Drivers of access to cardiovascular health care for rural Indigenous Peoples: a scoping review.

INTRODUCTION: Māori (the Indigenous Peoples of Aotearoa New Zealand) are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD health care. Rural Māori experience additional barriers to treatment access, poorer health outcomes and a greater burden of CVD risk factors compared to Non-Māori and Māori living in urban areas. Importantly, these inequities are similarly experienced by Indigenous Peoples in other nations impacted by colonisation. Given the scarcity of available literature, a systematic scoping review was conducted on literature exploring barriers and facilitators in accessing CVD health care for rural Māori and other Indigenous Peoples in nations impacted by colonisation. METHODS: The review was underpinned by Kaupapa Māori Research methodology and was conducted utilising Arksey and O'Malley's (2005) methodological framework. A database search of MEDLINE (OVID), PubMed, Embase, SCOPUS, CINAHL Plus, Australia/New Zealand Reference Centre and NZResearch.org was used to explore empirical research literature. A grey literature search was also conducted. Literature based in any healthcare setting providing care to adults for CVD was included. Rural or remote Indigenous Peoples from New Zealand, Australia, Canada, and the US were included. Literature was included if it addressed cardiovascular conditions and reported barriers and facilitators to healthcare access in any care setting. RESULTS: A total of 363 articles were identified from the database search. An additional 19 reports were identified in the grey literature search. Following screening, 16 articles were included from the database search and 5 articles from the grey literature search. The literature was summarised using the Te Tiriti o Waitangi (Treaty of Waitangi) Framework principles: tino rangatiratanga (self-determination), partnership, active protection, equity and options. Themes elucidated from the literature were described as key drivers of CVD healthcare access for rural Indigenous Peoples. Key driver themes included input from rural Indigenous Peoples on healthcare service design and delivery, adequate resourcing and support of indigenous and rural healthcare services, addressing systemic racism and historical trauma, providing culturally appropriate health care, rural Indigenous Peoples' access to family and wellbeing support, rural Indigenous Peoples' differential access to the wider social determinants of health, effective interservice linkages and communication, and equity-driven and congruent data systems. CONCLUSION: The findings are consistent with other literature exploring access to health care for rural Indigenous Peoples. This review offers a novel approach to summarising literature by situating the themes within the context of equity and rights for Indigenous Peoples. This review also highlighted the need for further research in this area to be conducted in the context of Aotearoa New Zealand.

Use of Consumer Wearables in Health Research: Issues and Considerations.

As wearable devices, which allow individuals to track and self-manage their health, become more ubiquitous, the opportunities are growing for researchers to use these sensors within interventions and for data collection. They offer access to data that are captured continuously, passively, and pragmatically with minimal user burden, providing huge advantages for health research. However, the growth in their use must be coupled with consideration of their potential limitations, in particular, digital inclusion, data availability, privacy, ethics of third-party involvement, data quality, and potential for adverse consequences. In this paper, we discuss these issues and strategies used to prevent or mitigate them and recommendations for researchers using wearables as part of interventions or for data collection.

Understanding the workforce that supports Maori and Pacific peoples with type 2 diabetes to achieve better health outcomes.

BACKGROUND: Prevalence of Type 2 diabetes mellitus (T2DM) is high among Maori and other Pacific Island peoples in New Zealand. Current health services to address T2DM largely take place in primary healthcare settings and have, overall, failed to address the significant health inequities among Maori and Pacific people with T2DM. Culturally comprehensive T2DM management programmes, aimed at addressing inequities in Maori or Pacific diabetes management and workforce development, are not extensively available in New Zealand. Deliberate strategies to improve cultural safety, such as educating health professionals and fostering culturally safe practices must be priority when funding health services that deliver T2DM prevention programmes. There is a significant workforce of community-based, non-clinical workers in South Auckland delivering diabetes self-management education to Maori and Pacific peoples. There is little information on the perspectives, challenges, effectiveness, and success of dietitians, community health workers and kai manaaki (KM) in delivering these services. This study aimed to understand perspectives and characteristics of KM and other community-based, non-clinical health workers, with a focus on how they supported Maori and Pacific Peoples living with T2DM to achieve better outcomes. METHODS: This qualitative study undertaken was underpinned by the Tangata Hourua research framework. Focus groups with dietitians, community health workers (CHWs) and KM took place in South Auckland, New Zealand. Thematic analysis of the transcripts was used to identify important key themes. RESULTS: Analysis of focus group meetings identified three main themes common across the groups: whakawhanaungatanga (actively building relationships), cultural safety (mana enhancing) and cultural alignment to role, with a further two themes identified only by the KM and CHWs, who both strongly associated a multidisciplinary approach to experiences of feeling un/valued in their roles, when compared with dietitians. Generally, all three groups agreed that their roles required good relationships with the people they were working with and an understanding of the contexts in which Maori and Pacific Peoples with T2DM lived. CONCLUSIONS: Supporting community based, non-clinical workers to build meaningful and culturally safe relationships with Maori and Pacific people has potential to improve diabetes outcomes.

