Tāne Ora – Take Whakataha
We now live longer and healthier lives than any Polynesians ever in history. While it is often useful to look to the past, we shouldn’t hunger for a world that never was. The Māori world is being reshaped and we need to confront the trauma that faces us. The health status of Māori men has been relatively neglected and there has been an inadequate health sector response to the serious inequalities that exist. Māori men as a population are socially diverse and there is an urgent need to focus on those who live in entrenched poverty. As we face these challenges it is important to remember that we are a dynamically adaptive culture – we need to stop recreating the old and embrace the new.
This engaging and provocative presentation warned against romanticising the past. At the same time, it is important to acknowledge the trauma that has resulted from colonisation. Sir Tipene reminded us that this process is ongoing – “rust never sleeps” – and we need to keep adapting in order to not only survive but to thrive. It is important that we have a critical approach to issues that arise in the modern world. Sir Tipene gave the example of opposition to genetic modification on the basis that it conflicts with tikanga Māori. Rather than simple knee-jerk reactions we need to start thinking differently and to develop kaupapa Māori approaches to confront the challenges that face Māori men’s health.
Aboriginal and Torres Strait Islander male health – an overview
Traditionally the role of Aboriginal and Torres Strait Islander men was held in high esteem; their roles and those of women were complementary. Colonisation has undermined this and emasculated the leadership of Indigenous men. This process of oppression and dispossession has created the problems seen in Indigenous communities today. Indigenous males have the worst health outcomes of any population group and poor access to health services. Interventions to address these issues need to act at all levels. The approach to Indigenous male health is inclusive and broad – male specific, but aimed at general health and wellbeing. Examples of effective approaches include men’s groups, counselling services, interventions based around rugby league clubs and male-specific clinics. Building capacity, including Indigenous men’s health workforce development, is a critical part of the strategy.
Dr Wenitong’s presentation highlighted many of the similarities in Indigenous male health between Australia and Aotearoa, but more importantly helped to elucidate some key steps that we can take to advance Māori men’s health. Some significant work has been undertaken in Australia including policy initiatives such as the Aboriginal and Torres Strait Islander Male Health Framework (2004), much of which we can learn from. Important themes include the need for Māori men to take a leadership role in improving our own health, the value of building on existing work (including getting evidence for effectiveness of existing programmes), advocating for male services within our organisations, identifying the broader benefits of addressing the health of Māori men (healthy males = healthy relationships = healthy whānau = healthy communities), and making Māori men’s health part of the planning process for all new policy.
Hauora Tāne – One Heart Many Lives
The Hauora O Te Hiku O Te Ika, Hauora Tāne – One Heart Many Lives project was initiated in November 2006, after kaimahi attended a social marketing workshop held in Waitangi lead by Pharmac and supported by the Northland DHB and the Te Taitokerau PHO. Kaimahi from a variety of disciplines learnt about social marketing strategies, as a way of providing assistance to engaging Māori Tāne aged ≥35 years to heart health screening. The presentation discussed the integral part played by each of those disciplines in a successful programme, the development of resources, workshops and presentations, and examples of data capture using evaluation tools. The presentation also discussed the need to monitor and manage screening outcomes.
The One Heart Many Lives programme emphasises the importance of men’s roles in the whānau, hapū and iwi. A key feature of this initiative in Te Taitokerau has been the involvement of Māori men from the beginning. One of the interesting themes at the conference was the role of Māori women in tāne ora. This project provides some insight into how wāhine can contribute – by facilitating and supporting Māori men to identify their own aspirations, priorities and solutions. It will be interesting to follow the development of this initiative, particularly to see if stronger evidence of improved health outcomes can be identified as a result of the interventions.
Mana tāne, mana wāhine, mana moutuhake
Since early contact, Māori have been defined by the colonisers as a “warrior race” and Māori men have come to be characterised as inherently violent. The media perpetuate and reinforce this image: for example, the majority of babies who die as a result of child abuse are not Māori, yet Māori child abuse is always highlighted in media coverage. The Toa tradition has always been about being strong, but not just in a physical sense – it also demands emotional and psychological strength. However, as a result of colonisation these traditions have been affected by European male identity, which inhibits the finer emotions and roles such as nurturing. Tāne need to reclaim these aspects of Māori masculinity. We also need to think about mana wāhine, which has been affected by colonial views about the status of women in society. We need to fully reclaim the cultural norms of equal, complementary roles for men and women. In terms of taking the Tāne Ora kaupapa forward, the purpose and direction of the waka need to be carefully determined. As tangata whenua we need to be able to make decisions in our own land – much of our poor health status relates to lack of political power.
