 lockdown. METHOD: Semi-structured key informant interviews were completed with five Maori health professionals, six Maori Telehealth patients, and six Maori in-clinic patients, about their healthcare consultation experiences during COVID-19 lockdown. Participants were asked about what worked, what did not work, and for suggestions to improve future Telehealth provision to Maori whanau. Kaupapa Maori methodology underpinned thematic analysis of the interviews. RESULTS: Key findings are presented in three overarching themes: benefits (safety, cost, time, options); challenges (health literacy, access to Information Technology (IT), supply and demand, limited physical assessment); and suggested improvements (systems fit for purpose, supporting IT and health literacy, Telehealth as a routine option, rapport building, and cross system efficiency and information sharing). CONCLUSION: Telehealth is a viable long-term option that can support Maori whanau access to healthcare.

Ethnic differences in metabolic achievement between Maori, Pacific, and European New Zealanders with type 2 diabetes.

AIMS: To compare variations in metabolic target achievement by ethnicity (Europeans, Maori and Pasifika) among patients with type 2 diabetes (T2DM) in Auckland, New Zealand (NZ) between 1994 and 2013. METHODS: 32,237 patients were enrolled. Adjusted marginal difference (European as reference) of systolic blood pressure (SBP), body mass index (BMI), HbA1c and total cholesterol, alongside the proportion achieving metabolic targets were estimated using multivariable mixed effect models at baseline, 1-, 2-, 3-, 4-, and 5-years, adjusted for covariates. RESULTS: Compared with Europeans, Maori and Pasifika had continuously, significantly higher HbA1c (by 0.3% (+3.5 mmol/mol) and 0.6% (+6.8 mmol/mol) respectively and BMI (+1.5 and +0.3 kg/m2 respectively) but lower SBP (-1.8 and -3.4 mmHg respectively) and TG (-0.03 and -0.34 mmol/L respectively), and insignificantly TC (+0.004 and +0.01 respectively), by 5-years of follow-up. While 49% Europeans were within target HbA1c, this was achieved by only 30% Maori and 27% Pasifika. Conversely, 41% Europeans, 46% Maori and 59% Pasifika achieved the SBP target (all P < 0.0001). CONCLUSIONS: Managing hyperglycemia appears to be more challenging than treating hypertension and dyslipidemia among Maori and Pasifika. New anti-hyperglycemia treatments, addressing health literacy, socioeconomic and any cultural barriers to management and self-management are urgently needed to reduce these disparities.

Connecting hapu mama (pregnant women) early to a lead maternity carer: striving for equity using the Best Start-Pregnancy Tool.

Introduction In Aotearoa New Zealand, lead maternity carers (LMCs) provide maternity care through pregnancy and birth, until 6 weeks' postpartum. An early LMC connection in pregnancy is associated with better maternal and perinatal health outcomes. However, hapu mama (pregnant women) may experience barriers to engaging with LMC, delaying screening, risk assessments, and education. These barriers contribute to inequitable health outcomes for Maori mama and pepi (Maori mothers and babies). A pro-equity approach to maternity care is warranted. Aim To investigate the LMC plan at the first point of contact with a primary care provider once pregnancy is confirmed, as well as selected risk factors to maternal and perinatal health for Maori and non-Maori hapu mama. Methods Data entered by primary care providers into the Best Start-Pregnancy Tool were analysed for 482 pregnant women from November 2020 to December 2021. Results Most hapu mama planned for midwifery care. About one-third of hapu mama had engaged with a midwife before their first GP visit after a confirmed pregnancy. Maori hapu mama were more likely to present with risk factors to maternal and perinatal health than non-Maori hapu mama. Discussion Primary healthcare providers have an expectation to connect hapu mama to a LMC by 10 weeks' gestation. More research is needed to identify how to best support Maori hapu mama to access a LMC early in pregnancy. The Best Start Kowae is an accessible online tool (currently in an implementation phase) for primary care providers and LMCs that promotes equitable health outcomes for Maori mama and pepi.

Using a randomised controlled trial to test the effectiveness of social norms feedback to reduce antibiotic prescribing without increasing inequities.

AIMS: Antibiotic overprescription is a key driver of antimicrobial resistance, and rates of community dispensing of antibiotics in New Zealand are high compared to other developed countries. We aimed to test whether a social-norm-based intervention successful elsewhere would have an effect on GPs with high prescribing rates of antibiotics. We also aimed to assess the effects on prescribing for Maori and Pacific patients. METHODS: A randomised controlled trial (n=1,214) tested the effects of a letter mailed to high-prescribing GPs that presented their prescribing data in comparison to their peers. RESULTS: In September-December 2019, after the letters were mailed, the antibiotic prescribing rate in the control arm was 178.8 patients prescribed antibiotics per 1,000 patients prescribed any medicine, and in the intervention arm it was 162.3, a relative difference of 9.2% (p<0.001). GPs in the intervention arm were responsible for an average of 173.5 prescriptions, versus an average of 186.8 prescriptions for GPs in the control arm, a relative difference of 13.3 or 7.1% (p<0.01). Exploratory analyses showed the intervention reduced prescribing to Maori and Pacific patients among historically high prescribing GPs but had no statistically significant impact on low prescribers. CONCLUSIONS: A targeted intervention using social norms reduced prescribing of antibiotics by high-prescribing GPs. Such an approach may be promising to address inequities in access to and use of antibiotics by Maori and Pacific peoples, historically underserved by prescribers, but further investigation is needed.