Tackling anxiety through innovation: Development and pilot study of an in-the-moment messaging intervention for young adults.

Objective: Anxiety disorders are highly prevalent around the world and are associated with significant disability, comorbidity and costs to society. Digital tools have the potential to deliver equitable, convenient and sustainable interventions for anxiety. We aimed to co-design and pilot-test an in-the-moment intervention to help young people manage anxiety. Young people with lived experience of anxiety were recruited to participate in co-design workshops with the results informing the development of the Tackling Anxiety through Innovation (TAI) intervention. TAI delivers personally tailored messaging prompting engagement in self-care behaviours at times of high anxiety/stress. Methods: Young people aged 16 to 24 years were recruited into a four-week pilot study. Participants completed the Depression Anxiety Stress Scale - 21 Items (DASS-21) at baseline and four-week follow up, as well as a survey to assess the acceptability of the intervention and its components. Results: Participants (n = 24) reported the intervention to be highly acceptable and useful. Participants scheduled an average of eight events over the 4 weeks. DASS-21 scores improved significantly from baseline to follow up: anxiety (mean difference 2.42 (SD = 3.65), p = 0.004), depression (3.79 (SD = 3.65), p < 0.001) and stress (3.50 (SD = 3.30), p < 0.001). Participants particularly liked the ability to personalise the messages, the timing and format of the messages, and the reminders to engage in helpful behaviours. Conclusions: This study adds to the evidence for the use of digital tools in delivering tailored anxiety self-management support to young people. Further refinement and expansion of the intervention are needed to determine its efficacy on a larger scale.

Navigating the long journey of heart failure-experiences of Maori and Pacific peoples.

AIMS: Maori and Pacific peoples in Aotearoa New Zealand experience significant inequities in heart failure rates, treatment and outcomes compared to NZ Europeans. We aimed to understand the experiences of Maori and Pacific people living with heart failure as they navigated care across primary and secondary settings. METHODS: This research involved a secondary analysis of data collected in a wider qualitative study investigating evidence-practice gaps of cardiovascular care experienced by Maori and Pacific people. From the wider pool of semi-structured interviews, we identified 24 people (seven Maori and 17 Pacific peoples, 23 from the North Island) living with heart failure, and applied template and framework analysis to explore their distinct experiences. RESULTS: Two major themes identified related to participants: 1) Condition-need for more support to understand and self-manage their heart failure condition, and 2) Journey-desire to feel well-connected to the health system in their heart failure journey. CONCLUSIONS: Addressing heart failure inequities for Maori and Pacific peoples requires that providers engage in clear and meaningful communication to support patient self-management. Strengthening pathways for Maori and Pacific patients and whanau (families) between primary and secondary services is required to reduce their likelihood of becoming disconnected from care.

Maori and Pacific families' experiences and perspectives of cardiovascular care; A qualitative study.

OBJECTIVE: This study aimed to understand the reasons behind evidence-practice gaps and inequities in cardiovascular care for Maori and Pacific people, as evidenced by the experiences and perspectives of patients and their families. METHODS: The research was guided by Maori and Pacific worldviews, incorporating Kaupapa Maori Theory and Pacific conceptual frameworks and research methodologies. Template analysis was used to analyse interview data from 61 Maori and Pacific people who had experienced a cardiovascular disease (CVD) risk assessment, acute coronary syndrome, and/or heart failure. RESULTS: The range of experiences relating to participants' heart health journeys are presented in five main themes: Context, Mana (maintaining control and dignity), Condition, People and Journey. CONCLUSIONS: Maori and Pacific people want to take charge of their heart health but face challenges. Participants described important obligations to family, community and tikanga (the culturally correct way of doing things). Participants described times when health care undermined existing responsibilities, their dignity and/or their mana, and they felt excluded from treatment as a result. IMPLICATIONS FOR PUBLIC HEALTH: Good reciprocal communication, stemming from a high-quality relationship is essential for successful outcomes. A workforce that is representative of the population it serves and is culturally safe lays the foundation for excellence in care.

The role of the primary healthcare research community in addressing the social and structural determinants of health: a call to action from NAPCRG 2023.

The need for effective primary healthcare to address social and structural determinants of health and to mitigate health inequalities has been well established. Here, we report on the international forum of the 2023 NAPCRG (formerly known as North American Primary Care Research Group) Annual Meeting. The aim of the forum was to develop principles for action for the primary healthcare research community on addressing social and structural determinants of health. From this forum, 10 key recommendations for the primary care research community were identified.