The impact of colonisation on the identities and roles of Māori men was a recurring theme at the conference. Some of the key tasks for us are to challenge colonial representations and reclaim a sense of what it is to be a Māori man. Now that the conference is over, it is important that we keep the momentum going and continue to draw attention to Māori men’s health. At the conference the concept of a national Māori men’s health coalition was floated and received significant support. Whatever form this ultimately takes, the main thing is that Māori men are engaged in the kaupapa and are striving for self-determination in relation to health.
Mortality results from a randomized prostate-cancer screening trial
This report presents interim results from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial on prostate-cancer mortality. From 1993 through 2001, 76,693 men were randomised to either 6 rounds of annual screening with prostate-specific antigen (PSA) plus 4 annual digital rectal exams (DREs; n=38,343) or to usual care as the control (n=38,350). Usual care sometimes included screening, as some organisations have recommended. In the screening group, rates of compliance were 85% for PSA testing and 86% for digital rectal examination. Rates of screening in the control group increased from 40% in the first year to 52% in the sixth year for PSA testing and ranged from 41 to 46% for digital rectal examination. At 7 years’ follow-up, screening was associated with a relative increase of 22% in the rate of prostate cancer diagnosis, compared with the control group. However, over an 11-year median follow-up, combined screening with PSA testing and a DRE did not reduce mortality; the rate of death from prostate cancer was very low and did not differ significantly between the two study groups.
Reference: New Engl J Med. 2009;360(13):1310-9.
Screening and prostate-cancer mortality in a randomized European study
Data are reported from the European Randomized Study of Screening for Prostate Cancer (ERSPC), initiated in the early 1990s to evaluate the effect of screening with prostatespecific- antigen (PSA) testing on death rates from prostate cancer. 182,000 men aged 50–74 years were randomly assigned to a group that was offered PSA screening at an average of once every 4 years or to a control group that did not receive such screening. During a median follow-up of 9 years, the cumulative incidence of prostate cancer was 8.2% in the screening group and 4.8% in the control group. PSA screening was associated with a 20% reduction in the rate of death from prostate cancer. The study showed an absolute reduction of approximately 7 prostate-cancer-related deaths per 10,000 men screened.
Screening for prostate cancer is a controversial issue, and these two articles provide much anticipated evidence from large trials. Taken together, they suggest that the effect of screening on prostate cancer mortality is modest at best. However, as the accompanying editorial states, the key question is not whether prostate screening is effective but whether it does more good than harm. In fact, any benefit comes at the cost of substantial overdiagnosis and overtreatment, which leads to adverse health outcomes. There tends to be a public perception that screening programmes are overwhelmingly a good thing – many people are not fully aware of the potential for harm. Decisions about whether to introduce screening programmes always need to carefully balance the risks and benefits. It seems that, at the present time anyway, there is not enough evidence to recommend a population-based prostate cancer screening programme in New Zealand.
Reference: New Engl J Med. 2009;360(13):1320-8.
Prostate cancer – are ethnic minorities disadvantaged?
These researchers analysed the ethnic mix of a database including men from the greater Wellington region presenting with clinically localised prostate cancer between 1996 and 2007, in an attempt to clarify whether fewer Māori men receive treatment than non-Māori men. The database included 271 men with lowrisk prostate cancer treated with brachytherapy (permanent iodine seed implantation), and 188 men with intermediate- or high-risk prostate cancer treated with radical external beam radiotherapy. Each man was allocated to a major ethnic group according to ethnic categories defined in the 2006 New Zealand Census. The observed ethnic mixes of men in the low- and intermediate/high-risk groups were compared with the expected percentages derived from Census and Cancer Registry data. Ten Māori men were on the database, compared to 44 expected, and one Pacific man, compared to 37 expected. The same pattern of underrepresentation of these ethnic minorities was seen for both low-risk and intermediate/high-risk localised prostate cancer.
Māori men are less likely to receive a diagnosis of prostate cancer yet significantly more likely to die of the disease than non-Māori men. This study shows that Māori men are under-represented among those presenting with localised prostate cancer. What this suggests is that by the time Māori men come into contact with the health system they are more likely to have cancer that has spread beyond the prostate. While we’re on the topic, let’s dispel a common myth: Māori do not have “a cultural reluctance to present for health care until forced to by disabling symptoms”. The real question we should ask is what is wrong with health services that makes Māori men, in particular, delay or avoid seeking care. At the Tāne Ora conference cardiovascular risk screening was available on site and men flocked to it. This shows that if care is accessible and provided in a culturally safe way Māori men will go.