Iwi (tribal) data collection at a primary health care organisation in Aotearoa.

INTRODUCTION Indigenous peoples' rights include the right to self-determine one's identity. For Maori, this includes self-assignment of ethnicity, and traditional identities such as Iwi (tribe). New Zealand's Ministry of Health requires health services to collect ethnicity data using standard protocols. Iwi data are also collected by some health services; however, with no health-specific protocols, little is known about Iwi data collection and quality. The National Hauora Coalition (NHC) Primary Healthcare Organisation (PHO) sought to understand Iwi data collection across its network of primary care providers. AIM To understand Iwi data collection at the NHC PHO; specifically, is it being routinely collected, how is it being collected and what are the results? METHODS In 2017, NHC's general practice clinics were invited to submit their enrolment forms, which capture ethnicity and potentially Iwi information, by e-mail to the audit team. Forms were reviewed to determine whether Iwi information was being collected and if so, what question was being used. Iwi numbers were collated from the annual data extract. RESULTS Thirty-three of a total of 35 clinics (94%) submitted their enrolment forms to the audit team. Nine of the 33 clinics (27%) sought Iwi name/s with a specific question on their enrolment form. Six different 'Iwi' questions were used by the nine clinics. The data extract revealed that the NHC had Iwi data for 13% (2672/20,814) of its Maori enrolments. Ngapuhi were the largest Iwi group at the NHC. DISCUSSION This is the first study to describe the quantity and quality of Iwi data collection in NZ primary care. Standard procedures for collecting, recording and using Iwi data are being developed by the NHC PHO. These could inform national protocols to optimise the quality of Iwi data.

An audit of nurses using standing order directives to administer medications to children at risk of contracting rheumatic fever.

AIM: The following article reports an audit, conducted between July 2014 and July 2017, of adherence to best practice in medication administration and documentation by nurses. METHOD: A sample of 47 registered nurses' (RNs') documentation relating to the administration of 939 medications using standing order directives were examined and scored by seven senior nurses and a medical practitioner against an audit tool. The scores were divided into four quartiles with the top two quartiles demonstrating best practice in adherence to safety standards for the administration of medication. RESULTS: Forty-three RNs (91.5%) scored in the top two quartiles. The remaining four RNs (8.5%), following supervision by a senior nurse, subsequently demonstrated improvement in their documentation to the quartile one range of the audit tool. This audit demonstrates that, following education in diagnosis and treatment of common childhood conditions, the majority of nurses who were audited could diagnose simple conditions of childhood and safely administer medications to them. Moreover, two years after the programme was introduced, the serious sequelae of acute rheumatic fever (ARF) reduced in children aged 5-12 years. CONCLUSION: RNs who took part in the audit used standing order directives to safely administer medications to children. RN prescribing throughout New Zealand should be explored as an effective means to provide timely treatment and improve patient outcomes.

Pacific Fono: a community-based initiative to improve rheumatic fever service delivery for Pacific Peoples in South Auckland.

BACKGROUND AND CONTEXT Rheumatic fever inequitably affects Maori and Pacific children in New Zealand. School-based throat swabbing services, such as the South Auckland Mana Kidz programme, are a key element of rheumatic fever prevention interventions. ASSESSMENT OF THE PROBLEM Counties Manukau has the highest national rates of rheumatic fever (4.7 per 100,000 for first recorded rates). Given these disparities, Mana Kidz undertook an exploratory, community-based initiative to improve its service delivery for Pacific Peoples. RESULTS Mana Kidz held a Pacific Leaders' Fono (meeting) to discuss initiatives to improve rheumatic fever outcomes in South Auckland focused around challenges and solutions for addressing rheumatic fever, effective engagement strategies and leadership qualities needed to drive initiatives. Oral and written responses from 66 attendees were collected and thematically analysed. Four key themes were identified around challenges and solutions for rheumatic fever: social determinants of health; cultural responsiveness; health system challenges; and education, promotion and literacy. Three effective engagement strategies were identified: by Pacific for Pacific; developing a rheumatic fever campaign; improving health services. Three key leadership attributes were identified: culturally responsive leaders; having specific expertise and skills; youth-driven leadership. STRATEGIES FOR IMPROVEMENT Mana Kidz has now created Pacific leadership roles in rheumatic fever governance groups, promotes Pacific workforce development and endorses Pacific-led initiatives and partnerships. LESSONS Recognising the value of critical reflection and the importance of good governance and collaborative, right-based partnerships in health services.

Mapping a route to Indigenous engagement in cancer genomic research.

Precision oncology guided by genomic research has an increasingly important role in the care of people with cancer. However, substantial inequities remain in cancer outcomes of Indigenous peoples, including Indigenous Maori in Aotearoa New Zealand (New Zealand). These inequities will be perpetuated unless deliberate steps are taken to include Indigenous peoples in all parts of cancer research-as research participants, in research leadership, and in research governance. This approach is especially important when there have been historical breaches of trust that have discouraged their participation in health research. This Personal View describes a precision oncology research roadmap for neuroendocrine tumour research, which seeks to reflect the values of New Zealand's Indigenous Maori people. This roadmap includes facilitating ongoing dialogue, Maori leadership, reciprocity, agreed kawa (guiding principles), tikanga (cultural protocols), and honest monitoring of what is and what is not being achieved. We challenge cancer researchers worldwide to generate locally appropriate roadmaps that honestly assess their practices to benefit Indigenous people internationally.

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.