The Use of Sensors to Detect Anxiety for In-the-Moment Intervention: Scoping Review.

BACKGROUND: With anxiety a growing issue and barriers to accessing support services, there is a need for innovative solutions to provide early intervention. In-the-moment interventions support individuals to recognize early signs of distress and use coping mechanisms to prevent or manage this distress. There is potential for wearable sensors linked to an individual's mobile phone to provide in-the-moment support tailored to individual needs and physiological responses. OBJECTIVE: The aim of this scoping review is to examine the role of sensors in detecting the physiological signs of anxiety to initiate and direct interventions for its management. METHODS: Relevant studies were identified through searches conducted in Embase, MEDLINE, APA PsycINFO, ProQuest, and Scopus. Studies were identified if they were conducted with people with stress or anxiety or at risk of anxiety and included a wearable sensor providing real-time data for in-the-moment management of anxiety. RESULTS: Of the 1087 studies identified, 11 studies were included in the review, including 5 randomized controlled trials and 6 pilot or pretesting studies. The results showed that most studies successfully demonstrated improvements in their target variables. This included overall anxiety and stress levels, and the implementation of in-the-moment stress and anxiety management techniques such as diaphragmatic breathing. There was wide variation in the types of sensors used, physiological measures, and sensor-linked interventions. CONCLUSIONS: This review indicates that sensors are potentially a useful tool in detecting anxiety and facilitating the implementation of a known control mechanism to reduce anxiety and improve mood, but further work is needed to understand the acceptability and effectiveness of this type of intervention.

The Impact of Patient Preference on Attendance and Completion Rates at Centre-Based and mHealth Pulmonary Rehabilitation: A Non-Inferiority Pragmatic Clinical Trial.

Purpose: Pulmonary rehabilitation (PR) is vital in the management of chronic respiratory disorders (CRDs) although uptake, attendance and completion are poor. Differing models of delivering PR are emerging in an attempt to increase the uptake and completion of this intervention. This study aimed to evaluate participant rate of attendance and completion of PR when given a preference regarding model of delivery (centre-based and mPR). Secondary aims were to evaluate the factors affecting patient preference for model of delivery and determine whether mPR is non-inferior to centre-based PR in health outcomes. Methods: A multi-centre non-inferiority preference based clinical trial in Auckland, New Zealand. Participants with a CRD referred for PR were offered the choice of centre-based or mHealth PR (mPR). The primary outcome was completion rate of chosen intervention. Results: A total of 105 participants were recruited to the study with 67 (64%) preferring centre-based and 38 (36%) mPR. The odds of completing the PR programme were higher in the centre-based group compared to mPR (odds ratio 1.90 95% CI [0.83-4.35]). Participants opting for mPR were significantly younger (p = 0.002) and significantly more likely to be working (p = 0.0001). Results showed that mPR was not inferior to centre-based regarding changes in symptom scores (CAT) or time spent in sedentary behaviour (SBQ). When services were forced to transition to telehealth services during COVID-19 restrictions, the attendance and completion rates were higher with telephone calls and video conferencing compared to mPR - suggesting that synchronous interpersonal interactions with clinicians may facilitate the best attendance and completion rates. Conclusion: When offered the choice of PR delivery method, the majority of participants preferred centre-based PR and this facilitated the best completion rates. mPR was the preferred choice for younger, working participants suggesting that mPR may offer a viable alternative to centre-based PR for some participants, especially younger, employed participants.

Understanding the barriers and facilitators that influence access to quality cardiovascular care for rural Indigenous peoples: protocol for a scoping review.

INTRODUCTION: Maori (the Indigenous peoples of New Zealand) are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD healthcare. Rural Maori experience additional barriers to treatment access, poorer health outcomes and a more significant burden of CVD risk factors compared with non-Maori and Maori living in urban areas. Importantly, these inequities are similarly experienced by Indigenous peoples in other nations impacted by colonisation. Given the scarcity of available literature, we are conducting a scoping review of literature exploring barriers and facilitators in accessing quality CVD healthcare for rural Maori and other Indigenous peoples in nations impacted by colonisation. METHODS AND ANALYSIS: A scoping review will be conducted to identify and map the extent of research available and identify any gaps in the literature. This review will be underpinned by Kaupapa Maori Research methodology and will be conducted using Arksey and O'Malley's (2005) methodological framework. A database search of MEDLINE (OVID), PubMed, Embase, SCOPUS, CINAHL Plus, Australia/New Zealand Reference Centre and NZResearch.org will be used to explore empirical research literature. A grey literature search will also be conducted. Two authors will independently review and screen search results in an iterative manner. The New Zealand Ministry of Health Te Tiriti o Waitangi (Treaty of Waitangi) Framework principles will be used as a framework to summarise and construct a narrative of existing literature. Existing literature will also be appraised using the CONSolIDated critERia for strengthening the reporting of health research involving Indigenous Peoples (CONSIDER) statement. ETHICS AND DISSEMINATION: Ethical approval has not been sought for this review as we are using publicly available data. We will publish this protocol and the findings of our review in an open-access peer-reviewed journal. This protocol has been registered on Open Science Framework (DOI:10.17605/osf.io/xruhy).