Reference: Anticancer Res. 2008;28(6B):3891-5.
Not in my hospital? Ethnic disparities in quality of hospital care in New Zealand: a narrative review of the evidence
This study reviewed the evidence for disparities in the quality of public hospital care for Māori and non-Māori in New Zealand. A literature review of Medline and Embase databases identified 11 studies that employed quality indicators that were specific to inpatient care. The studies varied in quality, some considering the impact of multiple confounding factors, as well as potential statistical bias from under-counting of Māori; others performing few methodological or statistical adjustments for these factors. Investigators also exhibited differing levels of commitment to the consideration of potential confounding factors. However, this review found robust evidence for the existence of healthcare disparities for Māori, in particular related to obstetric intervention and the incidence of potentially avoidable adverse events.
We often hear about problems related to Māori engagement with the health care system such as late presentation and poor compliance with treatment. This is particularly the case for Māori men. In effect, patients become labelled as ‘the problem’, which is misleading. This study supports the growing body of evidence that the health care system provides poorer quality care to Māori patients than to non-Māori. So to improve health care outcomes for Māori we shouldn’t just focus on health care behaviours – the health system needs to change. This includes improving cultural competence of health care professionals and addressing institutional racism at a health system level.
Reference: N Z Med J. 2009;122(1297):68-83.
Changing trends in indigenous inequalities in mortality: lessons from New Zealand
These researchers used standard demographic methods to construct abridged period lifetables for Māori and non-Māori in New Zealand from 1951 to 2006. Absolute [standardised rate difference (SRD)] and relative [standardised rate ratio (SRR)] mortality inequalities for Māori compared with European/Other ethnic groups (aged 1–74 years) were measured using the New Zealand Census-Mortality Study (an ongoing data linkage study that links mortality to census records) from 1981–84 to 2001–04. Life expectancy gaps and relative inequalities in mortality rates (aged 1–74 years) widened and then narrowed again, in tandem with changing economic inequalities and changing health inequalities between ethnic groups. Among females, the contribution of cardiovascular disease to absolute mortality inequalities steadily decreased, but was partly offset by an increasing contribution from cancer. Among males, the contribution of cardiovascular disease increased from the early 1980s to the 1990s, then decreased again. The extent of socio-economic mediation of the ethnic mortality inequality peaked in 1991–94, again more notably among males.
History tells us that Māori are the first to be affected in tough economic times, so this paper has particular relevance given the current recession. It reinforces the fact that ethnic inequalities in health are not a fixed phenomenon – they are exquisitely sensitive to changing social and economic conditions. So it should be possible to rapidly and significantly reduce health inequities between Māori and non-Māori through health and social policy directed at addressing these determinants of health. In the context of the current economic downturn, it will be important to closely monitor ethnic inequalities and respond appropriately to avoid adverse health and social outcomes for Māori.
Reference: Int J Epidemiol. 2009 Mar 30. [Epub ahead of print]
Neighborhood environments and physical activity among adults in 11 countries
This study conducted surveys in 2002–2003 in 11 countries to determine how neighbourhood attributes help adults meet health-enhancing physical activity guidelines. The participating countries were Belgium, Brazil, Canada, Colombia, China (Hong Kong), Japan, Lithuania, New Zealand, Norway, Sweden, and the U.S. (pooled sample of 11,541 adults living in cities). Participants indicated whether seven environmental attributes were present in their neighbourhood. Five of seven environmental variables were significantly related to meeting guidelines for physical activity, ranging from access to low-cost recreation facilities (OR 1.16) to pavements on most streets (OR 1.47). A graded association was observed, with the most activity–supportive neighbourhoods having 100% higher rates of sufficient physical activity compared to those with no supportive attributes.
If we want to improve health outcomes we need to think well beyond individual risk factors and extend our focus to social and physical environments. Interventions to increase physical activity in New Zealand have tended to be limited in scope, often relying on education and individual lifestyle modification. This type of approach on its own is totally inadequate – healthrelated behaviours are powerfully shaped by the environments we live in. This large international study provides a graphic illustration of how characteristics of neighbourhoods determine how physically active the inhabitants are. Interventions such as ensuring widespread access to lowcost recreation facilities are where we should be directing health promotion efforts.
Reference: Am J Prev Med. 2009;36(6):484-90.