Maori and Pacific peoples' experiences of a Maori-led diabetes programme.

AIM: Type 2 diabetes mellitus (T2DM) disproportionately affects Maori and Pacific peoples in Aotearoa (New Zealand). Despite this, the lived experiences of T2DM and its management by Maori and Pacific peoples are scarcely acknowledged in health literature. The present study examines the lived experiences of T2DM by Maori and Pacific participants in the Mana Tu diabetes programme. Mana Tu is a Maori-led diabetes support programme co-designed by the National Hauora Coalition (NHC) alongside patients with diabetes, clinicians, health service planners and whanau ora providers. METHOD: The study used qualitative methods underpinned by Kaupapa Maori (Maori approaches) approaches. Twenty-two semi-structured interviews were conducted with participants of the Mana Tu diabetes programme and their whanau (thirteen Maori, 9 Pacific) from Tamaki Makaurau (Auckland) and Te Tai Tokerau (Northland). RESULTS: The study identified barriers, facilitators and motivators for participants to live well with T2DM. Four key themes were constituted: (1) whanau experience of T2DM, (2) cultural safety in healthcare interactions, (3) whanau ora (collective family wellbeing) and (4) Kaupapa Maori approaches to health interventions. Themes were consistent across Maori and Pacific participants. CONCLUSION: Findings suggest that Maori-led health interventions can better support Maori and Pacific people living with T2DM and are needed to ensure these communities receive appropriate, responsive and equitable healthcare.

Indigenous health worker support for patients with poorly controlled type 2 diabetes: study protocol for a cluster randomised controlled trial of the Mana Tu programme.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) and its complications are more common among Maori and Pacific people compared with other ethnic groups in New Zealand. Comprehensive and sustained approaches that address social determinants of health are required to address this condition, including culturally specific interventions. Currently, New Zealand has no comprehensive T2DM management programme for Maori or Pacific people. METHODS AND ANALYSIS: The Mana Tu programme was developed by a Maori-led collaborative of primary healthcare workers and researchers, and codesigned with whanau (patients and their families) in order to address this gap. The programme is based in primary care and has three major components: a Network hub, Kai Manaaki (skilled case managers who work with whanau with poorly controlled diabetes) and a cross-sector network of services to whom whanau can be referred to address the wider determinants of health. The Network hub supports the delivery of the intervention through training of Kai Manaaki, referrals management, cross-sector network development and quality improvement of the programme. A two-arm cluster randomised controlled trial will be conducted to evaluate the effectiveness of the Mana Tu programme among Maori, Pacific people or those living in areas of high socioeconomic deprivation who also have poorly controlled diabetes (glycated haemoglobin, HbA1c, >65 mmol/mol (8%)), compared with being on a wait list for the programme. A total of 400 participants will be included from 10 general practices (5 practices per group, 40 participants per practice). The primary outcome is HbA1c at 12 months. Secondary outcomes include blood pressure, lipid levels, body mass index and smoking status at 12 months. This protocol outlines the proposed study design and analysis methods. ETHICS AND DISSEMINATION: Ethical approval for the trial has been obtained from the New Zealand Health and Disability Ethics Committee (17/NTB/249). Findings will be presented to practices and their patients at appropriate fora, and disseminated widely through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12617001276347; Pre-result.

Mana Tu: a whanau ora approach to type 2 diabetes.

In 2017, the National Hauora Coalition, a Maori-led Primary Health Organisation (PHO), was awarded a Long-Term Conditions Partnership Research grant to test the effectiveness of Mana Tu: a whanau ora approach to type 2 diabetes. With moves to replicate aspects of it in programmes around New Zealand, it is timely to describe the rationale for Mana Tu and the key components of its unique model of care. Mana Tu was developed in response to current ethnic and social inequities in type 2 diabetes rates, outcomes and wider determinants. It attempts to address various system, service and patient factors that impact on the whanau's ability to 'mana tu' or 'stand with authority' when living with a long-term condition. Results, including clinical, implementation and cost-effectiveness data, will be collected and analysed over the next two years.